SlideShare a Scribd company logo
1 of 34
Download to read offline
Chest pain in children
Chest pain
• Chest pain is common in children and adolescents.
• Despite the degree of concern that it generates, the
symptom is rarely associated with a serious cardiac
problem.
• The epidemiology of chest pain in youth is not well
understood, although available data suggest more
cases are classified as idiopathic than are attributed to
a more specific etiology (e.g., cardiac, respiratory).
• Studies approximate between 1% and 10% of pediatric
chest pain cases are due to cardiac etiologies.
history and physical Examination
• A properly done history and physical are often
the only tools required in the evaluation of
pediatric chest pain.
• Screening tests are not considered helpful
unless specifically indicated.
• Eliciting the patient’s or family’s concerns
about their complaint may be useful.
• A medical history of asthma, sickle cell disease,
collagen vascular disease, or a recent coughing
illness may be helpful.
• Long-standing diabetes mellitus and chronic
anemias are risk factors for ischemic chest pain.
• Inquire about a history of Kawasaki disease,
including the possibility of an undiagnosed case.
• The review of systems should include inquiries
about associated acute and chronic symptoms
and any precipitating factors.
History
• Inquire about choking episodes, recent trauma,
and exercise or activities that could cause pain
from muscle strain or overuse.
• It is critical to distinguish a history of exercise
(that could cause muscular chest wall pain) from
exercise as a precipitating factor (which may be
consistent with ischemic pain and mandates an
urgent cardiac evaluation).
• Associated syncope is very worrisome and also
mandates a cardiac evaluation.
History
• A medication history could provide clues to a potentially causative
etiology (oral contraceptives) or the possibility of mucosal injury
(e.g., tetracycline, NSAIDs); also investigate the possibility of
substance abuse, especially cocaine and methamphetamine.
• Evaluation of psychosocial factors in the child’s life is very
important.
• Ask about school attendance and performance, relationships with
friends and family, and any current stresses or conflicts.
• The family history should inquire about hypercholesterolemia,
Marfan syndrome, and cardiomyopathy.
• A family history of recurrent syncope or unexplained sudden death
may suggest hypertrophic cardiomyopathy or long QT syndrome.
• Heart disease in an adult family member may provoke anxiety-
related chest pain in a younger person.
History
• A complete thorough physical exam is
necessary; focusing on the chest exam may
miss findings pertinent to a noncardiac
underlying cause of chest pain.
Physical Examination
Etiology
• Musculoskeletal chest wall pain
• Trauma Fracture.
• Skin: herpes zoster
• breast disorders
• Respiratory: Asthma, Pleurisy (pleuritis)
• GIT: Gastroesophageal reflux disease
(esophagitis) Peptic ulcer disease
• Cardiac : Pericarditis & Myocarditis
• psychological disorders
Musculoskeletal
• Costochondritis is pain due to inflammation of the
costochondral joints (where the bony rib meets the
costal cartilage).
• It is a common cause of chest pain in children and is
usually unilateral, sharp, transient in nature, and can
be reproduced by palpation on examination.
• Tietze syndrome, a rare form of costochondritis,
affects a single chostochondral, costosternal or
sternoclavicular joint and causes notable swelling,
tenderness, and warmth localized to the affected joint.
Musculoskeletal
• Other skeletal causes of chest pain include
traumatic injury, spondyloarthritis, and stress
fractures. The latter should be considered in
athletes with repetitive upper extremity motions,
especially in the absence of a recognized acute
traumatic event; a bone scan should be
considered if suspicion is high and x-rays are
negative.
• Chest wall deformities (pectus carinatum, pectus
excavatum) are rare causes of pediatric chest
pain.
• Muscular chest wall pain is common in weight-lifters, but
carrying heavy back packs, severe coughing, and sports
involving rotation or twisting can also be causative.
• Sharp pain in the intercostal muscles can occur with
infection due to coxsackie and other enteroviruses.
• This pain (historically called pleurodynia or Bornholm
disease) is sudden in onset, paroxysmal, and accompanied
by fever and other systemic signs of enteroviral infection
(e.g., vomiting, headache, sore throat).
• Sometimes the illness exhibits a biphasic pattern with a
recurrence of the chest pain and fever several days after
the initial presentation.
Musculoskeletal
Breast Disorders
• Early puberty may cause chest pain related to
breast nodule development in males and
females.
• Other breast disorders including infections,
cystic disorders, pregnancy, and menstrual
swelling may cause chest pain in females.
Shingles (herpes zoster)
• Pain related to shingles (herpes zoster) may
precede the appearance of the rash.
• Children affected by hypersensitivity pain
syndromes may complain of pain with light
touch to their chest wall, or even with wearing
certain clothing; other somatic complaints are
typically present as well.
Asthma
• Chest pain is occasionally the initial presentation of
asthma.
• A history of nocturnal cough, atopy or a remote history of
bronchospasm may support the diagnosis.
• Bronchoconstriction is often reported by children as chest
pain.
• Prolonged cough (due to acute exacerbations or poor
control of asthma) can lead to soreness of chest wall
muscles.
• Asthma also sometimes presents with a complaint of chest
pain with running or exertion (with or without coughing).
• Chest x-ray findings are often normal, but may reveal
hyperinflation, atelectasis, or peribronchial thickening.
Psychogenic chest pain
• It is difficult to clearly define the role of psychological
disorders in cases of pediatric chest pain because of
inconsistent use of valid psychological assessment tools and
differences in research terminology in this area.
• Stress, anxiety, mood disorders, somatoform disorders,
depression, and psychotic disorders have all been
associated with chest pain; the validity of these diagnoses
is impacted by the use (or misuse or nonuse) of appropriate
psychological assessments.
• The psychological impact of organic causes of chest pain on
patients is also poorly defined, even though it is likely very
relevant to patients and families dealing with a serious
medical diagnosis.
• Providers must be cognizant of the importance of
using valid assessments to diagnose psychological
disorders; psychogenic chest pain should never
be a diagnosis of exclusion.
• Hyperventilation typically presents with rapid
breathing, dyspnea, anxiety, and sometimes with
palpitations, chest pain, paresthesias,
lightheadedness, and confusion.
