Clinical Guideline: Management of Chest Pain in Children

Guideline Detail

Board Approval Date: September 2020 Next Review date: September 2022 Status: Contents Summary of Guideline

Aims To improve the diagnosis and management of children with chest pain Objectives To provide evidence-based recommendations for appropriate diagnosis, investigation and management of children with chest pain Background Recurrent chest pain is not uncommon in children and is often accompanied by significant family anxiety. However chest pain in children, compared to adults, is much less likely to be as a result of cardiac pathology1. As such children referred from their general practitioner without any cardiac red flags should be reviewed in the local General Paediatric clinic. Those with red flags should be seen by the local Paediatrician with cardiology expertise who can involve tertiary services as appropriate

Diagnosis Common Paediatric causes include:

 Musculoskeletal strains; costochondritis  Respiratory infection and pleuritic pain.  Exacerbation of asthma  Gastroesophageal Reflux Disease  Precordial "catch"  Anxiety  Idiopathic

Cardiac Red Flags

Past Medical History Family History

Presenting Complaint Past Kawasaki disease Family history of sudden

Exertional Collapse death under 35 years Congenital heart disease

Exertional chest pain Inherited arrhythmias such Acquired heart disease - as long QT syndrome or Connective tissue disorders Brugada in first degree

relatives Homozygous hypercholesterolaemia

Drug History

Cocaine/amphetamine use

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Thorough history and examination CARDIAC RED FLAGS Discuss with on-call Full set of observations Perform an ECG consultant/Local PEC including BP

Treatment / Management

History Diagnoses to consider Management to consider Localised pain and pain on Musculoskeletal Reassurance palpation  Costochondritis Rest Prior physical exertion  Tietze’s syndrome  Precordial catch NSAIDs

 Slipping rib syndrome

Associated with meals Gastrointestinal Reassurance

Reflux symptoms  GORD Practical advice for feeding  Oesophagitis  Gastritis Antacids if persistent

History of anxiety Psychological Reassurance

Recent acute stressful  Psychogenic School nurse event  Anxiety induced hyperventilation Counselling Associated with particular stressors CAMHS

Associated respiratory Respiratory Specific treatment; oxygen/ symptoms & signs bronchodilator/ antibiotics etc  Pneumonia Cough  Pneumothorax Follow up especially if new Wheeze  Asthma diagnosis asthma Shortness of breath

Chest pain assoc. with: Cardiac PEC review +/- Echocardiogram/Exercise test Worse on leaning forward  Pericarditis Anti-inflammatories (NSAIDS) ECG changes  Ischaemia - anomalous coronary - coronary artery disease

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Fever Hematological D/w haematology team

Chest pain  Sickle cell – acute chest syndrome SOB

Audit and Monitoring Compliance This guideline will be audited on an annual basis. The PEC will be responsible for organising the audit in liaison with the network lead.

Audit results will be presented to the Network Board meeting, which will agree actions arising from the recommendations, and monitor the progress of the actions. Conflicts of Interests None Provenance: Authors: Dr J Murphy, Dr M Hayes & Dr R Pramod Clinical condition: Management of chest pain in children Target patient group: Children Target professional group : Paediatricians based in the Yorkshire & Humber Network Evidence Base:

References and Evidence levels: C. Expert consensus.

1. Babu P, Dickson S, Dhar D, et al G167(P) Chest pain in children is rarely cardiac does ecg help? Archives of Disease in Childhood 2015; 100: A71-A72. 2. Collins, S. A., Griksaitis, M. J., & Legg, J. P. (2013). 15-minute consultation: A structured approach to the assessment of chest pain in a child. Archives of disease in childhood-Education & practice edition, edpract 2013 3. http://www.rch.org.au/clinicalguide/guideline_index/Chest_pain/ 4. Bradford Teaching Hospitals –Department of Paediatrics – Management of chest pain in children guideline.

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