of acute anemia and its cause If an intra-abdominal source for chest pain from diaphragmatic irritation is under consideration, a serum amylase may be obtained in the workup of pancreatitis The evaluation of a possible right-sided subdiaphragmatic abscess would include liver function tests and further delineation by ultrasound or CT scan Findings of low PaO2 , EKG abnormalities, and a positive D -dimer are suggestive of pulmonary embolism This suspected diagnosis requires the performance of a helical CT scan for confirmation Esophageal causes of chest pain may often be diagnosed clinically in the ED with a trial of antacid therapy followed by H2 antagonist or proton pump inhibitors To confirm the findings of a hiatal hernia, esophagitis, or a radiolucent foreign body, a barium study or endoscopy may be required The clinician may consider peak expiratory flow testing and/or therapeutic trial of bronchodilators when asthma is suspected as the cause of chest pain Consultation with a pediatric cardiologist acutely for conditions such as myocarditis, pericarditis, acute MI, or significant findings on EKG may be necessary to assist with further workup and tests such as echocardiograms The decision to obtain an urgent echocardiogram depends on the clinical suspicion for diseases such as myocarditis, pericarditis, pericardial effusion, or signs of congestive heart failure Urgent consultation with a pediatric cardiologist should be considered for cases where there is chest pain with palpitations, syncope or chest pain radiating to back, jaw or left arm, patients with high-risk medical history, abnormal physical examination findings such as sustained tachycardia, tachypnea, bradycardia, noninnocent heart murmur, distant heart sounds, gallop, friction rub, increased pulmonic component of heart sounds, edema or swollen extremities or abnormal EKG findings such as low QRS voltages, ventricular hypertrophy, atrial enlargement, AV block, prolonged QTc, (S1, Q3, inverted T3) pattern, PR depression, ST-T segment changes, PVCs, WPW, or delta waves Typically, these patients should also receive a CXR as part of their evaluation Follow-up with a cardiologist, with exercise restriction until follow-up, may also be warranted for a concerning history such as exercise-induced chest pain without other cardiovascular symptoms, significant family history (see discussion under “Child With No Thoracic Trauma”) that places the child at high risk for cardiopulmonary disease, or borderline EKG findings that not meet full criteria for being abnormal Not infrequently, the workup of chest pain including tests such as an EKG or CXR is helpful in allaying parental fears of cardiac disease However, the clinician should be aware that in some cases where a cardiac or respiratory condition is not suspected, ordering unnecessary tests may actually increase a patient’s or parent’s concern that true pathology exists Definitive ongoing management requires referral to a primary care physician SUMMARY Chest pain in children is a relatively uncommon sign of serious disease, but often has great importance to the patient or family Most cases can be diagnosed by the emergency physician from the history and physical examination alone Most all cardiac causes of chest pain can be diagnosed from the full history, physical examination, and EKG Selective use of chest radiography and labs including troponin may be warranted in specific cases The physician should always consider drug-induced chest pain and other life-threatening conditions Patients with a history of exercise-induced chest pain, palpitations and/or syncope, medical history of underlying cardiopulmonary condition, suspected Kawasaki disease, collagen vascular disease, connective tissue disorders, hyperlipidemia, malignancy, thrombophilia, myopathies, history of drug use, oral contraceptive and cigarette use, and family history of sudden death, early coronary artery disease, cardiomyopathy, hypercholesterolemia, hypercoagulability disorders, hyperlipidemia, and pulmonary hypertension appear to be at higher risk of cardiovascular disease and warrant cardiology evaluation Psychogenic chest pain is a common occurrence and may be