Investigation of the Presence of Atopy in Pediatric Patients Visiting the Pediatric Cardiology Department due to Chest Pain

doi:10.21203/rs.3.rs-1987478/v1

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Investigation of the Presence of Atopy in Pediatric Patients Visiting the Pediatric Cardiology Department due to Chest Pain

https://doi.org/10.21203/rs.3.rs-1987478/v1

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Background

Chest pain is one of the important reasons for hospital admissions among children. However, it is known that the cause of chest pain is mostly not because of cardiac origin

Objectives

It was aimed to investigate asthma and other atopic diseases in children with chest pain that is not originated from cardiac problems.

Patients and Methods:

Children aged 6–18 years who were investigated for chest pain in the pediatric cardiology and pediatric allergy-immunology departments were included in the study. Hematological parameters, pulmonary function tests and skin prick tests were performed. Atopic diseases and existence of environmental factors (smoking exposure, presence of pet, stove use, wool use and mold) had been questioned.

Results

The non-cardiac chest pain group (Group 1) included 88 children (female: 53.4%) and mean age of 11.92 ± 3.35 years; the control group (Group 2) included 29 children (female: 53.8%) and 11.38 ± 1.95 years (p > 0.05). Family history of atopy (22.72%) and skin prick test positivity (28.4%) were higher in group 1 than group 2 (p = 0.006; p = 0.017 respectively). The presence of environmental factors except mold was significantly higher in group 1 (54.5%) than group 2 (3.4%) (p = 0.000). Asthma and allergic rhinitis were diagnosed in 44.32% and 9.09% of them. Idiopathic chest pain, musculoskeletal system disorders, gastroesophageal reflux and pneumonia were found in 23.86%, 11.36%, %7.95 and 3.41% of group 1 respectively.

Conclusions

In this study, the most common cause of non-cardiac chest pain was asthma, while idiopathic chest pain was the second most common. A detailed history and careful physical examination will accurately establish the cause of chest pain in most children.

asthma

atopy

chest pain

Chest pain is one of the important reasons for hospital admissions among children [1]. In addition, it is the second reason for referral to a pediatric cardiologist after murmur [1]. However, it is known that the cause of chest pain is mostly not because of cardiac origin [1-3]. Chest pain due to cardiac disorder was reported below 4% overall [1,4,5]. In order to find the main cause, the patient's complaints should be questioned in detail. It was reported that among the most common causes of chest pain in children are idiopathic. However, many pathologies such as musculoskeletal system and respiratory system disorders are some other factors that result in chest pain in children [1,4]. Chest pain and chest tightness are self-limiting conditions that can occur in respiratory system diseases and may occur during asthma attacks, yet the diagnosis can be confused [6,7]. Asthma is one of the most common chronic respiratory diseases in children, occurring with different symptoms [8]. It is characterized by airway obstruction, airway hypersensitivity, shortness of breath, chest tightness and cough [9].

The main purpose of this study was examination of asthma and other atopic diseases of the patients along with their clinical findings who has chest pain that is not originated from cardiac problems.

The study was approved by the local ethics committee (study identification number: E-46418926-050.01.04—69151). The follow-up study was conducted between June, 2021 and January, 2022. This study was carried out in accordance with the ethical standards specified in the 1964 Declaration of Helsinki. All patients or their parents gave their informed consent to be a part of the study. Among the patients applied the pediatric cardiology department with chest pain, those aged 6-18 years were selected. Patients with chest pain of cardiac origin after detailed physical examination, 12-lead electrocardiography and echocardiographic examination were excluded from the study. Patients with non-cardiac chest pain were referred to the pediatric allergy and immunology (PAI) department.

After physical examination and a detailed anamnesis in terms of atopic disease in the PAI department, complete blood count (CBC), total Immunoglobulin E (IgE) levels, pulmonary function tests (PFT) and skin prick tests (SPT) were performed. Hemoglobin (Hb), hematocrit (Htc), mean corpuscular volume (MCV,) white blood cell (WBC), eosinophil (Eos) and platelet (Plt) counts were taken from the CBC results.

