This document discusses pediatric chest pain, reviewing potential cardiac and non-cardiac causes. It outlines "red flags" that should prompt further cardiac workup, such as pain with exertion or a family history of sudden cardiac death. Three often missed chest wall syndromes are described in detail: Precordial catch syndrome, xiphodynia, and slipping rib syndrome. The document emphasizes taking a thorough history and physical exam to determine the likely etiology and appropriate workup and management for pediatric chest pain.

1. Pediatric Chest Pain
Frank W Meissner MD RDMS RCDS FACP FACC FCCP FASNC FACEP FAIMA CPHIMS CCDS ADHD-
CCSP
Adult - Child & Adolescent Psychiatrist

3. Th
Thought For Today!

4. Goals
Review differential diagnosis of pediatric chest pain
‘Red flag’s warnings that alert to cardiac sources
Review an evidence based cost-effective workup
Review three often missed chest wall syndromes
Precordial Catch Syndrome
Xiphodyna
Slipping Rib Syndrome

5. The Central Problem Of Chest Pain
Evaluation
Visceral Pain System is Poorly Localized in CNS
SO
Any Pain To Any Visceral Structure Can Fell Like
Heart Pain

6. Chest Pain in Kids
7th of common reasons for consulting a practitioner
Chronic in 1/4 to 1/3 of children
40% miss school
70% have activities restricted
In adolescents
44% think they are having a heart attack
12% think they have serious heart disease
12% think they have cancer

7. 16 y/o Hispanic Male presents with pleuritic sub-sternal chest pain
He developed the pain 2 D’s after swimming with his father
The pain was continuous, moderate intensity, pleuritic and positional, non
exertion in nature
No chronic medical problems
He gave a history of having a race with his father to see how fast he could go
from the deep end of the pool to the surface of the water
An Illustrative But
Unusual Case of
Pediatric Chest
Pain

8. Pain
Cardiac
MI/Angina
Pericarditis /Myocarditis
Arrhythmia esp Pathological Tachycardia’s
Cardiomyopathies
Endocarditis
Gastrointestinal
GERD/Gastritis
Nutcracker esophagus
Esophageal foreign body
Caustic Ingestion
Splenomegaly/Mononucleosis
Miscellaneous
Malignancy
Rheumatological Disease (SLE/KD)
Toxic/Ilicit Drugs (Cocaine/Methamphetamine
Musculoskeletal/Skin
Chest Wall Contusion
Costochondritis
Slipping Rib Syndrome
Pericardial ‘Catch’ Syndrome
Xiphodynia
Herpes Zoster
Pulmonary
Asthma
Pneumonia
Pneumothorax (spontaneous)
Pulmonary Embolus
HbSS/Acute Chest Syndrome
Barotrauma
Psychiatric
Panic attacks/anxiety
Psychosomatic
Malingering
Depression

9. Cardiac Causes of Chest Pain
In Pediatric Age Group
~ 1-5% have a cardiac etiology
Missed Cardiac diagnosis could be fatal
Retrospective Chart Review - Pediatric ED - Jan 2005 -
Nov 2008
Age < 19 yrs with Chief Complaint of Chest Pain
Excluded patients with known prior cardiac dz
N=4,2888
4264 (99.4%) non-cardiac Chest Pain
24 (0.6%) Cardiac Related Chest Pain
Drossner, DM et al. Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain. AJEM 2011(29), 632-8

10. Cardiac Etiologies In Study

11. “Red Flags”
History
Pain with Exertion, Dyspnea with Exertion, Exertional Syncope*
Pain Radiating to Back, Jaw, Left Arm, or Shoulders
Increasing Pain with Supine Position
Chest Pain with Fever
Past Medical History
Hx/o Systemic Inflammatory Disease, e.g. rheumatological/vasculitits
Hx/o hyper-coagulable state
Hx/o malignancy
Family History (1st Degree Relative (Parents, Sibs))
SCD
Cardiomegaly
Hyper-coagulable state

12. “Red Flags”
Physical Examination
Grossly Abnormal Vital Signs
Cardiac Examination
Pathological Murmur, Gallop Rhythm, Pericardial Rub
Diminished Femoral Pulses
Persistent/Unexplained Tachycardia
Presence of Holo-systolic Murmur, JVD
Pulmonary
Focal/absent Lung Sounds
Crackles
Extremities
Peripheral Edema

13. Workup
Detailed Pain History
Location, Character, Duration****, Precipitants, Aggravating Factors,
Palliating Factors, Radiation Pattern, Associated Symptoms of
Ischemia
Detailed Family History of Primary Family (Parents, Sibs)
Substance Use History Especially Therapeutic and Recreational
Stimulants
Careful Physical Examination
(+) EKG & Chest X-ray >98% will establish etiology
Little Yield From Biochemical Testing
POC U/S (echo highly useful tool - but requires detailed training and
lots of proctored examinations

14. Chest Pain With Normal Physical Examination

15. Chest Pain With Abnormal Physical Examination

16. ****
**** Synovitis, Acne, Pustulosis, Hyperostosis, and Ostetis Syndrome

17. Precordial Catch Syndrome
Made by history
Originally described in 1955 by Miller and Trexidor
Stabbing, shooting, needle-like, or knife-like
Highly localized - Pxts can locate area of pain with 1-2
fingers generally centered in L parasternal border, right
anterior chest
Causes the patient to hold breathe or have shallow
breath
Duration of pain is brief, transient, < 3 minute
Can have a dull ache as a stigmata lasting for mins to
hours

18. Xiphodyna
Never Thought About Cause of
Chest and Upper Abdominal Pain
Diagnosis is Established By
Reproduction of Pain with
Moderate Intensity of
Pressure on the Xiphoid
process
Certain Diagnosis If Pain Is
Relieved by Injection of
Xiphoid Process with
Combination of
Lidocaine/Marcaine/Kenalog
Red Color represents Muscle Attachments

19. Slipping Rib Syndrome
Often misdiagnosed
1st described in 1919
Classically patients c/o sharp stating pain followed by dull aching sensation for hours to days
Slipping sensations or popping sensations are commonly experienced with activities such as
bending, coughing, deep breathing, lifting, reaching, rising from a chair, stretching, or turning in bed
Etiology is hyper-mobility of the lower ribs (8-10) due to weakness of the rib-sternum, rib-cartilage
and/or rib-vertebral ligaments
Diagnosis is with the use of the Hooking Maneuver
Placing your fingers under the lower costal margin and pulls the hand in an anterior direction
Pain or a clicking sensation = (+) test
Rib block which relieves the pain is confirmatory for the diagnosis