Chest Pain in Children: A Prospective Study

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ABSTRACT. In a prospective study of children with the

primary complaint of chest pain, 43 patients were identified. This gave an occurrence (per patient visits) of 0.288%. The average age was 12.9 years for boys and 11.80 years for girls.

Diagnostic categories identified were idiopathic chest pain

(45%), costochondritis (22.5%), chest pain secondary to bronchitis (12.5%), miscellaneous (10%), chest pain second

ary to muscle strain (5%), and chest pain secondary to trauma

(5%).Thesesixcategories

arediscussed

intermsofage,sex,

and results of laboratories studies. It is concluded that chest

pain in children is not as ominous a symptom as it is in adults,

and that it infrequently signals underlying cardiac disease or

other serious disease that is not apparent from a thorough history and physical examination. Pediatrics, 57:648-651,

1976, CHESTPAIN,DIAGNOSIS.

Recurrent and unexplainable pain in children is a common problem in pediatric practice.' Apley lists recurrent abdominal pain and limb pain as occurring in 11% and 4% of children, respective ly.2 Children in the late pre-teens and early teens seem to be most plagued by this recurrent prob lem, and girls are affected more commonly than

boys.'6 The pain is often generated by the

patient's reaction to emotional stress.―7 Although chest pain is a common manifestation of serious underlying disease in adults, it is felt to be an infrequent pediatric complaint. This pro spective study was undertaken to define the

common causes of chest pain in children, develop

guidelines for its evaluation, and to formulate a

psychoemotional profile of the child who complains of chest pain.

PATIENTSAND METHODS

All children seen in the Milwaukee Children's

Hospital outpatient department, emergency room, or cardiac clinics during a nine-week period, with the primary complaint of chest pain, were included in this study. Forty-three such patients were identified. The total number of

visits during the nine-week period was available

rather than the total number of patients pre

senting for care. Thus, an occurrence rather than an incidence rate is reported.

All patients underwent a thorough history and

physical examination and appropriate studies

deemed necessary to manage their presenting complaint. Patients were then referred to the cardiac clinic for further evaluation that included a second history and physical examination, a

psychiatric interview, complete blood count,

erythrocyte sedimentation rate, urinalysis, SGOT, chest X-ray, and electrocardiogram. Four to eight weeks later, telephone follow-up evaluation was

(Received

September

8; revision

acceptedforpublication

ADDRESS FOR REPRINTS: (W.J.G.) Milwaukee Children's

Hospital, 1700 \Vest Wisconsin Avenue, Milwaukee,

Wisconsin 53233.

ChestPainin Children:A ProspectiveStudy

David J. Driscoll, M.D., Lucille B. Glicklich, M.D., and William J. Gallen, M.D.

From the Medical College of \Visconsin and tile Milwaukee aiildren ‘¿aHospital, Departments of Pediatrics

done to determine the status of the patient's complaint. Chi-square analysis of data was used unless otherwise stated.

Forty-three patients were identified in a nine

week period. Of these 43, three refused to be

included in the study. There were 14,895 visits during that time period, giving an occurrence

rate of 0.288%. There were 22 boys and 18 girls.

The average age of the boys was 12.29 years

(range, 5 to 19 years) and that of the girls, 11.80 years (range, 5 to 17 years). Non-black girls were significantly younger than black girls (8.5 vs. 12.98 years; P < .1).

Six diagnostic categories were identified and compared. Idiopathic chest pain was identified in 18 patients (45%) after a thorough history and physical and laboratory examination. Costochon dritis was diagnosed in nine patients (22.5%) on the basis of history, tenderness to palpation of one or more costochondral or chondral sternal junc tions, and normal laboratory findings. Chest pain associated with coughing and bronchitis was diag nosed in five patients (12.5%). Miscellaneous causes of chest pain were noted in four patients (10%) and included a child with sickle-C hemo globinopathy, lobar pneumonia, a “¿viral-like―

syndrome, and a patient whose chest X-ray

suggested disc space narrowing (the last two

patients did not return for follow-up or further evaluation). Muscle strain secondary to weight lifting and vigorous sports activities was exhibited by two patients (5%), and two patients (5%) had chest pain as a result of direct trauma to the chest cage.

