Chest pain in adolescents

In children and in adolescents, chest pain is relatively common and self-limiting. The close association between chest pain, cardiopathies and sudden death is the cause of intense anxiety in boys and their parents and even doctors. The most frequent causes of chest pain, the diagnosis and the eventual treatment are examined. Finally, the causes of chest pain due to drug abuse (in particular cocaine) and to CO poisoning are also examined. Good knowledge of the problem, an accurate anamnesis and a careful objective exam are useful to choose the most suitable treatment.     

Chest pain in children

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 identified 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. Laboratory tests were not helpful in establishing the etiology of chest pain.     

Chest pain in children

Chronic chest pain is a complaint that frequently prompts referral to pediatric cardiology clinics although very few pediatric patients with this symptom will be found to have cardiac disease. This review will discuss the common non-cardiac and cardiac causes of chest pain. Guidelines on the office management of this group of patients will be presented as well as the indications for referring patients for evaluation and treatment by the subspecialist.     

Chest pain, dyspnea on exertion, and exercise induced asthma in children and adolescents

The contribution of maximal exercise tests to the evaluation of 180 patients with chest pain associated with exercise (n = 147) or dyspnea on exertion (DOE, n = 33) was examined. The ages ranged from 5 to 22 (mean 13.2) years, and 68 patients were females. All patients had a normal cardiovascular examination, electrocardiogram, chest x-ray, and 2D-echocardiogram. Maximal exercise tests were performed on a treadmill or bicycle ergometer, and flow volume loops were performed before and after exercise (n = 65). Exercise tests did not reveal any cardiovascular abnormalities, but 14 patients with chest pain (9.5%) and seven patients with DOE (21.2%) developed exercise-induced asthma. Postexercise decrease in peak expiratory flow rate was 26.2 +/- 3.7 percent in patients with chest pain and 39.4 +/- 8.9 percent in those with DOE. Only five patients had a personal history and four others had a family history of asthma. Seven patients had a personal or family history of allergies. Implications: exercise-induced asthma should be considered in pediatric patients with symptoms of chest pain or dyspnea on exertion; when exercise tests are performed, flow volume loops should be included before and after exercise; maximal exercise tests are unlikely to unmask any cardiovascular abnormalities in such patients.     

Chest pain among adolescents with anorexia nervosa

Chest pain is common among adolescents. However, chest pain among adolescents with eating disorders is unique. We report a case of an anorexic adolescent presenting to the emergency room with acute onset of chest pain due to spontaneous pneumomediastinum. The pathophysiology, etiology, and risk factors of chest pain among adolescents with anorexia nervosa are reviewed.     

Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma.

Chest pain in children and adolescents, unlike in adults, is rarely of cardiac origin and its etiology is frequently unknown. In this age group, chest pain can limit normal activity and sports participation. The reported incidence of exercise-induced asthma in children with chest pain is less than 20%. For this study, 88 otherwise healthy children and adolescents with chest pain followed a treadmill protocol without a warm-up period designed to obtain a target heart rate of 180 or greater during the first several minutes of exercise. Patients maintained this workload for 6 to 8 minutes. Pulmonary function tests performed prior to exercise and at 2, 5, 10, 15, 20, and 25 minutes revealed a decrease in forced expiratory volume in 1 second or peak expiratory flow rate of greater than or equal to 15% in 64 (72.7%) children. Inhaled albuterol resulted in subjective improvement in 97% (35/36) and objective improvement in 70% (25/36) of patients. In otherwise healthy children and adolescents with chest pain, the incidence of exercise-induced asthma seems greater than previously reported. Treatment with bronchodilators may help these patients lead a more active life-style.     

Chest pain and dysphagia in adolescents caused by diffuse esophageal spasm

Five adolescents, 13-18 years of age, underwent esophageal manometric studies because of chronic symptoms suggestive of esophageal dysfunction. Four of five patients had episodic nonexertional midchest pain; two patients experienced intermittent dysphagia. The manometric findings for these adolescents were consistent with a primary motility disorder known as diffuse esophageal spasm, a condition not previously reported in this age group. This represents approximately 1% of all pediatric patients undergoing esophageal manometry at our institution for the past 5 years. They have been followed for at least 2 years and three have experienced gradual resolution of their symptoms with normalization of manometric findings. Our report emphasizes two main points: (a) Diffuse esophageal spasm may cause chest pain and dysphagia in adolescents; and (b) the clinical history and esophageal manometric findings establish the diagnosis of diffuse esophageal spasm.     

