Chest Pain in Children

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1068

PEDIATRICS

Vol. 75 No. 6 June 1985

Chest

Pain in Children

Steven

M. Selbst,

MD

From the Department of Pediatrics, College of Physicians and Surgeons, Columbia

University, Babies Hospital, New York

ABSTRACT. In a retrospective study of chest pain, 267

children were identified. This gave an occurrence rate (per patient visit) of 0.249%. Male patients were identi-fled as often as female patients, and teenagers as often

as children less than age 12 years. Chest pain was found to be present for more than 1 month in 8.6% and for more than 1 year in 7.8%. Idiopathic chest pain was the most common diagnosis made, followed by functional pain (anxiety related) and musculoskeletal pain.

Labo-ratory tests were not helpful in establishing the etiology

of chest pain. Pediatrics 1985;75:1068-1070; chest pain, heart disease, musculoskeletal pain, electrocardiogram.

get follow-up information from each patient. The following questions were asked: (1) Do you still have chest pain? (2) How often? (3) Does it wake you from sleep or keep you from falling asleep?

(4) Are you getting medication or treatment for this pain? (5) Are you worried about your chest pain? (6) How would you describe you general state

of health? (a) Excellent,

(b)

Good, (c) Poor.

The method used for statistical analysis was the

x2

test. All P values of .05 or less were considered significant.

RESULTS

Chest pain in children has long been considered

benign, rarely associated with organic disease.

However, most of our knowledge about children’s chest pain is anecdotal.

We reviewed all reports of patients whose pre-senting complaint was chest pain and who were evaluated in a pediatric emergency room during a

2-year period.

METHODS

All patients with the complaint of chest pain who were seen at our pediatric emergency room from

May 7, 1979 to Aug 11, 1981 were identified through

the computerized register. For each patient visit,

an

encounter sheet was completed by the health care professional; data from this sheet formed the

basis for selection by the computer. Other basic

information such as age, date, and unit number were coded. The charts of these patients were ana-lyzed, and the diagnosis listed by the examining physician was accepted. An attempt was made to

Received for publication Oct 18, 1982; accepted July 25, 1984.

Reprint requests to (S.M.S.) Division of General Pediatrics, The

Children’s Hospital of Philadelphia, 34th St and Civic Center

Blvd, Philadelphia, PA 19104.

Patients

A total of 267 patient charts were reviewed.

Charts of 19 other patients could not be located. There were 107,043 visits during the study period, giving an occurrence rate of 0.249%. Of the charts reviewed, there were 129 boys and 138 girls. The youngest patient was 21 months old, and the oldest was 19 years old. There were 135 children less than age 12 years, and 132 children aged 12 to 19 years. Of those older children (aged 12 to 19 years), half (66) were male. Of those identified as having chest pain, 166 were Hispanic, 87 were black, 13 were white, and one was Indian.

Pain

The chest pain was acute (one day or less) in onset in 98 (36%) patients. Another 89 children (33%) had chest pain lasting two days to 1 month, 23 children (8.6%) had chest pain lasting several months, and 21 (7.8%) had had the pain for 1 year or longer. In 36 children (13.5%), the duration of the pain was unknown.

Forty-three patients (16%) had been evaluated

in our emergency room more than once for chest pain. Sixteen patients (6%) had two or more addi-tional visits for chest pain. Another 20 children

(7.5%) had been seen in the emergency room for

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* Twenty-item serum chemistry analysis including

electro-lytes, liver function tests, and renal function tests.

TABLE 1. Diagnostic Categories for Chest Pain

ARTICLES

1069

Pat

No. ients

%

No. of Patients

<l2yr

No. of Patients

l2yr

Idiopathic 76 28% 42 34

Functional (anxiety) 45 17% 16 29

Musculoskeletal 39 15% 19 20

Costochondritis 26 10% 10 16

Gastrointestinal pathology, “esophagitis,” 18 7% 7 11

“heartburn”

Cough or upper respiratory tract infec- 16 6% 13 3

tion

Asthma 11 4% 4 7

Trauma 10 4% 8 2

Arrhythmia 7 3% 7 0

Pneumonia 6 2% 4 2

Other 13 4% 5 8

Total 135 132

leg pain, back pain, or abdominal pain, at some

other time.

History

Of the 267 patients, 41 (15%) had a history of a

previous heart murmur or heart disease; 36 (13%)

had a history of asthma; 45 (17%) had a cough at the time they were seen with chest pain; 19 (7%) had a history of recent trauma to the chest. History of smoking was sought in only ten patients, and

three

of these were smokers.

Family history was obtained in only 87 patients (33%). Of those questioned, only one patient had a family history positive for chest pain. Twenty-one

children had a family history positive for heart disease and 16 children had a family history positive

for lung disease, including asthma.

Diagnosis

Several diagnostic categories were identified and

compared (see Table 1). Idiopathic chest pain was

the most common diagnosis. This category includes

impressions such as “benign,” “idiopathic,”

“un-known,” or “normal child” as the only explanation for the chest pain. The category of functional chest pain refers to anxiety-related chest pain. Of those seven children thought to have arrhythmia as the cause of chest pain, two had premature junctional beats, four were thought to have had supraventric-ular tachycardia that resolved before the examina-tion, and another had a sinus arrhythmia. The examining physician thought this latter child might have noticed the irregularity in heart beat (sinus

arrhythmia) and then complained of discomfort.