All participants and their families had been questioned in terms of asthma, other atopic diseases and existence of environmental factors (smoking exposure, presence of pet, stove use, wool use and mold).

Asthma was diagnosed and treated with reference to the Global Initiative for Asthma (GINA) protocols [8]. The diagnosis of asthma is based on variability in respiratory symptoms, hypersensitivity in respiration and limitation of expiration (FEV1: forced expiratory volume 1). Spirometry results may sometimes not be compatible with asthma. In this case, the diagnosis of asthma was made with signs of improvement after treatment [8,10,11].

All participants underwent SPT with inhalant allergens [grass pollens, tree pollens, weed pollens, house dust mites [HDM], molds, and animal dander] and food allergens (egg mix, cow milk, beef, chicken, soya flour, wheat flour, rice flour and cacao).

Children who did not have chest pain and no cardiac pathology, who applied to the pediatric cardiology department due to participation in sports, and who agreed to participate in the study were included in the control group. Those with chronic diseases other than atopic disease and those who had a psychiatric disease at any time were not participated in the study.

Childhood asthma control test (C-ACT) was used to evaluate asthma control process of pediatric patients in the last month. C-ACT was made in 2007 by Liu et al [12] and Turkish version was done in 2009 [13]. The level of control in asthma was reported as "controlled" and "poorly controlled" based on C-ACT scores.

Statistical analysis

Descriptive statistics for continuous variables are expressed as mean, standard deviation, minimum and maximum values expressed as numbers and percentages for categorical variables. Kolmogorov-Smirnov and Shapiro-Wilk normality tests were performed to determine whether the data were suitable for normal distribution. Statistical analyzes of the data belonging to the normally distributed variables as a result of the normality test were performed with the Student t test in two independent groups, and the statistical analyzes of the data belonging to the variables that did not show normal distribution were made with the Mann-Whitney U test in two independent groups. Categorical variables were compared with the chi-square test (Fisher's exact). Results were given as mean±SD with 95% confidence interval, significance was evaluated at the p<0.05 level. SPSS 23.0 (IBM SPSS statistics 22) package computer program was used to analyze the data statistically.

A total of 105 patients who applied to the pediatric cardiology department with chest pain were evaluated. 3 patients (2.86%) with mitral valve prolapse were excluded and another 102 patients without cardiac problems were referred to the PAI department. Among the participants, 4 patients with chronic diseases, 3 patients with active systemic infections and 7 patients who did not come for control were excluded from the study (Figure 1).

The non-cardiac chest pain group (Group 1) included 88 (female: 53.4%) and mean age of 11.92 ± 3.35 years; the control group (Group 2) included 29 children (female: 53.8%) and 11.38 ± 1.95 years. There was no difference between the groups in terms of age and gender (p>0.05) (Table 1).

Hematological parameters and total IgE levels were not different between the groups (p>0.05). In group 1, 53 (60.2%) of the children who were able to perform PFT had normal FEV1 and 18 (20.5%) had low values (FEV1: 60-80). The results were normal in all of the children who were able to perform PFT in the group 2. Lower values were significantly higher in group 1 than in group 2 (p=0.014) (Table 1).

The presence of environmental factors was significantly higher in group 1 (54.5%) as compare to group 2 (3.4%) (p<0.0001). In group 1, smoking exposure (36.4%), wool use (25%), presence of pet (23.9%), and stove use (13.6%) were significantly higher than group 2 (p=0.001, p=0.003, p=0.004, and p=0.039, respectively). There was no difference between the two groups in terms of the presence of mold (p=0.243) (Table 2).

In Group 1, there were 20 patients (22.72%) whose mother, father or sibling had atopic disease. In group 2, there was no history of family atopy. There was a significant difference between groups in in this respect (p=0.006) (Table 2).

SPT was positive in 28.4% of patients in group 1 which was significantly higher than group 2 (6.9%) (p=0.017). Of 25 patients; 7 were sensitized to tree mix pollens, 5 to HDM, 5 to soya flour, 3 to grass pollens, 3 to cat, 2 to dog, 1 to milk and 1 to beef (Table 2).