Chest pain had been first complained of from two hours to 12 years prior to presentation with an average of 244 days (Table I). Children with idiopathic chest pain tended to have a longer history of symptoms (798 days) than did the other

groups alone or combined. This difference was

significant when compared to those with chest pain associated with bronchitis (P < .01) and to those with costochondritis (P < .015). 0

Telephone follow-up was done four to eight

weeks after examination. Thirty-one patients

were contacted. Fewer children with idiopathic chest pain resolved their symptom (4 of 13) as

compared to the remaining groups (14 of 17;

P < .025; Table I).

Children with idiopathic chest pain were more

°Analyzed l)V f-test on log transformed data.

TABLE I

RESOLUTION OF THE COMPLAINT OF CHEST PAIN

Duration (days) Resolution

1@@

@ —¿@

Etiology Mean Range .Vo. %

Idiopathic 797.8 1 to 4,380 4 of 13 30

Costochondritis 96.8 21 to 365 4 of 6 66

Bronchitis 5.8 1 to 16 4 of 4 100

Miscellaneous 245.0 3 to 730 2 of 3 66

Muscle strain 0.5 .08 to 1 2 of 2 1(X)

Direct trauma 9.5 1 to 18 2 of 2 100

compliant in keeping their return appointments than were the other groups of children.

(P < .05).

There appeared to be no relationship between the diagnostic categories and a positive family history of chest pain or heart or lung disease.

Except for chest X-ray, laboratory studies added little to a thorough history and physical examination in identifying the nature of chest pain. Chest X-ray revealed cardiomegaly in the

patient with sickle-C hemoglobinopathy, a right

upper lobe infiltrate in a patient with pneumonia, and suggested a narrow disc space in one other patient. Normal electrocardiograms were noted

in all patients except for the presence of left

ventricular hypertrophy in the child with sickle-C hemoglobinopathy and a minor atrial arrhythmia in one other patient. Hematologic and urine examinations were normal.

Patients were divided into two groups: (1) those with nonrecurrent chest pain (symptoms of less than six months in duration) and (2) those with

recurrent chest pain (symptoms of more than six months in duration). There were no significant

differences between these two groups in regard to age, resolution of symptoms, or quality of pain.

An etiology could be found for chest pain in 65% of the cases in which the pain had been present

for less than six months, but in only 33% of the

cases in which pain had been present more than six months.

Although it has been suggested that metaphor ical description of pain may indicate its func tional nature,5 in this study, the child's descrip tion of the pain seemed to be related to interview technique or number of interviews rather than to

etiology of the symptom. Ninety-seven percent

(30 of 31) of the patients described their symp toms in dramatic, metaphorical terms (example;

RESULTS

°Ten patients were lost to telephone follow-up.

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649

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“¿sharplike a knife―) during the psychiatric inter

view, while only 38% (15/40) offered such a description during the preceding medical inter view.

Thirty-one of the 40 children included in this study were interviewed by a child psychiatrist, with particular attention to the child's affect, his interpretation of the pain, his perception of his environment, and the affect of this symptom on his education and family or social activities. The

examiner was not aware of the patient's diagnosis at the time of the interview. Fifteen girls and 16

boys were in the sample.

Seven children expressed worry over their pain, four were overtly sad, two appeared angry by look and verbal expression, three exhibited a high level of anxiety, one spoke extensively about other ailments and illnesses, and one requested hospital ization.

The symptom meant “¿heart―to 16 (52%) of the

children. Four (13%) related it to chest wall or muscle, three (10%) to respiratory tract, one (3%) to a skin infection, and one (3%) to his nipple and mildly hypertrophied breast tissue. Six (19%) were

unsure. Eighteen children were able to bring to

memory relatives or acquaintances who had chest pain mainly related to heart disease. Eighteen children described the pain as “¿sharplike a needle― and 12 as “¿dulllike pressing or pound ing.― Of the 31 children, 14 perceived their environment as presenting problems in the form of domestic conflicts, school difficulties, parent child disagreements, and peer problems. In none of the children did chest pain interfere with school or social activities for either repeated or prolonged episodes. In this regard, it did not fit the categories of either school phobia―or conver sion reaction.10'1' One child volunteered a request to return for further talks with the psychiatrist.

These varied interview responses followed no specific pattern which might differentiate the

idiopathic cases from those of known etiology for

chest pain. Both groups of children showed similar responses and concern over the chest pain. The intensity of the responses did not, however, indicate the emotional problems in most of the

cases.