• Careful evaluation often reveals anxiety or
underlying psychological concerns.
Psychogenic chest pain
Precordial catch syndrome
• Precordial catch syndrome (Texidor twinge) is
classically described as a benign condition
characterized by brief paroxysms of sharp, well-
localized pains in the midsternal or precordial
region.
• Episodes are brief (30 seconds to 3 minutes), self-
resolving, and exacerbated by deep breathing.
• Expert opinions vary regarding whether this
phenomenon is a distinct entity, or if it should be
considered an idiopathic etiology of chest pain.
Pericarditis & Myocarditis
• Infections are rare but serious causes of chest pain in
children.
• Chest pain is frequently a prominent symptom in
pericarditis; it is usually exacerbated by lying down or with
inspiration.
• Physical examination findings include a friction rub, muffled
heart sounds, tachycardia, neck vein distention, and pulsus
paradoxus.
• Myocarditis presents with a more subtle but progressive
illness, including fever, chest pain, vomiting, and shortness
of breath. Electrocardiograms are abnormal in each of
these conditions, and cardiomegaly is evident on chest x-
ray.
Pneumothoraces
• Asthma, cystic fibrosis, and connective tissue disorders
(Marfan syndrome, Ehlers-Danlos syndrome, ankylosing
spondylitis) are risk factors for pneumothoraces.
• Pneumonias due to certain pathogens (e.g., Pneumocystis
jirovecii in immunodeficient conditions or staphylococcal,
anaerobic gram negative pathogens) also predispose to the
development of pneumothoraces.
• Healthy children may also develop spontaneous
pneumothorax; cocaine use is a risk factor.
• Forceful vomiting is a rare cause of esophageal rupture
causing pneumomediastinum (Boerhaave syndrome).
• Traumatic or iatrogenic causes should also be considered.
Pleurisy (pleuritis)
• Movement and deep breathing often
aggravate the pain associated with pleurisy
(pleuritis) or pleural effusions.
• Bacterial pneumonias are the most common
cause of pleuritis in children; collagen vascular
disorders can also be causative.
Pulmonary emboli
• Risk factors for venous thrombosis (e.g., oral
contraceptives, recent abortion or surgery
[especially cardiac], the presence of a central
venous line, immobilization, sepsis,
hypercoagulable states, vascular malformations)
should raise suspicion for pulmonary emboli.
• Associated symptoms include dyspnea, cough,
hypoxia, and occasionally, hemoptysis.
• If emboli are suspected, appropriate labs and
imaging (spiral CT or pulmonary angiography)
should be performed.
Slipping rib syndrome
• Slipping rib syndrome is characterized by pain along
the lower rib margin of the upper abdomen,
sometimes associated with a slipping sensation and a
popping or clicking sound.
• Although a clear consensus on the cause of the pain is
lacking, a commonly presumed etiology is that trauma
to the eighth, ninth, or tenth rib causes a sprain-like
injury, which increases the mobility of the rib and
allows impingement on an intercostal nerve.
• Reproduction of the pain by hooking the fingers under
the anterior costal margins and pulling the ribs forward
is characteristic.
GERD (gastroesophageal reflux
disease)
• Symptoms of GERD (gastroesophageal reflux
disease) vary by age; common symptoms in older
children and adolescents are abdominal or
substernal pain, vomiting or regurgitation,
increased pain after meals or when recumbent,
and relief with antacids.
• A trial of empiric therapy is appropriate in
children with typical symptoms, although a
positive response is not confirmatory of GERD
since spontaneous resolution of symptoms (due
to any cause) can occur.
Peptic ulcer disease (PUD)
• Peptic ulcer disease (PUD) frequently
presents with a chronic intermittent history of
dull or aching pain and often includes
nighttime complaints.
• The pain may be epigastric or poorly localized
abdominal pain; it may or may not be relieved
by antacids.
Eosinophilic esophagitis (EoE)
• Eosinophilic esophagitis (EoE) is diagnosed by
endoscopic biopsies showing localized
eosinophilic infiltrates of the esophagus.
• The condition is being increasingly recognized in
all age groups; abdominal pain and vomiting are
more common in younger children and
dysphagia, chest pain, and food impaction are
more likely in adolescents.
• Other atopic diseases and food allergies are
commonly associated.
Cardiac causes
• Consultation with a cardiologist is
recommended because of the potentially
serious (ischemic) nature of chest pain caused
by severe obstructive lesions; it is also
considered a more cost-effective alternative to
obtaining additional studies without
consultation.
• Hypertrophic cardiomyopathy is a genetic disorder
transmitted in an autosomal dominant pattern, although a
large proportion of cases are considered de novo
mutations.
• Classic physical examination findings include a left
ventricular lift and a harsh systolic ejection murmur that is
increased with any maneuver that decreases venous return
(Valsalva maneuver, rising from squatting to standing).
• As the development of hypertrophy is gradual over years,
examination findings in children may be limited to
nonspecific murmurs; cardiac evaluation is indicated
whenever there is a known family history.
• Unless suspected to be asthma, chest pain that is
precipitated by exercise or running or is associated with
syncope or palpitations warrants urgent cardiac
consultation.
• Myocardial ischemia is rare in children overall, although an
increasing number of children are at risk due to advances in
care and treatment of congenital and acquired (Kawasaki)
heart disease.
• Unlike adults with atherosclerotic heart disease, children
do not experience classic angina-type pain (i.e., chest
pressure or squeezing sensation with radiation to neck,
jaws or arms); rather, the symptoms of myocardial ischemia
in younger patients are nonspecific and include irritability,
nausea, vomiting, abdominal pain, failure to thrive, shock,
syncope, seizures, or sudden cardiac arrest.
• The presentation of congenital coronary
artery abnormalities may be subtle or abrupt
with few identifiable risk factors.
• However, children with a history of heart
surgery (e.g., repair of tetralogy of Fallot or
transposition of the great arteries), congenital
heart conditions, or a history of Kawasaki
disease warrant a higher threshold of
awareness for risk of ischemic chest pain.
• Coronary artery anomalies are rare but can be
associated with severe ischemia.
• The physical examination may be normal or may
include tachypnea, tachycardia, pallor,
diaphoresis, distant heart tones, a murmur
consistent with mitral regurgitation, or a gallop
rhythm suggesting myocardial dysfunction.
• Echocardiogram and angiography are used in
diagnosis.
Chest pain in children
Chest pain in children
Chest pain in children
THANKS FOR YOUR
Attention

