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Letter to the Editor

To the editor: We read with interest the excellent article by Massin et al on chest pain in children.1 The authors analyzed the etiology to chest pain and the diagnostic workup of 168 consecutive children seen in their emergency department with the primary diagnosis of chest pain over a 5-year period. Chest wall pain was present in 64% of the patients. Other causes included pulmonar y (13%), psychological (9%), cardiac (5%), traumatic (5%), and gastrointestinal (4%) problems. The organic causes were easily identified or suspected by history and physical examination. Chest radiography, electrocardiography (ECG), and blood analysis were performed in most patients with suspected nonorganic chest pain, but in no case were organic diseases diagnosed by those ancillary studies. Likewise, we analyzed the etiology and diagnostic workup of all children who presented to the emergency department of the Alberta Children’s Hospital between April 1, 1993, and July 31, 1994, with a primary complaint of chest pain.2 There were 115 (46 males and 69 females) patients in the study. The mean age of the patients was 7.8 years (S.D ± 1.2). Sixty patients (52%) did not have laboratory, ECG, or radiologic investigations. Of the 33 chest radiographs that were ordered, 30 were reported by the radiologist as appearing normal. ECGs were performed on 18 patients (16%), and of these 14 were interpreted as appearing normal by a pediatric cardiologist. The etiologies of chest pain in these 115 patients were as follows: chest wall pain (48.7%), respiratory disease (7%), cardiac disease (1.7%), psychogenic cause (2.6%), and idiopathic (40%). We agree with Massin et al that organic causes of chest pain are usually musculoskeletal in origin and most likely secondary to muscle strain.2,3 Muscle strain may result from strenuous exercise or direct trauma to chest. Idiopathic chest pain is a common cause of chest pain in children, accounting for 20–45% of all cases in most studies.2-4 In our study, this comprised 40% of our study population. Chest pain in the pediatric age group is rarely cardiac in origin. We recommend that the best tools that the attending physician has to determine the true etiology of chest pain are a thorough history and physical examination.2 The patient history should include the onset, location, type, duration, severity, and frequency of the chest pain. Other characteristics such as radiation of pain, associated symptoms, precipitating or relieving factors, recent trauma, strenuous exercise, and drug use should also be solicited. A good history should encompass a past medical history, family history, as well as the existence of any potential social stresses. The physical examination should be thorough and must include light and deep palpation of the chest wall. Chest wall tenderness is a major clinical finding in patients with noncardiac chest pain and is often bilateral, in the midclavicular line, best elicited with fingertip pressure to the costochondral junctions and the rib margins.2,3 We have also demonstrated that laboratory testing is of limited value in the assessment of chest pain in children.2 These should be ordered only when indicated by the history or physical examination. Chest radiography is generally considered useful if the history or physical examination suggests significant trauma or in the setting of suspected pulmonary or cardiac disease. An ECG is indicated in the clinical setting of arrhythmia, significant heart murmurs, or abnormal heart sounds or when structural heart disease, myocardial ischemia, myocarditis, or pericarditis is suspected.