Chronic chest pain in children and adolescents

Chest pain is a common symptom of older children and adolescents. The majority of the conditions causing it are benign and self-limiting. Almost all diagnoses can be made with a thorough history and physical examination. Most important, the patient and parents need to be assured that there is no heart defect and that there is no imminent danger of dying.     

Complex regional pain syndromes in children and adolescents

Background: The purpose of the present paper was to assess efficiency of treatment and long-term functional outcome of complex regional pain syndromes (CRPS) in children who were treated in the chronic pain clinic at a major tertiary hospital in Israel.
Methods: The files of 14 children with CRPS were analyzed retrospectively. Demographic data, initiating event, referring source, time needed for referral to pain clinic, clinical evaluation, treatment, recurrence and complications were recorded.
Results: Fourteen children with CRPS types I and II were included in the study. Girls were affected in 71%. Lower extremities were affected in 57%. The median time from onset of symptoms to seeking medical help was 4.46 weeks (range 2–82 weeks). The median time to referral to pain clinic was 24.51 weeks (range 1.2–94). In 45% the referral source was the pediatrician. A total of 85.8% of patients were referred to various consultations before the pain clinic. Most children had reduced pain and improved function on non-invasive treatment approach. Invasive treatments were used in 28.5%. Full or partial recovery was accomplished in 93%. Recurrence was observed in 29%.
Conclusions: CRPS in children and adolescents is still underdiagnosed, although many of the epidemiologic features of pediatric CRPS are similar in different countries/cultures. Early recognition and management is the major factor in improving outcome and preventing resistant CRPS, but even children with delayed diagnosis still have a good outcome. The management of this disease by an experienced multidisciplinary team is recommended. Because psychosocial factors play an important role, it is recommended to provide psychological evaluation and cognitive behavioral treatment as soon as possible.     

Pharmacologic management of pain in children and adolescents

In the management of chronic pain conditions, the combination of pharmacologic measures with physical and psychologic modalities becomes even more important. A pain clinic and pain consultation service are one model that facilitates this combined approach. Initial management of mild to moderate pain begins with nonopioid analgesics such as acetaminophen and NSAIDs. Persistent severe pain of a neuropathic character merits careful trials of antidepressants or anticonvulsants. Traditionally, use of opioids for chronic pain not due to cancer has been discouraged for adults as well as children. Recently, this view was challenged by reports by Portenoy and Foley and by Taub, who followed a group of adults with chronic pain due to a variety of conditions. They found that the majority of these patients, if managed with opioids on a regular schedule as part of an overall treatment program, could be made comfortable and were able to increase their level of functioning for several years. In general, dosage escalation and compulsive drug-seeking behaviors were not seen. Since this report was retrospective and did not involve children, caution must be applied in extrapolating these findings to children. For example, remarkably little is known about the effects of chronic opioid administration in childhood on growth and development. Certainly, this issue deserves further study before general recommendations can be made. It seems prudent to emphasize the importance of maximizing nonpharmacologic and nonopioid approaches in the management of chronic pain in children prior to embarking on long-term use of opioids.     

Chest pain in children referred to a cardiology clinic

One hundred consecutive patients (54 girls, 46 boys) referred to a pediatric cardiology department with the primary complaint of chest pain were evaluated. The age distribution was 2.5–16.0 years (mean 11.3 years for girls and 9.9 years for boys). The history showed 17% of patients with chest pain, 22% with heart disease, and 19% with recent death in the family. The time course of the pain was longer than 1 week in 92 patients. Localization was on the left precordium in 60 patients, and there was no radiation from the original site in 66 cases. Ninety-two percent of cases were idiopathic in origin. Of the 74 patients who had a psychiatric interview, 55 (74%) had psychiatric symptoms and 5 required psychiatric care. Anxiety, conversion disorder, and depression were the main psychiatric symptoms.     

Chest pain in children. Follow-up of patients previously reported

During a 1-year period, 407 children with chest pain were seen in the Emergency Department of Children's Hospital of Philadelphia. Analysis of the clinical data of these children was reported previously. The authors successfully followed 149 of these children for 6 months or more, and 51 for 2 years or more. These patients returned for an average of 3.4 visits during the follow-up period. Thirty-four percent of the initial diagnoses were altered. Usually, during the follow-up period, the authors concluded that chest pain resulted from nonorganic causes. A new organic etiology was uncovered in only 12 of 149 cases. Only 1 child was found to have a heart abnormality (mitral valve prolapse), and 3 were found to have asthma. Chest pain did not resolve during the follow-up period in 43 percent of those followed. Children with chest pain should have follow-up care because of the persistence of symptoms, but serious disease is unlikely to be found over time.     