More Related Content

What's hot

Heart failure in childhood
Heart failure in childhoodHeart failure in childhood
Heart failure in childhoodReyad Al_Faky
 
Haemorrhagic disease of newborn
Haemorrhagic disease of newbornHaemorrhagic disease of newborn
Haemorrhagic disease of newbornRabi Dhakal
 
Respiratory failure in children
Respiratory failure in childrenRespiratory failure in children
Respiratory failure in childrenMohammad Rezaei
 
Necrotizing enterocolitis
Necrotizing enterocolitisNecrotizing enterocolitis
Necrotizing enterocolitisMohamed Fazly
 
Pneumonia in children by dr. sundar karki
Pneumonia in children  by dr. sundar karkiPneumonia in children  by dr. sundar karki
Pneumonia in children by dr. sundar karkiDr. Sundar Karki
 
Heart failure in children
Heart failure in childrenHeart failure in children
Heart failure in childrenAzad Haleem
 
Infective Endocarditis in Children
Infective Endocarditis in ChildrenInfective Endocarditis in Children
Infective Endocarditis in ChildrenMaj Jahangir Alam
 
Approch to cough in children
Approch to cough in childrenApproch to cough in children
Approch to cough in childrenHAMAD DHUHAYR
 
prematurity
prematurityprematurity
prematurityssn zhd
 
Myocarditis in children
Myocarditis in childrenMyocarditis in children
Myocarditis in childrenAzad Haleem
 
Approach to chronic cough in children
Approach to chronic cough in childrenApproach to chronic cough in children
Approach to chronic cough in childrenAzad Haleem
 

What's hot (20)

INFECTIVE ENDOCARDITIS IN CHILDREN
INFECTIVE ENDOCARDITIS IN CHILDRENINFECTIVE ENDOCARDITIS IN CHILDREN
INFECTIVE ENDOCARDITIS IN CHILDREN
 
Heart failure in childhood
Heart failure in childhoodHeart failure in childhood
Heart failure in childhood
 
Haemorrhagic disease of newborn
Haemorrhagic disease of newbornHaemorrhagic disease of newborn
Haemorrhagic disease of newborn
 
Respiratory failure in children
Respiratory failure in childrenRespiratory failure in children
Respiratory failure in children
 
Necrotizing enterocolitis
Necrotizing enterocolitisNecrotizing enterocolitis
Necrotizing enterocolitis
 
Sepsis in children
Sepsis in childrenSepsis in children
Sepsis in children
 
Necrotizing enterocolitis
Necrotizing enterocolitisNecrotizing enterocolitis
Necrotizing enterocolitis
 
hypoxic ischemic encephalopathy
  hypoxic ischemic encephalopathy  hypoxic ischemic encephalopathy
hypoxic ischemic encephalopathy
 
Pneumonia in children by dr. sundar karki
Pneumonia in children  by dr. sundar karkiPneumonia in children  by dr. sundar karki
Pneumonia in children by dr. sundar karki
 
Heart failure in children
Heart failure in childrenHeart failure in children
Heart failure in children
 
Hepatic encephalopathy
Hepatic encephalopathyHepatic encephalopathy
Hepatic encephalopathy
 
Pediatric cardiomyopathy
Pediatric cardiomyopathyPediatric cardiomyopathy
Pediatric cardiomyopathy
 
Hepatitis acute
Hepatitis acute Hepatitis acute
Hepatitis acute
 
Approach to a child with respiratory distress
Approach to a child with respiratory distressApproach to a child with respiratory distress
Approach to a child with respiratory distress
 
Infective Endocarditis in Children
Infective Endocarditis in ChildrenInfective Endocarditis in Children
Infective Endocarditis in Children
 
Approch to cough in children
Approch to cough in childrenApproch to cough in children
Approch to cough in children
 
Hypoxic Ischemic Encephalopathy
Hypoxic Ischemic EncephalopathyHypoxic Ischemic Encephalopathy
Hypoxic Ischemic Encephalopathy
 
prematurity
prematurityprematurity
prematurity
 
Myocarditis in children
Myocarditis in childrenMyocarditis in children
Myocarditis in children
 
Approach to chronic cough in children
Approach to chronic cough in childrenApproach to chronic cough in children
Approach to chronic cough in children
 

Similar to Chest pain in children

Chest pain in children + algoritmo
Chest pain in children + algoritmoChest pain in children + algoritmo
Chest pain in children + algoritmogisa_legal
 
Chest pain cardiac or not Dr Yasser Diab
Chest pain cardiac or not Dr Yasser DiabChest pain cardiac or not Dr Yasser Diab
Chest pain cardiac or not Dr Yasser DiabYasser Diab
 
Pediatric Febrile Seizures اختلاجات دراطفال
Pediatric Febrile Seizures اختلاجات دراطفالPediatric Febrile Seizures اختلاجات دراطفال
Pediatric Febrile Seizures اختلاجات دراطفالDr.Mujeebullah Mahboob
 
Rheumatoid heart disease
Rheumatoid heart diseaseRheumatoid heart disease
Rheumatoid heart diseasePriya
 