chronic or related to an acute stressful event The possibility of cardiac disease needs to be addressed directly by the examining physician to alleviate fully the patient’s (or family’s) anxiety The most common causes of organic chest pain are musculoskeletal (traumatic or inflammatory) and infectious disorders, usually self-limited or easily treated diseases Occasionally, serious abdominal, pulmonary, or cardiac problems require immediate attention Suggested Readings and Key References Angoff GH, Kane DA, Giddins N, et al Regional implementation of pediatric cardiology chest pain guideline using SCAMP methodology Pediatrics 2013;132:e1010–e1017 Brown JL, Hirsh DA, Mahle WT Use of troponin as a screen for chest pain in the pediatric emergency department Pediatr Cardiol 2012;33:337–342 Cava JR, Sayger PL Chest pain in children and adolescents Pediatr Clin North Am 2004;51:1553–1568 Dalal A, Czosek RJ, Kovach J, et al Clinical presentation of pediatric patients at risk for sudden cardiac arrest J Pediatr 2016;177:191–196 Drossner DM, Hirsh DA, Sturm JJ, et al Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain Am J Emerg Med 2011;29:632– 638 Friedman KG, Kane DA, Rathod RH, et al Management of pediatric chest pain using a standardized assessment and management plan Pediatrics 2011;128(2):239–245 Hayes D, Jr Chest pain Hemothorax Clin Pediatr (Phila) 2007;46(8):746–747 Hyman PE, Bursch B, Sood M, et al Visceral pain-associated disability syndrome: a descriptive analysis J Pediatr Gastroenterol Nutr 2002;35:663– 668 Johnson NN, Toledo A, Andom EE Pneumothorax, pneumomediastinum and pulmonary embolism Peidatr Clin North Am 2010;57(6):1357–1383 Kane DA, Fulton DR, Saleeb S Needles in hay: chest pain as the presenting symptom in children with serious underlying cardiac pathology Congenit Heart Dis 2010;5:366–373 Khairandish Z, Jamali L, Haghbin S Role of anxiety and depression in adolescents with chest pain referred to a cardiology clinic Cardiol Young 2017;27(1):125–130 Kundra M, Yousaf S, Maqbool S, et al Boerhaave syndrome—unusual cause of chest pain Pediatr Emerg Care 2007;23(7):489–491 Mahle WT, Cambell RM, Favaloro-Sabatier F Myocardial infarction in adolescents Pediatrics 2007;151:150–154 Massin MM, Bourguignont A, Coremans C, et al Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic Clin Pediatr 2004;43:231–238 Neff J, Anderson M, Stephenson T, et al Radiographs in the emergency department utilization criteria evaluation—pediatric chest pain Pediatr Emerg Care 2012;28(5):451–454 Perez-Brandão C, Trigo C, F Pinto F Pericarditis—Clinical presentation and characteristics of a pediatric population Rev Port Cardiol 2019;38(2):97–101 Perry T, Zha H, Oster ME, et al Utility of a clinical support tool for outpatient evaluation of pediatric chest pain AMIA Annu Symp Proc 2012;2012:726–733 Rodriguez-Gonzalez M, Sandchez-Codez MI, Lubian-Gutierrez M, et al Clinical presentation and early predictors for poor outcomes in pediatric myocarditis: a retrospective study World J Clin Cases 2019;7(5):548–561 Sabri MR, Ghavanini AA, Haghighat M, et al Chest pain in children and adolescents: epigastric tenderness as a guide to reduce unnecessary work-up Pediatr Cardiol 2003;24(1):3–5 Saleeb SF, Li WY, Warren SZ, et al Effectiveness of screening for lifethreatening chest pain in children Pediatrics 2011;128(5):e1062–e1068 Walthen JE, Rewers AB, Yetman AT, et al Accuracy of ECG interpretation in the pediatric emergency department Ann Emerg Med 2005;46(6):507–511 Yildirim A, Karakurt C, Karademir S, et al Chest pain in children Int Pediatr 2004;19(3):175–179 ... of pediatric cardiology chest pain guideline using SCAMP methodology Pediatrics 2013;132:e1010–e1017 Brown JL, Hirsh DA, Mahle WT Use of troponin as a screen for chest pain in the pediatric emergency. .. presentation of pediatric patients at risk for sudden cardiac arrest J Pediatr 2016;177:191–196 Drossner DM, Hirsh DA, Sturm JJ, et al Cardiac disease in pediatric patients presenting to a pediatric. .. Myocardial infarction in adolescents Pediatrics 2007;151:150–154 Massin MM, Bourguignont A, Coremans C, et al Chest pain in pediatric patients presenting to an emergency department or to a cardiac