Chest pain

PIC Endorsed

Key points

The cause of most paediatric chest pain is unknown or self-limiting causes eg musculoskeletal pain
A serious cardiac or respiratory condition is highly unlikely to be the cause of new-onset chest pain in a previously-well child
The goal of assessment is to rule out serious causes and manage appropriately
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

Trauma patients, those who are critically unwell or have clear signs of cardiorespiratory compromise should have senior staff involved early. See Resuscitation: hospital management of cardiopulmonary arrest, Major paediatric trauma – the primary survey
Offer simple analgesia (eg Paracetamol and Ibuprofen) while you are assessing your patient
Treatment will be cause specific
The flowchart below provides a guide for further management based on the presence of specific risk for serious underlying disease

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

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)

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)

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)

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)

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)

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)

Turner, A et al. Boerhaave Syndrome Stat Pearls. 2021/ https://www.ncbi.nlm.nih.gov/books/NBK430808/(viewed 3 Feb 2022)

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)

Pleurisy. Better Health Channel Factsheet https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/pleurisy (viewed 3 Feb 2022)

Royal Children’s Hopsital COVID-19 Clinical Practice Guideline https://www.rch.org.au/clinicalguide/guideline_index/COVID-19/ (viewed 3 Feb 2022)

The Royal Children's Hospital Melbourne

Clinical Practice Guidelines

Chest pain

See also

Key points

Background

Assessment

History

Risk factors for serious or life-threatening conditions

Examination

Management

Approach to the management of chest pain

Consider consultation with local paediatric team when

Consider consultation with cardiology team when

Consider consultation with relevant specialist team when

Consider transfer when

Consider discharge when

Parent information

Additional notes

Causes

History

Assessment & Investigations

Cardiac

Pulmonary

Musculoskeletal

Gastro-intestinal

Other

Reference List