Sony downsyndrom
Sony downsyndromSony downsyndrom
Sony downsyndromSony George
 
GROUP 2 RMHN PULMONARY HEART DISEASE.pptx
GROUP 2 RMHN PULMONARY HEART DISEASE.pptxGROUP 2 RMHN PULMONARY HEART DISEASE.pptx
GROUP 2 RMHN PULMONARY HEART DISEASE.pptxLevyChilimunda
 
Chest pain PPT BY Dr bidya sms jaipur
Chest pain PPT BY Dr bidya sms jaipurChest pain PPT BY Dr bidya sms jaipur
Chest pain PPT BY Dr bidya sms jaipurBidyalakshmee Yumnam
 
Clinical tips in cardiovascular emergencies
Clinical tips in cardiovascular emergenciesClinical tips in cardiovascular emergencies
Clinical tips in cardiovascular emergenciesAhmed Mohsen
 
Clinical tips in cardiovascular emergencies copy
Clinical tips in cardiovascular emergencies   copyClinical tips in cardiovascular emergencies   copy
Clinical tips in cardiovascular emergencies copyAhmed Mohsen
 
Sudden unexpected death in infancy
Sudden unexpected death in infancySudden unexpected death in infancy
Sudden unexpected death in infancyAshwini Gowda
 
Rheumatic heart disease sushila
Rheumatic heart disease sushilaRheumatic heart disease sushila
Rheumatic heart disease sushilaSushilaHamal
 
Rheumatic heart disease sushila
Rheumatic heart disease sushilaRheumatic heart disease sushila
Rheumatic heart disease sushilaSushilaHamal
 
Coronary artery disease
Coronary artery diseaseCoronary artery disease
Coronary artery diseaseLih Yin Chong
 
Outpatient medicine
Outpatient medicineOutpatient medicine
Outpatient medicine399195
 

Similar to Chest pain in children (20)

Chest pain in children + algoritmo
Chest pain in children + algoritmoChest pain in children + algoritmo
Chest pain in children + algoritmo
 
Chest pain cardiac or not Dr Yasser Diab
Chest pain cardiac or not Dr Yasser DiabChest pain cardiac or not Dr Yasser Diab
Chest pain cardiac or not Dr Yasser Diab
 
Pediatric Febrile Seizures اختلاجات دراطفال
Pediatric Febrile Seizures اختلاجات دراطفالPediatric Febrile Seizures اختلاجات دراطفال
Pediatric Febrile Seizures اختلاجات دراطفال
 
Rheumatoid heart disease
Rheumatoid heart diseaseRheumatoid heart disease
Rheumatoid heart disease
 
Torticollis
TorticollisTorticollis
Torticollis
 
Sony downsyndrom
Sony downsyndromSony downsyndrom
Sony downsyndrom
 
GROUP 2 RMHN PULMONARY HEART DISEASE.pptx
GROUP 2 RMHN PULMONARY HEART DISEASE.pptxGROUP 2 RMHN PULMONARY HEART DISEASE.pptx
GROUP 2 RMHN PULMONARY HEART DISEASE.pptx
 
Chest pain Ppt by Dr bidya
Chest pain Ppt by  Dr bidya Chest pain Ppt by  Dr bidya
Chest pain Ppt by Dr bidya
 
Chest pain PPT BY Dr bidya sms jaipur
Chest pain PPT BY Dr bidya sms jaipurChest pain PPT BY Dr bidya sms jaipur
Chest pain PPT BY Dr bidya sms jaipur
 
Clinical tips in cardiovascular emergencies
Clinical tips in cardiovascular emergenciesClinical tips in cardiovascular emergencies
Clinical tips in cardiovascular emergencies
 
Clinical tips in cardiovascular emergencies copy
Clinical tips in cardiovascular emergencies   copyClinical tips in cardiovascular emergencies   copy
Clinical tips in cardiovascular emergencies copy
 
Peds Disease.pptx
Peds Disease.pptxPeds Disease.pptx
Peds Disease.pptx
 
Sudden unexpected death in infancy
Sudden unexpected death in infancySudden unexpected death in infancy
Sudden unexpected death in infancy
 
Acute abdominal pain evaluation in emergency department
Acute abdominal pain evaluation in emergency department Acute abdominal pain evaluation in emergency department
Acute abdominal pain evaluation in emergency department
 
Rheumatic heart disease sushila
Rheumatic heart disease sushilaRheumatic heart disease sushila
Rheumatic heart disease sushila
 
Rheumatic heart disease sushila
Rheumatic heart disease sushilaRheumatic heart disease sushila
Rheumatic heart disease sushila
 
Pleural diseases
Pleural diseasesPleural diseases
Pleural diseases
 
Coronary artery disease
Coronary artery diseaseCoronary artery disease
Coronary artery disease
 
Report ps 3
Report ps 3Report ps 3
Report ps 3
 
Outpatient medicine
Outpatient medicineOutpatient medicine
Outpatient medicine
 

More from Azad Haleem

Pediatric Pharmacology:Pharmacokinetics and pharmacodynamics .pptx
Pediatric  Pharmacology:Pharmacokinetics and pharmacodynamics  .pptxPediatric  Pharmacology:Pharmacokinetics and pharmacodynamics  .pptx
Pediatric Pharmacology:Pharmacokinetics and pharmacodynamics .pptxAzad Haleem
 
Neonatal Hypoglycemia approach and Management .pptx
Neonatal Hypoglycemia approach and Management .pptxNeonatal Hypoglycemia approach and Management .pptx
Neonatal Hypoglycemia approach and Management .pptxAzad Haleem
 
Preterm infants Nutrition .pptx
Preterm infants Nutrition .pptxPreterm infants Nutrition .pptx
Preterm infants Nutrition .pptxAzad Haleem
 
