When children complain of chest pain, the least likely scenario is that the pain comes from the heart. A more common reason is pain from the muscles and bones/ribs of the rib cage, stomach or respiratory tract organs (bronchi, lungs ...).

The child usually comes to the clinic when they complain about "a throbbing pain" or "as if someone stabbed them with a knife", with this unpleasant feeling lasting for a short amount of time and the child can locate it with their finger.

The probability of such pain coming from the heart is low, especially if the pain occurs in a certain body position, when moving or pressing with a finger.

Pain originating from the heart is usually in the wider chest area and is described as burning, tearing, or pressure in the chest. They most often occur during physical activity when they can be accompanied by rapid fatigue, a feeling of irregular heartbeat, dizziness, and even loss of consciousness. If someone in the family had a congenital heart defect or died suddenly, then there is a great chance that a heart disease could be the culprit.

When talking to the child and their parents, the doctor should always ask under what circumstances (previously healthy or sick child) the pain occurred, how often it occurs and whether something provokes or alleviates it.

A child with chest pain must be examined, primarily to check their vital signs and conduct a cardiovascular examination, including examination of the abdomen and respiratory organs.

Sometimes it is necessary to conduct more complex medical examinations (ECG, ultrasound of the heart, stress test), as well as targeted laboratory tests (troponins, pro BNP).

Often the diagnosis is made only on the basis of anamnesis (talking to the child and parents), although in many cases the cause of chest pain cannot be determined.

In addition to the above mentioned, the task of the doctor is to assure the patient and family that the child is not in danger (after excluding serious cardiac disease) and to introduce appropriate treatment (analgesics, antacids, anti-allergy drugs...).

Palpitations are by definition an unpleasant feeling of one's own heartbeat.

Patients report irregular heartbeat (arrhythmia), rapid heartbeat (tachycardia) or parents bring a child and say that their "chest rises as hard as the heart".

Cardiac arrhythmia in children is usually a harmless occurance (when they inhale, the heart speeds up, and when they exhale, it slows down), but in some cases it can be the first manifestation of a serious illness.

Rapid heartbeat normally occurs during physical activity, fever, excitement or fear, in which cases it is not a problem.

Since young children have a thin wall of the rib cage, it rises easily during normal heartbeat, which is usually faster in children than in adults.

Accelerated heartbeat can be a manifestation of some systemic diseases or the use of medications.

Palpitations that require treatment are those that most often begin/stop abruptly, disrupt daily routine activities, or last for hours or days. Anamnestic data on the existing heart disease in the patient or in the family suggest heart disease.

For quick orientation, it is necessary to feel the pulse on the arm and determine whether it is incorrect and whether it corresponds to what the patient feels. If the patient or parent can count the heart beats, then the tachycardia is most likely not dangerous.

Patients often report non-existent palpitations.

In order to determine the cause of palpitations, in addition to anamnestic data, it is necessary to perform a complete cardiovascular examination and look for signs of non-cardiac diseases.

In case of very fast heart beat, as well as in case of frequent and long-lasting palpitations, one should urgently visit the nearest health institution, where a 12-channel ECG will be performed, or conduct a variant of ECG monitoring such as continuous telemetry or holter ECG.

When palpitations are infrequent, well tolerated, and short-lasting, increased monitoring is advised, avoiding stimuli and with increased fluid intake.

Palpitations that occur during physical exercise require a stress test, and potentially lethal palpitations require an electrophysiological study (EPS).

Although very rare (approximately 3 cases per 100,000 athletes per year), the sudden death of young athletes is a serious health problem.

Sudden death on the sports field is a tragic event that deeply shakes the family, other athletes, institutions (schools, universities or professional associations), sports health workers and the community.

When it happens, it is heavily featured in the media because young athletes are considered the healthiest part of the population, and are often seen as heroes. Instinctively, everyone's first thought is whether there is an intervention that could prevent the sudden death of athletes.

The most common causes of sudden cardiac death (SCD) on the sports field are heart muscle diseases (cardiomyopathy), coronary artery diseases, some syndromes and cardiac arrhythmias.

Many of these diseases can be asymptomatic and sudden cardiac death is often the first and only manifestation of the disease.

The risk of sudden death increases with age and is more common in male athletes.

Young athletes are by definition individuals aged 12 to 35, who regularly train and participate in official sports competitions.

Athletes at risk of SCD are identified through preventive cardiovascular examinations, in an authorized health institution, by a sports doctor.

First, in a large population of athletes, seemingly healthy athletes who may have a life-threatening cardiovascular disease (CVD) are separated from those who may not. This is achieved by testing based primarily on ECG.

