A 12-year-old boy who recently had a viral upper respiratory tract infection presents with a sharp, substernal chest pain which is relieved by leaning forward but worse on deep inspiration. Examination reveals a pericardial friction rub. There is no murmur and breath sounds were normal. His ECG shows the following changes (figure 3).13

The history of a recent viral infection with a normal respiratory examination makes an infective cardiac cause more likely. The child does not show signs of failure and his ECG does not show any arrhythmias. This makes a diagnosis of myocarditis unlikely. The ECG changes are consistent with pericarditis (table). This child should be treated with ibuprofen and discussed with the cardiology team.

This review presents a number of cases that highlight the key aspects of assessing a child who presents with chest pain. We hope that you now feel more confident in distinguishing the different causes of chest pain in children.

What is the most common cause of chest pain in children?

Asthma.

Musculoskeletal.

Cardiac.

Gastro-oesophageal reflux.

Pulmonary embolism.

What is the most important investigation when seeing a child with chest pain?

Chest X-ray.

Troponin.

ECG.

History.

CT pulmonary angiogram.

Which two features are indicative of benign early repolarisation?

Changes involving only the precordial leads.

Changes occurring in four stages.

Common in athletes and children of Afro-Caribbean origin.

Associated with a pericardial rub.

Occurs above the age of 50.

Which two are red flags for cardiac chest pain?

The presence of ST elevation (<2 mm) in the precordial leads.

History of congenital heart disease.

Associated with chest wall tenderness on palpation.

Exertional syncope.

Improves with ibuprofen.

Which scenarios would you discuss with cardiology?

A 7-year-old child who had a syncopal episode while swimming.

A 13-year-old adolescent who complains of chest pain with chest wall tenderness.

A 6-year-old child who previously had an arterial switch operation as a baby complaining of chest pain.

A 15-year-old adolescent who presents with a 5-month history of right-sided chest pain.

A 14-year-old adolescent who presents with a 3-hour history of chest tightness associated with palpitations and nausea.

Answers to the quiz are at the end of the references.