Preterm : ABCDE; approach to nutritional assessment in preterm infants.pptx
Preterm : ABCDE; approach to nutritional assessment in preterm infants.pptxPreterm : ABCDE; approach to nutritional assessment in preterm infants.pptx
Preterm : ABCDE; approach to nutritional assessment in preterm infants.pptxAzad Haleem
 
Breastfeeding VS formula feeding .pptx
 Breastfeeding VS formula feeding .pptx Breastfeeding VS formula feeding .pptx
Breastfeeding VS formula feeding .pptxAzad Haleem
 
Role of Supplements in Growth Failure in Children .pptx
Role of Supplements in Growth Failure in Children .pptxRole of Supplements in Growth Failure in Children .pptx
Role of Supplements in Growth Failure in Children .pptxAzad Haleem
 
Degludec Insulin therapy in children
Degludec Insulin therapy in childrenDegludec Insulin therapy in children
Degludec Insulin therapy in childrenAzad Haleem
 
Viral hemorrhagic fevers.pptx
Viral hemorrhagic fevers.pptxViral hemorrhagic fevers.pptx
Viral hemorrhagic fevers.pptxAzad Haleem
 
Micronutrient deficiencies in children .pptx
 Micronutrient deficiencies in children  .pptx Micronutrient deficiencies in children  .pptx
Micronutrient deficiencies in children .pptxAzad Haleem
 
Insulin therapy in children.pptx
Insulin therapy in children.pptxInsulin therapy in children.pptx
Insulin therapy in children.pptxAzad Haleem
 
Diagnostic test for testicular and ovarian disorders in children 2.pptx
Diagnostic test for testicular and ovarian disorders in children 2.pptxDiagnostic test for testicular and ovarian disorders in children 2.pptx
Diagnostic test for testicular and ovarian disorders in children 2.pptxAzad Haleem
 
Diagnostic test for Adrenal disorders in children 2.pptx
Diagnostic test for Adrenal disorders in children 2.pptxDiagnostic test for Adrenal disorders in children 2.pptx
Diagnostic test for Adrenal disorders in children 2.pptxAzad Haleem
 
Diagnostic test for Thyriod disorders in children.pptx
Diagnostic test for Thyriod disorders in children.pptxDiagnostic test for Thyriod disorders in children.pptx
Diagnostic test for Thyriod disorders in children.pptxAzad Haleem
 
Achondroplasia in children.pptx
Achondroplasia in children.pptxAchondroplasia in children.pptx
Achondroplasia in children.pptxAzad Haleem
 
Respiratory Syncytial Virus in children
Respiratory Syncytial Virus in childrenRespiratory Syncytial Virus in children
Respiratory Syncytial Virus in childrenAzad Haleem
 
Growth failure in Children.pptx
Growth failure in Children.pptxGrowth failure in Children.pptx
Growth failure in Children.pptxAzad Haleem
 
Adenoid Enlargement in children.pptx
Adenoid Enlargement in children.pptxAdenoid Enlargement in children.pptx
Adenoid Enlargement in children.pptxAzad Haleem
 
Postbiotics in children
 Postbiotics in children Postbiotics in children
Postbiotics in childrenAzad Haleem
 
Bronchial Asthma in children .pptx
Bronchial Asthma in children .pptxBronchial Asthma in children .pptx
Bronchial Asthma in children .pptxAzad Haleem
 
Fever in Children .pptx
Fever in Children .pptxFever in Children .pptx
Fever in Children .pptxAzad Haleem
 

More from Azad Haleem (20)

Pediatric Pharmacology:Pharmacokinetics and pharmacodynamics .pptx
Pediatric  Pharmacology:Pharmacokinetics and pharmacodynamics  .pptxPediatric  Pharmacology:Pharmacokinetics and pharmacodynamics  .pptx
Pediatric Pharmacology:Pharmacokinetics and pharmacodynamics .pptx
 
Neonatal Hypoglycemia approach and Management .pptx
Neonatal Hypoglycemia approach and Management .pptxNeonatal Hypoglycemia approach and Management .pptx
Neonatal Hypoglycemia approach and Management .pptx
 
Preterm infants Nutrition .pptx
Preterm infants Nutrition .pptxPreterm infants Nutrition .pptx
Preterm infants Nutrition .pptx
 
Preterm : ABCDE; approach to nutritional assessment in preterm infants.pptx
Preterm : ABCDE; approach to nutritional assessment in preterm infants.pptxPreterm : ABCDE; approach to nutritional assessment in preterm infants.pptx
Preterm : ABCDE; approach to nutritional assessment in preterm infants.pptx
 
Breastfeeding VS formula feeding .pptx
 Breastfeeding VS formula feeding .pptx Breastfeeding VS formula feeding .pptx
Breastfeeding VS formula feeding .pptx
 
Role of Supplements in Growth Failure in Children .pptx
Role of Supplements in Growth Failure in Children .pptxRole of Supplements in Growth Failure in Children .pptx
Role of Supplements in Growth Failure in Children .pptx
 
Degludec Insulin therapy in children
Degludec Insulin therapy in childrenDegludec Insulin therapy in children
Degludec Insulin therapy in children
 
Viral hemorrhagic fevers.pptx
Viral hemorrhagic fevers.pptxViral hemorrhagic fevers.pptx
Viral hemorrhagic fevers.pptx
 
Micronutrient deficiencies in children .pptx
 Micronutrient deficiencies in children  .pptx Micronutrient deficiencies in children  .pptx
Micronutrient deficiencies in children .pptx
 
Insulin therapy in children.pptx
Insulin therapy in children.pptxInsulin therapy in children.pptx
Insulin therapy in children.pptx
 
Diagnostic test for testicular and ovarian disorders in children 2.pptx
Diagnostic test for testicular and ovarian disorders in children 2.pptxDiagnostic test for testicular and ovarian disorders in children 2.pptx
Diagnostic test for testicular and ovarian disorders in children 2.pptx
 
