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Clinical Practice Guidelines

Chest pain

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  • See also

    Pneumonia
    Primary Spontaneous pneumothorax 
    COVID-19

    Key points

    1. The cause of most paediatric chest pain is unknown or self-limiting causes eg musculoskeletal pain
    2. A serious cardiac or respiratory condition is highly unlikely to be the cause of new-onset chest pain in a previously-well child
    3. The goal of assessment is to rule out serious causes and manage appropriately
    4. Reassurance with or without simple analgesia is often all that is necessary

    Background

    • Cardiac-related causes account for as few as 1% of children who present with chest pain
    • In children without risk factors for serious disease (see below), the most commonly identified causes of chest pain include:
      • Musculoskeletal pain/costochondritis
      • Precordial catch
      • Respiratory infection or asthma
      • Upper gastrointestinal or biliary
      • Anxiety     
    • Investigations such as ECG, CXR and blood tests should be reserved for children with risk factors identified on history and examination. Others such as echocardiogram or CT pulmonary angiogram should be discussed with a senior clinician

    Assessment

    History

    A thorough history is key to identifying a likely cause and minimising unnecessary investigation

    • Timing of symptom onset (acute onset more likely to have identifiable cause)
    • Duration of symptoms
    • Site of pain
    • Reproducibility (consider exertional or positional)
    • Quality (crushing central chest pain or worse with inspiration)
    • Radiation
    • Associated symptoms (eg dizziness, shortness of breath, palpitations)
    • Aggravating and relieving factors
    • Recent injury
    • Recent illness or vaccination (eg myopericarditis secondary to COVID-19 mRNA vaccination)
    • Underlying condition (eg Duchenne muscular dystrophy)
    • Family history of serious cardiac or pulmonary conditions (eg arrhythmia, cardiomyopathy, pulmonary hypertension, sudden death)

    Risk factors for serious or life-threatening conditions

    Cardiac

    Pulmonary embolus

    Respiratory

    Gastrointestinal

    • First episode severe chest pain
    • Pain radiating to arm or back
    • Associated dizziness or syncope
    • Congenital/acquired cardiac disease
    • Family history sudden cardiac death or arrhythmia
    • History of Kawasaki disease
    • Connective tissue disease
    • Longstanding diabetes
    • Immobility
    • Recent surgery
    • Hypercoagulability
    • Central venous catheter
    • Pleuritic pain
    • Haemoptysis
    • Fever
    • Cough
    • Lethargy
    • Pleuritic chest pain
    • Chronic respiratory disease
    • Chest pain after vomiting
    • Recurrent vomiting
    • Odynophagia
    • Dysphagia
    • Food impaction
    • Other atopic history
    • Neck pain or discomfort
    • Epigastric pain or discomfort
    • Recent heavy alcohol consumption
    • History of ingested foreign body
    • Suspicion button battery ingestion

     

    Examination

    Should aim to identify signs of cardiorespiratory distress:

    • tachypnoea and increased work of breathing
    • hypoxia
    • abnormal pulse or BP
    • distended neck veins, muffled heart sounds
    • deceased chest expansion
    • absent breath sounds
    • altered conscious state

    Management

    Approach to the management of chest pain

    Chest pain diagram 

    Consider consultation with local paediatric team when

    • Advice required regarding escalation of care
    • Further monitoring or investigations required as an inpatient
    • Other comorbidities present with unclear cause for chest pain

    Consider consultation with cardiology team when

    • Acute cardiac condition diagnosed or abnormal investigations
    • Normal investigations but ongoing concern for underlying cardiac condition from history, exam or family history
    • Known congenital or acquired cardiac condition with chest pain

    Consider consultation with relevant specialist team when

    • Acute pulmonary embolism diagnosed
    • Risk factors for PE but requiring shared decision-making regarding investigations or follow up

    Consider transfer when

    Care and support from cardiology, respiratory, haematology or intensive care unit required beyond scope of local health service