One teenager who complained of chest pain was found on examination to have a suprapubic tender

mass. Further examination revealed that she was

pregnant. One child who had repeated visits for

TABLE 2. Laboratory Tests in Patients with Chest

Pain

Total Results

Patients

Normal Abnormal

Chest roentgenogram 76 71 5

ECG 100 91 9

Urine analysis or 28 28 0

hematocrit

SMAC* 5 5 0

ESR 7 7 0

T3/T4 2 1 1

Echocardiogram 1 1 0

Ascheim-Zondek test 1 0 1

for pregnancy

chest pain and palpitations was noted to have

per-sistent tachycardia as well. After the patient was

initially referred to a psychiatrist for presumed functional pain, thyroid studies revealed that she

was hyperthyroid. (T3 1.26, T4 16.7)

Age was a significant factor in several diagnostic categories. Teenagers (aged 12 to 19 years) had a higher incidence of functional chest pain, 29 v 16

(P < .05), than younger children who had more

cardiorespiratory problems (asthma, pneumonia,

cough, pleuritis, and arrhythmia) as a cause of chest pain, 30 v 14 (P < .025).

Sex was not compared in the diagnostic

cate-gories, except for functional pain. Here it was found that girls had pain secondary to anxiety signifi-cantly more commonly than boys, 30 v 15 (P < .05).

Laboratory Findings

Laboratory tests were not helpful in making the

diagnosis (Table 2). In all, 76 children (28%) had

chest roentgenograms; and 71 had normal findings.

Of the five children with abnormal

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1070

CHEST

PAIN

IN CHILDREN

graphic findings, one child known to have tetralogy of Fallot had a large heart; one child had situs inversus, as was already known and three children had pneumonia, as had been suspected before the roentgenographic confirmation. ECG for 100 chil-dren (37%) revealed normal findings for 91. The nine ECGs with abnormal findings included seven abnormalities that had been noted on previous ECGs and two cases of premature junctional beats. One ECG showed ST elevation that was not further investigated.

Follow-up

All patients were sent a questionnaire in May 1982. Only 60 patients (22%) returned it. Another 54 (20%) questionnaires were returned by the Post Office because the patients were no longer at the address, and these patients could not be located; 153 patients failed to return the questionnaires.

Of the 60 who responded, 35 still had chest pain. Twenty-one of these patients said the pain woke them from sleep or prevented sleep. Only four said they were receiving medication for chest pain. It is not known what medication these children received, except for the one child with hyperthyroidism, who

is known to be taking propylthiouracil. She denies having recent chest pain. Thirty-four children or their parents indicated they were worried about the chest pain. One 10-year-old girl, thought to have

functional pain at the time of this study, was fol-lowed at this medical center for a neurologic prob-lem. After 1#{189}years of intermittent chest pain, an echocardiogram was obtained; this showed mitral valve prolapse. This patient’s mother also had a history of mitral valve prolapse.

DISCUSSION

This study concurs with others in concluding that chest pain is a commonly encountered symptom in pediatrics.’3 The occurrence rate found here was

similar to that reported by Driscoll et al.’ Chest pain occurs in children of all ages. The age of the patient does, however, have importance in terms of the diagnosis. Our study suggests that functional pain was significantly more common in teenagers

(P < .05) and pain due to cardiorespiratory prob-lems (cough, asthma, pneumonia, pleuritis, and ar-rhythmia) was more common in younger children

(P < .025).

Furthermore, sex does not seem to be important in determining who gets chest pain. However, this study agrees with that of Asnes et al2 in finding that functional or psychogenic chest pain is signifi-cantly more common in female children (P < .05).

This study also agrees with that of Pantell and Goodman3 that chest pain is a chronic, recurring

problem in many children. Although most children

are seen for medical attention because of acute pain, some children seem troubled with this symptom for extended periods of time. On follow-up, 35 children reported that they still had chest pain at times,

even 1 or 2 years after their initial visit for this

study.

This study did not determine whether cigarette

smoking is an important factor in the pediatric patient with chest pain because this history was not sought from most of the patients. Friedman et al,4 in a study that included more than 800

teen-agers and several thousand adults, concluded that cigarette smoking was associated with chest pain. Perhaps, pediatricians should investigate this his-tory in each patient with chest pain.

From this study, one might consider that serious

underlying disease (ie, cardiac or pulmonary dis-ease) is rare in the child who is initially seen with chest pain. It is conceivable that some cases of mitral valve prolapse were missed here, and this diagnosis should be considered, especially in girls with repeated episodes of chest pain associated with light-headedness, palpitations, or syncope.5 How-ever, it is not likely that pneumothorax,

pericardi-tis, or other serious diseases were missed in this study because patients with such conditions are usually ill and the underlying disease is quickly

apparent. Although no patient had serious

conse-quences from chest pain, follow-up was only

avail-able in 22% of the children. Thus, one cannot yet

conclude that chest pain is an innocuous symptom in children.

Finally, this study disagrees with findings of Driscoll et al’ that a chest roentgenogram is worth-while or justifiable. Laboratory tests were not

usu-ally more helpful than the history and physical examination. Laboratory tests should only be

or-dered

if they are indicated on the basis of history and physical examination.

ACKNOWLEDGMENT

The author thanks Dr Michael Katz for his help in

revising this manuscript, and J. Cambrelen for his help

in gathering data.

REFERENCES

1. Driscoll DJ, Glicklich LB, Gallen WJ: Chest pain in

chil-dren: A prospective study. Pediatrics 1976;57:648-651

2. Asnes R, Santulli R, Bemporad J: Psychogenic chest pain in children. Clin Pediatr 1981;20:788-791

3. Pantell RH, Goodman BW Jr: Adolescent chest pain: A prospective study. Pediatrics 1983;71:881-887

4. Friedman G, Sieglaub A, Dales L: Cigarette smoking and

chest pain. Ann Intern Med 1975;83:1-7

5. Levine H: Difficult problems in the diagnosis of chest pain.

Am Heart J 1980;100:108-118

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1985;75;1068

Pediatrics

Steven M. Selbst