Diagnostic test for Adrenal disorders in children 2.pptx
Diagnostic test for Adrenal disorders in children 2.pptxDiagnostic test for Adrenal disorders in children 2.pptx
Diagnostic test for Adrenal disorders in children 2.pptx
 
Diagnostic test for Thyriod disorders in children.pptx
Diagnostic test for Thyriod disorders in children.pptxDiagnostic test for Thyriod disorders in children.pptx
Diagnostic test for Thyriod disorders in children.pptx
 
Achondroplasia in children.pptx
Achondroplasia in children.pptxAchondroplasia in children.pptx
Achondroplasia in children.pptx
 
Respiratory Syncytial Virus in children
Respiratory Syncytial Virus in childrenRespiratory Syncytial Virus in children
Respiratory Syncytial Virus in children
 
Growth failure in Children.pptx
Growth failure in Children.pptxGrowth failure in Children.pptx
Growth failure in Children.pptx
 
Adenoid Enlargement in children.pptx
Adenoid Enlargement in children.pptxAdenoid Enlargement in children.pptx
Adenoid Enlargement in children.pptx
 
Postbiotics in children
 Postbiotics in children Postbiotics in children
Postbiotics in children
 
Bronchial Asthma in children .pptx
Bronchial Asthma in children .pptxBronchial Asthma in children .pptx
Bronchial Asthma in children .pptx
 
Fever in Children .pptx
Fever in Children .pptxFever in Children .pptx
Fever in Children .pptx
 

Recently uploaded

Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxKatherine Villaluna
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxheathfieldcps1
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptxmary850239
 
Presentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a ParagraphPresentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a ParagraphNetziValdelomar1
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptxSandy Millin
 
5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...CaraSkikne1
 
HED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdfHED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdfMohonDas
 
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptxPISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptxEduSkills OECD
 
CapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptxCapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptxCapitolTechU
 
Patterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxPatterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxMYDA ANGELICA SUAN
 
How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17Celine George
 
How to Solve Singleton Error in the Odoo 17
How to Solve Singleton Error in the  Odoo 17How to Solve Singleton Error in the  Odoo 17
How to Solve Singleton Error in the Odoo 17Celine George
 
Ultra structure and life cycle of Plasmodium.pptx
Ultra structure and life cycle of Plasmodium.pptxUltra structure and life cycle of Plasmodium.pptx
Ultra structure and life cycle of Plasmodium.pptxDr. Asif Anas
 
How to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 SalesHow to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 SalesCeline George
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?TechSoup
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxDr. Santhosh Kumar. N
 
How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17Celine George
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxraviapr7
 

Recently uploaded (20)

Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptxPractical Research 1: Lesson 8 Writing the Thesis Statement.pptx
Practical Research 1: Lesson 8 Writing the Thesis Statement.pptx
 
The basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptxThe basics of sentences session 10pptx.pptx
The basics of sentences session 10pptx.pptx
 
3.21.24 The Origins of Black Power.pptx
3.21.24  The Origins of Black Power.pptx3.21.24  The Origins of Black Power.pptx
3.21.24 The Origins of Black Power.pptx
 
Presentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a ParagraphPresentation on the Basics of Writing. Writing a Paragraph
Presentation on the Basics of Writing. Writing a Paragraph
 
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
2024.03.23 What do successful readers do - Sandy Millin for PARK.pptx
 
5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...5 charts on South Africa as a source country for international student recrui...
5 charts on South Africa as a source country for international student recrui...
 
Finals of Kant get Marx 2.0 : a general politics quiz
Finals of Kant get Marx 2.0 : a general politics quizFinals of Kant get Marx 2.0 : a general politics quiz
Finals of Kant get Marx 2.0 : a general politics quiz
 
HED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdfHED Office Sohayok Exam Question Solution 2023.pdf
HED Office Sohayok Exam Question Solution 2023.pdf
 
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptxPISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
PISA-VET launch_El Iza Mohamedou_19 March 2024.pptx
 
Prelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quizPrelims of Kant get Marx 2.0: a general politics quiz
Prelims of Kant get Marx 2.0: a general politics quiz
 
CapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptxCapTechU Doctoral Presentation -March 2024 slides.pptx
CapTechU Doctoral Presentation -March 2024 slides.pptx
 
Patterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptxPatterns of Written Texts Across Disciplines.pptx
Patterns of Written Texts Across Disciplines.pptx
 
How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17How to Use api.constrains ( ) in Odoo 17
How to Use api.constrains ( ) in Odoo 17
 
How to Solve Singleton Error in the Odoo 17
How to Solve Singleton Error in the  Odoo 17How to Solve Singleton Error in the  Odoo 17
How to Solve Singleton Error in the Odoo 17
 
Ultra structure and life cycle of Plasmodium.pptx
Ultra structure and life cycle of Plasmodium.pptxUltra structure and life cycle of Plasmodium.pptx
Ultra structure and life cycle of Plasmodium.pptx
 
How to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 SalesHow to Manage Cross-Selling in Odoo 17 Sales
How to Manage Cross-Selling in Odoo 17 Sales
 
What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?What is the Future of QuickBooks DeskTop?
What is the Future of QuickBooks DeskTop?
 