    For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services

    Consider discharge when

    • Chest pain has resolved or improved with simple analgesia and no serious cause has been identified
    • Vital signs are normal
    • Appropriate follow up planning is arranged with GP or specialist

    Parent information

    Raising Children Network: Chest Pain

    Additional notes

    Key examination and investigation findings that may suggest an uncommon but serious cause of chest pain

    Causes

    History

    Assessment & Investigations

    Cardiac

    Myocarditis

    • Non-specific symptoms mimicking respiratory disease or sepsis
    • Recent viral illness eg coxsakie, parvovirus, influenza
    • Recent (1-14 days post) mRNA vaccine received (higher risk adolescent males and after 2nd dose)
    • Dizziness or syncope
    • Feelings of palpitations
    • Abnormal BP and or heart rate
    • ECG changes possible (eg sinus tachycardia, non-specific ST segment and T wave changes)
    • CXR changes possible
    • Troponin raise possible
    • CRP / ESR raise possible
    • (see COVID-19)

     

    Pericarditis

    • Retrosternal chest pain
    • Pain improved by sitting upright or leaning forward
    • Recent (1-14 days post) mRNA vaccine received (higher risk adolescent males and after 2nd dose)
    • Tachycardia
    • Pericardial rub
    • ECG changes possible (eg diffuse ST elevation with PR depression; T wave flattening; deep symmetrical T wave inversion)
    • CXR changes possible (if effusion present)
    • Troponin raise possible
    • CRP/ESR raise possible
    • (see COVID-19)

     

    Endocarditis

    • Fever of unknown origin
    • Congenital or acquired cardiac condition
    • Cardiac surgery history
    • Valvulopathy or replacement
    • Aboriginal or Torres Strait Islander
    • Recent dental procedure
    • Recent skin infection or procedure
    • Dukes Criteria for IE
    • CXR changes possible
    • Cardiac echo

     

    Aortic dissection

    • Acute onset ‘tearing’ chest pain
    • Pain radiates to back
    • Known connective tissue disease eg Marfan, Ehlers-Danlos
    • History of Kawasaki disease
    • Known aortic root dilatation
    • New murmur with no alternative aetiology
    • Difference in BP’s upper limbs
    • Pericardial effusion
    • Pleural effusion
    • CXR changes possible

    Arrhythmias

    • Palpitations
    • Exertional chest pain
    • Syncope
    • Dizziness
    • Family history of arrhythmias eg Brugada
    • Family history of sudden cardiac death
    • Abnormal BP +/- heart rate
    • ECG abnormalities possible
    • Electrolytes abnormalities

     

    Cardiac ischaemia

    • Pain radiating to arm or neck
    • Blunt chest trauma
    • Cocaine, methamphetamine or synthetic cannabinoids use
    • Known cardiac disease or cardiac surgery
    • Kawasaki disease history
    • Hypercoagulability history eg SLE
    • Hyperlipidaemia history or family history
    • Long standing diabetes history
    • Abnormal BP and or heart rate
    • Arrhythmias
    • ECG changes (ST and T wave changes)
    • Raised troponin

     

    Pericardial effusion

    Screen for risk factors:

    • infective (recent viral, bacterial, TB, fungal)
    • auto-immune history eg lupus
    • neoplastic eg neoplastic
    • post procedure (recent cardiac / thoracic surgery)
    • post MI (unlikely paediatrics)
    • uremic (chronic renal failure, especially if pre-dialysis stage)
    • recent treatment radiation
    • drugs (rare)
    • Hypotension
    • Distended neck veins
    • Muffled heart sounds
    • CXR changes possible

    Pulmonary

    Pulmonary embolus

    • Recent surgery or immobility
    • Malignancy
    • Hyepercoagulability history
    • CVAD in situ or recent
    • Pleuritic pain
    • Haemoptysis
    • Dyspnoea
    • Hypoxia with no other cause
    • Tachycardia with no other cause
    • Tachypnoea with no other cause
    • ECG changes possible (eg tachycardia, RBBB, right sided T wave changes)
    • CXR changes possible