DISCUSSION

Chest pain in children classically is described as occurring in various disorders such as spontaneous pneumothorax, pericarditis, thoracic outlet syn

drome, costochondritis, idiopathic hypertrophic

subaortic stenosis, asthma, pneumonia, sickle cell

disease, esophagitis, leukemia, and various tumors

of the chest. In such instances, chest pain is an

associated rather than a primary complaint and the underlying disease is readily diagnosed. Our feeling that chest pain is a frequent primary complaint in the pediatric age group was borne out by the fact that 43 cases were identified over a nine-week period. Furthermore, it becomes quite obvious after interviewing a series of patients (and their parents) with this problem that chest pain is

viewed as a serious omen and there is an over

whelming concern that the child may have heart

disease. These fears may well stem from the

communication media's dramatic emphasis on

coronary artery disease and heart surgery.

From this study, it is apparent that chest pain

in children is not as ominous a symptom as it is in adults, that serious underlying disease presenting as chest pain in children is unusual, and that cardiac disease rarely presents as chest pain in children. Furthermore, an organic etiology is less

likely to be found if the complaint has been

present for more than six months, and children in whom no etiology can be found are niore likely to complain recurrently of chest pain. Certainly, all

children presenting with chest pain should

undergo a thorough history and physical examina tion, and if this fails to provide an obvious

diagnosis, a chest X-ray is a worthwhile and

justifiable procedure.

Psychiatric evaluation revealed that the chest pain often caused concern in the child and the family but there was no evidence that psychiatric

disturbance initiated the pain. Pain is an

emotional experience whether it derives from

organic or other causes; it need not, however, be

due to an emotional cause. There is a tendency to label pain unexplained by organic disease as

“¿psychiatric'‘¿but thorough diagnosis is necessary to substantiate this.

In dealing with the family of a child with chest

pain, the physician must delicately balance his

approach between being too “¿laboratory

conscious― and reinforcing the child's and

parents' preoccupation with heart disease, and on

the other hand, not being concerned and thor

ough enough in his evaluation with the result that major pathology is missed or the family is uncon vinced of the well-being of the child.

SUMMARY

Although the complaint of chest pain is a

common pediatric problem, its underlying cause is usually benign. A thorough history, physical examination, and chest X-ray provide a reason

able and reliable approach to this symptom in

survey of 1,000 school children. Arch Dis Child 33:165, 1958.

7. Apley J, MacKeith R: The Child and His Symptoms. Philadelphia, FA Davis Co, 1968.

8. Flinn DE: Functional chest pain. Aerospace Med 38:1167,1967.

9. Schmitt B: School phobia—the great imitator: A pedia trician's viewpoint. Pediatrics 48:433, 1971.

10. Friedman S: Conversion symptoms in adolescents. Pediatr Clin North Am 20:873, 1973.

11. Rock N: Conversion reactions in childhood: A clinical

study on childhood neuroses. Am Acad Child PsychiatryJ 10:65,1971.

ACKNOWLEDGMENT

We are indebted to David Z. Friedberg, M.D., for his helpful critical review of this manuscript and to John Kalbfleisch, Ph.D., for his statistical analysis of the data. the pain is not necessarily of emotional origin but

may be.

REFERENCES

1. Apley J: The child with recurrent abdominal pain. Pediatr Gun North Am 14:63, 1967.

2. Apley J: A common denominator in the recurrent pains of childhood. Proc B Soc Med 51:1023, 1958. 3. Green M: Psychogenic, recurrent abdominal pain. Pedi

atrics 40:84, 1967.

4. Oster J: Recurrent abdoniinal pain, headaches and limb

pain in children and adolescents. Pediatrics 50:429, 1972.

5. Launiala K, Visakorpi JK: Recurrent abdominal pain in

children: A review of somatic aspects. Acta Paediatr Scand 60:724, 1971.

6. Aple@ J, Naish N: Recurrent abdominal pain: A field

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CHEMICALRISKS

How should we approach the problem posed by the existence of large numbers of chemicals, both natural and man-made, that we suspect of being

capable of causmg cancers?

. . . There is no neutral scientific judge. We all speak from our own point of

view and attitude . . . The decision about the balance of benefit and risk must be, in the end a political one, since it is based not on the fact but on opinion about which risks are worth taking—especially when the risks are taken by one social group and much of the benefit accrues to other groups.

Corn mentary : Seventeen Principles About Cancer or Something

(Lancet 1:571, 1976)

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1976;57;648

Pediatrics

David J. Driscoll, Lucille B. Glicklich and William J. Gallen

Chest Pain in Children: A Prospective Study

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Pediatrics

David J. Driscoll, Lucille B. Glicklich and William J. Gallen

Chest Pain in Children: A Prospective Study

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