M-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptxM-2- General Reactions of amino acids.pptx
M-2- General Reactions of amino acids.pptx
 
How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17How to Add a New Field in Existing Kanban View in Odoo 17
How to Add a New Field in Existing Kanban View in Odoo 17
 
Education and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptxEducation and training program in the hospital APR.pptx
Education and training program in the hospital APR.pptx
 

Chest pain in children

  • 2. Chest pain • Chest pain is common in children and adolescents. • Despite the degree of concern that it generates, the symptom is rarely associated with a serious cardiac problem. • The epidemiology of chest pain in youth is not well understood, although available data suggest more cases are classified as idiopathic than are attributed to a more specific etiology (e.g., cardiac, respiratory). • Studies approximate between 1% and 10% of pediatric chest pain cases are due to cardiac etiologies.
  • 3. history and physical Examination • A properly done history and physical are often the only tools required in the evaluation of pediatric chest pain. • Screening tests are not considered helpful unless specifically indicated. • Eliciting the patient’s or family’s concerns about their complaint may be useful.
  • 4. • A medical history of asthma, sickle cell disease, collagen vascular disease, or a recent coughing illness may be helpful. • Long-standing diabetes mellitus and chronic anemias are risk factors for ischemic chest pain. • Inquire about a history of Kawasaki disease, including the possibility of an undiagnosed case. • The review of systems should include inquiries about associated acute and chronic symptoms and any precipitating factors. History
  • 5. • Inquire about choking episodes, recent trauma, and exercise or activities that could cause pain from muscle strain or overuse. • It is critical to distinguish a history of exercise (that could cause muscular chest wall pain) from exercise as a precipitating factor (which may be consistent with ischemic pain and mandates an urgent cardiac evaluation). • Associated syncope is very worrisome and also mandates a cardiac evaluation. History
  • 6. • A medication history could provide clues to a potentially causative etiology (oral contraceptives) or the possibility of mucosal injury (e.g., tetracycline, NSAIDs); also investigate the possibility of substance abuse, especially cocaine and methamphetamine. • Evaluation of psychosocial factors in the child’s life is very important. • Ask about school attendance and performance, relationships with friends and family, and any current stresses or conflicts. • The family history should inquire about hypercholesterolemia, Marfan syndrome, and cardiomyopathy. • A family history of recurrent syncope or unexplained sudden death may suggest hypertrophic cardiomyopathy or long QT syndrome. • Heart disease in an adult family member may provoke anxiety- related chest pain in a younger person. History
  • 7. • A complete thorough physical exam is necessary; focusing on the chest exam may miss findings pertinent to a noncardiac underlying cause of chest pain. Physical Examination
  • 8. Etiology • Musculoskeletal chest wall pain • Trauma Fracture. • Skin: herpes zoster • breast disorders • Respiratory: Asthma, Pleurisy (pleuritis) • GIT: Gastroesophageal reflux disease (esophagitis) Peptic ulcer disease • Cardiac : Pericarditis & Myocarditis • psychological disorders
  • 9. Musculoskeletal • Costochondritis is pain due to inflammation of the costochondral joints (where the bony rib meets the costal cartilage). • It is a common cause of chest pain in children and is usually unilateral, sharp, transient in nature, and can be reproduced by palpation on examination. • Tietze syndrome, a rare form of costochondritis, affects a single chostochondral, costosternal or sternoclavicular joint and causes notable swelling, tenderness, and warmth localized to the affected joint.
  • 10. Musculoskeletal • Other skeletal causes of chest pain include traumatic injury, spondyloarthritis, and stress fractures. The latter should be considered in athletes with repetitive upper extremity motions, especially in the absence of a recognized acute traumatic event; a bone scan should be considered if suspicion is high and x-rays are negative. • Chest wall deformities (pectus carinatum, pectus excavatum) are rare causes of pediatric chest pain.
  • 11. • Muscular chest wall pain is common in weight-lifters, but carrying heavy back packs, severe coughing, and sports involving rotation or twisting can also be causative. • Sharp pain in the intercostal muscles can occur with infection due to coxsackie and other enteroviruses. • This pain (historically called pleurodynia or Bornholm disease) is sudden in onset, paroxysmal, and accompanied by fever and other systemic signs of enteroviral infection (e.g., vomiting, headache, sore throat). • Sometimes the illness exhibits a biphasic pattern with a recurrence of the chest pain and fever several days after the initial presentation. Musculoskeletal
  • 12. Breast Disorders • Early puberty may cause chest pain related to breast nodule development in males and females. • Other breast disorders including infections, cystic disorders, pregnancy, and menstrual swelling may cause chest pain in females.
  • 13. Shingles (herpes zoster) • Pain related to shingles (herpes zoster) may precede the appearance of the rash. • Children affected by hypersensitivity pain syndromes may complain of pain with light touch to their chest wall, or even with wearing certain clothing; other somatic complaints are typically present as well.
  • 14. Asthma • Chest pain is occasionally the initial presentation of asthma. • A history of nocturnal cough, atopy or a remote history of bronchospasm may support the diagnosis. • Bronchoconstriction is often reported by children as chest pain. • Prolonged cough (due to acute exacerbations or poor control of asthma) can lead to soreness of chest wall muscles. • Asthma also sometimes presents with a complaint of chest pain with running or exertion (with or without coughing). • Chest x-ray findings are often normal, but may reveal hyperinflation, atelectasis, or peribronchial thickening.
  • 15. Psychogenic chest pain • It is difficult to clearly define the role of psychological disorders in cases of pediatric chest pain because of inconsistent use of valid psychological assessment tools and differences in research terminology in this area. • Stress, anxiety, mood disorders, somatoform disorders, depression, and psychotic disorders have all been associated with chest pain; the validity of these diagnoses is impacted by the use (or misuse or nonuse) of appropriate psychological assessments. • The psychological impact of organic causes of chest pain on patients is also poorly defined, even though it is likely very relevant to patients and families dealing with a serious medical diagnosis.