    Pneumothorax

    • Tall/thin adolescents
    • Acute pain or dyspnoea after cough/Valsalva manoeuvre
    • Acute onset, severe, stabbing chest pain
    • Can be pleuritic
    • Can have normal exam
    • Sweating
    • Tachypnoea and or tachycardia
    • Decreased/absent breath sounds
    • Hyper resonance on percussion
    • Asymmetric lung expansion
    • CXR changes

     

    Acute Chest Syndrome

    • Known sickle cell disease
    • Current or recent infection, dehydration, fever, hypoxia, sedatives or surgery
    • Fever/dehydration signs
    • Tachypnoea/tachycardia
    • CXR changes possible

     

    Exercise Induced Asthma

    • Exercise induced chest pain with dyspnoea/cough
    • Previous history asthma
    • Other atopic history
    • Salbutamol responsive
    • Tachypnoea
    • Talking short sentences
    • Hypoxia
    • Widespread wheeze

     

    Pneumonia

    • Fever
    • Cough
    • Increased WOB
    • Lethargic
    • Fever
    • Tachypnoea and WOB
    • Hypoxia
    • Localised crackles or absent breath sounds

     

    Pleural Effusion and Empyema

    • Chest pain, can be pleuritic
    • Fever >48 hrs despite antibiotics
    • Lethargy
    • Dyspnoea/WOB
    • Unilateral chest pain
    • Refusal to lie on one site
    • Localised decreased air entry
    • Localised dull percussion
    • Decreased chest expansion
    • Apparent scoliosis (due to pain/muscle spasm)
    • CXR changes

     

    Pleurisy

    • Sharp stabbing localised chest pain
    • Pain worse with deep breathing, coughing, movement, certain positions (pleuritic)
    • May have recent or current cough or fever
    • May be entirely well apart from new pleuritic chest pain
    • May hear pleuritic rub over area of chest pain
    • CXR normal (unless underlying condition causing pleuritic pain eg pleural effusion)

     

    Inhaled Foreign Body

    • High degree suspicion children <4 years age
    • High degree suspicion older children with developmental impairment
    • Might present days to weeks after event
    • Persistent cough,fever, wheeze or consolidation
    • Haemoptysis
    • Increased WOB/stridor
    • Colour changes if acute event
    • May have normal exam
    • Stridor/voice changes
    • Tachypnoea
    • Hypoxia
    • Focal wheeze
    • Localised decreased air entry
    • Asymmetrical chest movement
    • CXR might appear normal, look for air trapping
    • Ask for inspiratory, expiratory and lateral decubitus views

     

    Musculoskeletal

    Muscle Strain / Trauma

    • Recent trauma
    • Recent overuse (ask about activities, hobbies, jobs)
    • Chronic cough
    • Localised area of chest pain
    • Worse with movement or deep breathing
    • Localised area or muscle groups of tenderness
    • Reproducible with palpation, movement, deep breathing
    • Bruising

     

    Precordial Catch

    • Sudden and sharp onset chest pain
    • Pain along left lower sternal border or cardiac apex area
    • Onset can be during rest or activity but not during sleep
    • The episode can lead to shallow breathing as a way to cope with pain and feelings of intense anxiety due to pain
    • Episodes are intense but brief lasting 30 seconds to 3 minutes
    • Normal exam
    • No special investigations

    Costochondritis

    • Sharp or dull chest pain
    • Gradual or rapid onset
    • Pin point area to 2 or 3 adjacent ribs
    • Reproducible with palpation, movement or deep breathing
    • Tenderness to palpation of costochondral junctions Reproducible localised pain or discomfort
    • Usually unilateral
    • Usually ribs 2 to 5
    • No swelling