When the patients in group 1 were evaluated in terms of additional complaints in PAI department, shortness of breath (40.90%) and cough (11.36%) were the most common complaints. Nasal congestion (9.09 %), sneeze (7.95%), gastroesophageal reflux (GER) symptoms (7.95%), effort dyspnea (5.68 %) palpitation (5.68%), itchy nose (3.40 %) and snoring (2.27%) were also seen to a lesser extent (Table 3). When the histories of the patients were questioned, it was learned that 12 (13.63%) had asthma, 9 (10.22%) had AR, 7 (7.95%) had GER, and 17 (19.3%) had both AR and adenoid vegetation at any point in their lives (Table 3). According to the detailed clinical history and physical examination of the patients, asthma and AR were diagnosed in 39 (44.32%) and 8 (9.09%) of them. Except for atopic diseases, idiopathic chest pain, musculoskeletal system disorders, GER and pneumonia were found in 23.86%, 11.36%, %7.95 and 3.41% of patients respectively (Table 3). In patients diagnosed with asthma and AR, while SPT positivity was found to be significantly higher in AR (5 of 8 patients with AR, p=0.027 and 8 of 39 patients with asthma, p=0.679), no difference was observed between them in terms of IgE levels (p>0.05).

Appropriate treatments were given to those with asthma, AR, GER and pneumonias. In the follow-up after 1 month, it was observed that the complaints of all but 5 of the patients were completely resolved. Although the complaints of 5 patients (3 with asthma, 2 with GER) decreased, they did not completely resolve. 36 patients given asthma treatment were “controlled” and 3 patients were “poorly controlled” according to C-ACT.

In this study, non-cardiac chest pain in children was evaluated in terms of atopic diseases. It was found that approximately half of the patients had asthma and nearly 10% had AR. These findings have important implications because chest pain in children is one of the important reasons for applying to both the ED and the pediatric cardiology department [1,4,5,14]. Majority of patients and their families assume that their child's chest pain is of cardiac origin.15 On the other hand, most children with chest pain are not severe, and for most, the pain is not acute in nature.16 Furthermore, cardiac causes can be detected in very few of them [1,4,5,14]. Similar to previous studies [1,4,5], cardiac-induced chest pain was found to be less than 4% in this study. Therefore, other possible causes of chest pain should be investigated.

In previous study in which 50 patients presented with chest pain, costochondral/musculoskeletal chest pain, exercise-induced asthma, gastrointestinal-related chest pain, and psychogenic chest pain were detected in 76%, 12%, 8%, and 6% of children respectively [17]. In the study of Li et al, 103 patients who applied to the ED with chest pain were examined in detail [14]. While idiopathic chest pain was the most common, pulmonary causes (bronchitis, pneumonia, asthma, and hyperventilation) were seen in the second place with a rate of approximately 25% and to a lesser extent musculoskeletal (6.7%), gastrointestinal (5.8%) and cardiac (2.0%) causes identified. In another study also; pediatric patients admitted to the ED with chest pain were examined in the cardiology department. While the most common cause of chest pain was chest wall pain, pulmonary causes (13%) and asthma (4%) were seen less frequently [18].

Chest pain may be the first sign of asthma in children. In some studies, it has been suggested that this is the only or the most prominent symptom in the presence of "chest pain variant asthma" [19, 20]. The cause of chest pain seen in asthma may be related to chronic inflammation in the airway and the narrowing of the airway caused by this inflammation [20]. Further, chest pain in a child with asthma may be caused by overuse or strain on the rib cage muscles [7]. In addition, bronchoconstriction in asthma can create a feeling of tightness in the chest which can be interpreted as pain by children [19].

In this study, the rate of atopic diseases such as asthma and AR was much higher. This may be due to the fact that the clinical findings of the patients who applied to the ED and other departments were different. In addition, allergic and exercise-induced asthma may be underestimated if research is not done [18]. In this study, when other complaints of patients were questioned, shortness of breath was found as the most common complaint. Moreover, some of them were found to have effort dyspnea and cough. These are important findings in terms of asthma [19]. In addition to these conditions, the diagnosis of asthma was found higher in this study because physicians who examined the patients were highly experienced in terms of asthma.