Epidemiology of low back pain in children and adolescents

It has been estimated that over 80% of the population will report low back pain (LBP) at some point in life, and each year 7% of the adult population consult their GP with symptoms. Prevalence increases with age, reaching a peak during the sixth decade of life. Until recently little was known about LBP at young ages. Clinically it was perceived to be uncommon-with few children consulting because of LBP in primary care. Large prospective epidemiological studies have shown that, in those free of LBP at baseline, the best predictor of future onset is a previous history of LBP. Therefore, to understand the epidemiology of LBP, and what predisposes someone to a trajectory of LBP in adult life, it is important to examine the condition at young ages, to determine factors responsible for onset of initial episodes, and to examine whether LBP in childhood is related to symptoms in adulthood.     

Chest pain in children: diagnosis through history and physical examination.

INTRODUCTION: Chest pain is a common complaint in the pediatric age group and can be a physically and emotionally distressing symptom. Although chest pain in children rarely indicates serious cardiac problems, chest pain is perceived as "heart pain" to most children and their families and presents a diagnostic challenge to health care providers. METHODS: A prospective study was conducted to identify specific factors in history taking and physical examination that permit accurate diagnosis of the cause of pediatric chest pain. Fifty children (ages 5-21 years; mean, 13 years), referred to the cardiology clinic with the chief complaint of chest pain, underwent systematic history taking, physical examination, and electrocardiogram testing. RESULTS: The following diagnoses were made: 38 children (76%) had musculoskeletal/costochondral chest pain, 6 children (12%) had exercise-induced asthma, 4 children (8%) had chest pain resulting from gastrointestinal causes, and 2 children (4%) had chest pain resulting from psychogenic causes. DISCUSSION: All the children in this study had noncardiac causes of their chest pain. This finding supports previous research suggesting that chest pain in children is rarely of cardiac origin. This article reviews the causes of pediatric chest pain and suggests an approach to its evaluation and management.     

Epidemiology of low back pain in children and adolescents.

It has been estimated that over 80% of the population will report low back pain (LBP) at some point in life, and each year 7% of the adult population consult their GP with symptoms. Prevalence increases with age, reaching a peak during the sixth decade of life. Until recently little was known about LBP at young ages. Clinically it was perceived to be uncommon-with few children consulting because of LBP in primary care. Large prospective epidemiological studies have shown that, in those free of LBP at baseline, the best predictor of future onset is a previous history of LBP. Therefore, to understand the epidemiology of LBP, and what predisposes someone to a trajectory of LBP in adult life, it is important to examine the condition at young ages, to determine factors responsible for onset of initial episodes, and to examine whether LBP in childhood is related to symptoms in adulthood.     

Chest pain in pediatrics

Chest pain in the pediatric population is a common and mostly benign occurrence. A thorough history and physical examination are usually all that are necessary in excluding the rare, life-threatening causes of chest pain. These rare, life-threatening events require immediate evaluation, treatment, and subspecialty consultation. Idiopathic chest pain is the most common diagnosis, and the symptoms are typically chronic. laboratory testing is usually nondiagnostic, costly, and burdensome to patients and therefore unnecessary. A long-term, trusting relationship with the patients and their families is needed to reassure them and allow symptoms to resolve.     

Japanese clinical guidelines for chronic pain in children and adolescents

Chronic pain is a common problem in pediatric practice. The prevalence of chronic pain in children is >30%. Because pain indicates emotional expression as well as the physiological reaction toward infection, injury, and inflammation, both physiological and psychological assessments are essential to determine primary interventions for chronic pain. The Japanese Society of Psychosomatic Pediatrics Task Force of clinical practice guidelines for chronic pain in children and adolescents compiled clinical evidence and opinions of specialists associated with the primary care of pediatric chronic pain in the Japanese ‘clinical guidelines for chronic pain in children and adolescents’ in 2009, which are presented herein. The guidelines consist of three domains: general introduction to chronic pain; chronic abdominal pain; and chronic headache. Each section contains information on the physiological mechanism, psychological aspects, assessment methods, and primary interventions for pediatric chronic pain. These guidelines are expected to help disseminate knowledge on primary interventions for chronic pain in children and adolescents.