    Bone destruction:
    Osteomyelitis /
    Bone neoplasm

    • Localised chest pain
    • Can be subacute or chronic pain
    • Night time pain or awakening from sleep
    • Pain persisting after minor trauma
    • May be well clinically
    • Non-specific localised bony tenderness
    • Localised soft tissue swelling
    • CXR changes possible

     

    Gastro-intestinal

    Gastro-oesophageal reflux/ oesophagitis

    • Heartburn
    • Non-specific chest pain
    • Epigastric discomfort or pain
    • Recurrent vomiting
    • Odynophagia
    • Food refusal
    • Possible epigastric discomfort/tenderness

    Other

    Breast tenderness

    • Localised to breast tissue area
    • Premenstrual or cyclic:  PMS
    • Non-cyclic pain: consider fibro-adenoma, breast cyst or breast abscess
    • Breast lump right under the areola = breast bud
    • Other features puberty supports breast bud diagnosis
    • Consider ultrasound if breast pathology suspected
    • Fever, redness or axillary lymphadenopathy indicates possible infection

    Shingles

    • Prodrome of pain or hyperalgesia over one or more dermatome that does not cross midline
    • History of previous shingles
    • Confirmed contact
    • If rash present: clusters of vesicles on red bases that is confined to one more dermatome that does not cross midline

    Psychogenic

    • Mental health history
    • Drug/alcohol use
    • Social stressors
    • Consider HEEADSSS screen
    • Transient hyperventilation +/- tachycardia
    • Normal exam
    • Normal ECG

     

    Last updated January 2023

  • Reference List

    1. Gal Garbut et al. Paediatric Chest Pain. Paediatrics in Review AAP. 2020 https://publications.aap.org/pediatricsinreview/article-abstract/41/9/469/958/Pediatric-Chest-Pain?redirectedFrom=fulltext (viewed 3 Feb 2022)
    2. Perth Children’s Hospital Chest Pain Clinical Practice Guideline https://pch.health.wa.gov.au/For-health-professionals/Emergency-Department-Guidelines/Chest-pain(viewed 3 Feb 2022)
    3. Children’s Health Queensland Hospital and Health Service Chest Pain Clinical Practice Guideline https://www.childrens.health.qld.gov.au/wp-content/uploads/PDF/guidelines/gdl-00740.pdf(viewed 3 Feb 2022)
    4. Children’s Health Queensland Hospital and Health Service Arrhythmias in Children Factsheet https://www.childrens.health.qld.gov.au/fact-sheet-arrhythmias-in-children/(viewed 3 Feb 2022)
    5. Children’s Health Queensland Hospital and Health Service Cardiac Infections Guidelines https://www.childrens.health.qld.gov.au/chq/health-professionals/antimicrobial-stewardship/guidelines/cardiac-infections/(viewed 3 Feb 2022)
    6. Anne M. Proulx. Paediatric Chest Pain. Am Fam Physician. 2009. 80(6):617-620. https://www.aafp.org/afp/2009/0915/p617.html (viewed 3 Feb 2022)
    7. Turner, A et al. Boerhaave Syndrome Stat Pearls. 2021/ https://www.ncbi.nlm.nih.gov/books/NBK430808/(viewed 3 Feb 2022)
    8. Yaxley, J et al. Eosinophilic oesophagitis – A guide for primary care. 2015. 44(10). https://www.racgp.org.au/afp/2015/october/eosinophilic-oesophagitis-%E2%80%93-a-guide-for-primary-care/ (viewed 3 Feb 2022) 9. Slipping Rib Syndrome. Physiopaedia https://www.physio-pedia.com/Slipping_Rib_Syndrome (viewed 3 Feb 2022)
    9. Pleurisy. Better Health Channel Factsheet https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pleurisy (viewed 3 Feb 2022)
    10. Royal Children’s Hopsital COVID-19 Clinical Practice Guideline https://www.rch.org.au/clinicalguide/guideline_index/COVID-19/ (viewed 3 Feb 2022)