Useful pathognomonic markers are necessary for diagnosing asthma; however, any pathognomonic marker has not been developed yet. Hence, many factors should be evaluated simultaneously when diagnosing asthma. Therefore, the diagnosis is made with a detailed clinical history and physical examination [8,21]. It is also important to question family history, as asthma is a genetic disease [22,23]. Studies have reported that approximately 60-70% of asthmatic patients are allergic whereas, 30% of allergic patients have asthma [21]. In this study, according to the past medical history and clinical findings of the patients, asthma and AR were diagnosed as 44.3% and 9.1% respectively. Additionally, a family history of atopy was found in 22.7% of the patients in group 1, which was significantly higher than in group 2. This result is an important implication, since the presence of a family history of atopy is a risk factor in asthma and other atopic diseases in children [21-23]. In addition, SPT positivity in 28.4% of the patients was detected. While SPT positivity was found to be significantly higher in AR, this significance was not found in asthma.

Spirometry is not diagnostic for asthma but, together with the history and physical examination, it is a complementary test in diagnosing asthma [24]. In this study, the FEV1 of the patients who were able to perform the pulmonary function test were found to be lower than the control group.

In this study, as the cause of chest pain was determined to be mostly asthma, some risk factors especially environmental factors were also examined and it was observed that exposure to these factors was higher in group 1. It is very important to question the triggering environmental factors to the patients and regulation of these factors has an important effect in relieving symptoms [21]. Exposure to environmental factors can trigger asthma symptoms and cause chest pain [25,26]. In this study, smoking exposure, presence of pet, presence of stove and wool use were found significantly higher in group 1 than control group. These results draw attention to the importance of environmental factors in the development of such symptoms in children.

It is known that airway hypersensitivity and serum IgE levels in asthma can be affected by genetics [21,23]. However, total IgE levels of our patients with chest pain diagnosed with asthma and AR were not different from the control group.

After the treatment given to the patients, the majority of the complaints were resolved, which suggests that we should question children in detail better and more frequently in terms of asthma and other disorders [22].

In this study, other causes of chest pain were also investigated. Although idiopathic chest pain and musculoskeletal system disorders were seen more common after asthma, GER and pneumonia were also detected. Unlike this study, idiopathic chest pain and musculoskeletal system disorders were detected more common in some studies [5,14]. The reason for the higher diagnosis of asthma in this study may be due to the fact that in the differential diagnosis, patients were examined in more detail in this respect.

In this study, children with chest pain that is not originated from cardiac problems were discussed. The clinical findings of these patients, the presence of an atopic disease such as asthma, and the presence of other causes of chest pain were investigated. In fact, although very few cases of chest pain are caused by the cardiac problems, families are worried because they think it is due to cardiac disease. Also, since most of them are undiagnosed, there may be frequent applications to the hospital. Because of these reasons, real cause of chest pain in children is needed to be understood. The reason of chest pain in most children may be found accurately by a detailed history and careful physical examination. In this study, presence of atopy in the family, allergen sensitivity and exposure to environmental factors were seen as associated with chest pain. Since asthma was found to be high in our study, we suggest that children with chest pain should be evaluated especially in terms of asthma and other atopic diseases. As a result, it is important to evaluate children with chest pain complaints together with the pediatric cardiology and PAI department.

Authors contribution section: F.D. and M.T.D. conceived and designed the evaluation and drafted the manuscript. M.T.D. participated in designing the evaluation, performed parts of the statistical analysis and helped to draft the manuscript. F.D. re-evaluated the clinical data, revised the manuscript and performed the statistical analysis and revised the manuscript. F.D. and M.T.D. collected the clinical data, interpreted them and revised the manuscript. All authors read and approved the final manuscript.

Conflict of Interest: None

Funding: None

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Tables 1-3 are available in the supplementary files section.

No competing interests reported.

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Investigation of the Presence of Atopy in Pediatric Patients Visiting the Pediatric Cardiology Department due to Chest Pain

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Abstract

Background

Objectives

Patients and Methods:

Results

Conclusions

Figures

Introduction

Patients And Methods

Results

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

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