  • 16. • Providers must be cognizant of the importance of using valid assessments to diagnose psychological disorders; psychogenic chest pain should never be a diagnosis of exclusion. • Hyperventilation typically presents with rapid breathing, dyspnea, anxiety, and sometimes with palpitations, chest pain, paresthesias, lightheadedness, and confusion. • Careful evaluation often reveals anxiety or underlying psychological concerns. Psychogenic chest pain
  • 17. Precordial catch syndrome • Precordial catch syndrome (Texidor twinge) is classically described as a benign condition characterized by brief paroxysms of sharp, well- localized pains in the midsternal or precordial region. • Episodes are brief (30 seconds to 3 minutes), self- resolving, and exacerbated by deep breathing. • Expert opinions vary regarding whether this phenomenon is a distinct entity, or if it should be considered an idiopathic etiology of chest pain.
  • 18. Pericarditis & Myocarditis • Infections are rare but serious causes of chest pain in children. • Chest pain is frequently a prominent symptom in pericarditis; it is usually exacerbated by lying down or with inspiration. • Physical examination findings include a friction rub, muffled heart sounds, tachycardia, neck vein distention, and pulsus paradoxus. • Myocarditis presents with a more subtle but progressive illness, including fever, chest pain, vomiting, and shortness of breath. Electrocardiograms are abnormal in each of these conditions, and cardiomegaly is evident on chest x- ray.
  • 19. Pneumothoraces • Asthma, cystic fibrosis, and connective tissue disorders (Marfan syndrome, Ehlers-Danlos syndrome, ankylosing spondylitis) are risk factors for pneumothoraces. • Pneumonias due to certain pathogens (e.g., Pneumocystis jirovecii in immunodeficient conditions or staphylococcal, anaerobic gram negative pathogens) also predispose to the development of pneumothoraces. • Healthy children may also develop spontaneous pneumothorax; cocaine use is a risk factor. • Forceful vomiting is a rare cause of esophageal rupture causing pneumomediastinum (Boerhaave syndrome). • Traumatic or iatrogenic causes should also be considered.
  • 20. Pleurisy (pleuritis) • Movement and deep breathing often aggravate the pain associated with pleurisy (pleuritis) or pleural effusions. • Bacterial pneumonias are the most common cause of pleuritis in children; collagen vascular disorders can also be causative.
  • 21. Pulmonary emboli • Risk factors for venous thrombosis (e.g., oral contraceptives, recent abortion or surgery [especially cardiac], the presence of a central venous line, immobilization, sepsis, hypercoagulable states, vascular malformations) should raise suspicion for pulmonary emboli. • Associated symptoms include dyspnea, cough, hypoxia, and occasionally, hemoptysis. • If emboli are suspected, appropriate labs and imaging (spiral CT or pulmonary angiography) should be performed.
  • 22. Slipping rib syndrome • Slipping rib syndrome is characterized by pain along the lower rib margin of the upper abdomen, sometimes associated with a slipping sensation and a popping or clicking sound. • Although a clear consensus on the cause of the pain is lacking, a commonly presumed etiology is that trauma to the eighth, ninth, or tenth rib causes a sprain-like injury, which increases the mobility of the rib and allows impingement on an intercostal nerve. • Reproduction of the pain by hooking the fingers under the anterior costal margins and pulling the ribs forward is characteristic.
  • 23. GERD (gastroesophageal reflux disease) • Symptoms of GERD (gastroesophageal reflux disease) vary by age; common symptoms in older children and adolescents are abdominal or substernal pain, vomiting or regurgitation, increased pain after meals or when recumbent, and relief with antacids. • A trial of empiric therapy is appropriate in children with typical symptoms, although a positive response is not confirmatory of GERD since spontaneous resolution of symptoms (due to any cause) can occur.
  • 24. Peptic ulcer disease (PUD) • Peptic ulcer disease (PUD) frequently presents with a chronic intermittent history of dull or aching pain and often includes nighttime complaints. • The pain may be epigastric or poorly localized abdominal pain; it may or may not be relieved by antacids.
  • 25. Eosinophilic esophagitis (EoE) • Eosinophilic esophagitis (EoE) is diagnosed by endoscopic biopsies showing localized eosinophilic infiltrates of the esophagus. • The condition is being increasingly recognized in all age groups; abdominal pain and vomiting are more common in younger children and dysphagia, chest pain, and food impaction are more likely in adolescents. • Other atopic diseases and food allergies are commonly associated.
  • 26. Cardiac causes • Consultation with a cardiologist is recommended because of the potentially serious (ischemic) nature of chest pain caused by severe obstructive lesions; it is also considered a more cost-effective alternative to obtaining additional studies without consultation.
  • 27. • Hypertrophic cardiomyopathy is a genetic disorder transmitted in an autosomal dominant pattern, although a large proportion of cases are considered de novo mutations. • Classic physical examination findings include a left ventricular lift and a harsh systolic ejection murmur that is increased with any maneuver that decreases venous return (Valsalva maneuver, rising from squatting to standing). • As the development of hypertrophy is gradual over years, examination findings in children may be limited to nonspecific murmurs; cardiac evaluation is indicated whenever there is a known family history.
  • 28. • Unless suspected to be asthma, chest pain that is precipitated by exercise or running or is associated with syncope or palpitations warrants urgent cardiac consultation. • Myocardial ischemia is rare in children overall, although an increasing number of children are at risk due to advances in care and treatment of congenital and acquired (Kawasaki) heart disease. • Unlike adults with atherosclerotic heart disease, children do not experience classic angina-type pain (i.e., chest pressure or squeezing sensation with radiation to neck, jaws or arms); rather, the symptoms of myocardial ischemia in younger patients are nonspecific and include irritability, nausea, vomiting, abdominal pain, failure to thrive, shock, syncope, seizures, or sudden cardiac arrest.
  • 29. • The presentation of congenital coronary artery abnormalities may be subtle or abrupt with few identifiable risk factors. • However, children with a history of heart surgery (e.g., repair of tetralogy of Fallot or transposition of the great arteries), congenital heart conditions, or a history of Kawasaki disease warrant a higher threshold of awareness for risk of ischemic chest pain.
  • 30. • Coronary artery anomalies are rare but can be associated with severe ischemia. • The physical examination may be normal or may include tachypnea, tachycardia, pallor, diaphoresis, distant heart tones, a murmur consistent with mitral regurgitation, or a gallop rhythm suggesting myocardial dysfunction. • Echocardiogram and angiography are used in diagnosis.