It is crucial that the selection of potentially healthy and potentially unhealthy athletes is carried out by competent and experienced sports doctors (sports medicine specialist or sports cardiologist), primarily for two reasons:

• The first is to avoid serious health consequences - unjustified exclusion from competition or misinterpreting a potentially deadly heart disease as a normal variant of a sports heart.
• The second is to avoid costly medical examinations due to excessive referral to further, otherwise, more expensive diagnostic tests. The percentage of false-positive findings (athletes with a normal heart but a positive result) should not exceed 9% for the prevention program to be sustainable.

Further examination (usually ultrasound of the heart) of those with a positive or suspicious test should rule out or diagnose a CVD and prevent SCD on the sports field through appropriate treatment.

The medical examination algorithm is given in Table 1.

Table 1.

The manner in which the health of athletes is determined in order for them to safely participate in sports competitions depends on the specifics of the health system, socio-economic circumstances and cultural characteristics of each country.

Thus, for example, in USA, a strategy is in place that includes medical history (personal and family) and physical examination, without a 12-channel ECG or other tests. Most European Cardiac Societies and Sports Medical Federations have adopted ECG-based prevention, which is also recommended by the International Olympic Committee.

Twenty-five years of experience in applying one such screening in Italy has unequivocally shown that the introduction of ECG has led to a significant reduction (up to 89%) of the SCD of athletes in this country. Despite this, the professional public around the world is still debating the optimal prevention of sudden cardiac death in athletes.

What is the situation in Montenegro?

First of all, the care for the health of athletes is regulated by the "Rulebook on the conditions for performing health examinations of athletes", from 2015. This rulebook was written on the basis of the Law on Sports from 2013, which is no longer in force.

According to the Rulebook, health examinations should be performed in an "authorized health institution", and according to the current law from 2018, in a specially established institution that has not yet commenced its operation.

The question arises where amateur athletes, child athletes and professional athletes should be examined. It is also questionable whether the health institutions where medical examinations of athletes are currently performed can provide the necessary quality and scope of health services as prescribed by the Rulebook/Law.

The definition of a syncope is a sudden and transient loss of consciousness accompanied by a fall, caused by reduced blood flow to the brain.

It is more common in adolescents (60% of girls have lost consciousness at least once in their lifetime).

Patients typically feel "as if they will lose consciousness", associated with nausea, paleness, sweating, blurred vision or a temporary loss of it, and dizziness, after which they faint. Very soon after getting into a horizontal position, they become conscious and behave normally.

The circumstances under which loss of consciousness most often occurs are:

• suddenly standing up from a sitting/lying position
• long standing or sitting
• physical exhaustion, overheating, dehydration,
• and can be potentiated by fear, or pain.

Syncopes are most often explained by a somewhat "lively" reflex that is characteristic of the period of rapid growth and development of the child in adolescence.

The amount of blood that the heart pumps is, in these circumstances, up to 25% less than usual, so the bodies (baroreceptors) in the aorta react, which, by activating the so-called sympathetic nervous system, cause excessive pumping of blood from the heart, accompanied by constriction of blood vessels.

As a counter-reflex, the parasympathetic nervous system is awakened, leading to an excessive drop in blood pressure and slowed heart rate, reduced blood flow to the brain, which leads to fainting.

This excessive reflex will most likely stabilize when growth and development are completed, between the age of 18 and 21. Until then, a certain lifestyle should be adopted and implemented that will reduce the risk of fainting.

When a loss of consciousness occurs in a patient, the main goal of the doctor is to assess whether the loss of consciousness happened due to:

• Epilepsy
• Cardiovascular disease

Fortunately, the vast majority of cases are a harmless condition called vasovagal syncope or nerve-mediated syncope. The biggest danger of this unpleasant condition is, in addition to upsetting the parent, a fall and the possibility of a head injury.

There is a large number of diagnostic procedures available to the doctor, often used irrationally, and more than half of the diagnosis lies in an "accurate description of the events and circumstances under which the loss of consciousness occurred" (so-called anamnesis).

For example, if the unconsciousness occurred suddenly, ie. without a warning (not preceded by a feeling that one will lose consciousness, without blurred vision, nausea...) or during/shortly after physical exertion and not going away on its own, the most probable reason is heart disease.

In epilepsy, the loss of consciousness occurs with a hint - prodrome, accompanied by cramps of the whole body and extremities, lasting a long time. The child is lethargic and confused after an epileptic seizure. It is almost always an epileptic seizure if the crisis of consciousness occurs in a lying position.

Adolescent syncopes can occur as part of a conversational reaction, typically in the presence of an audience, when they fall without injury, with normal skin appearance and heart rate and unusually long duration.

In case of suspected heart disease, in addition to physical examination, ECG, ultrasound of the heart, holter-ECG and exercise test are also used, and in case of unexplained syncopes, electrophysiological studies (EPS).

In order to reduce the risk of fainting, until the "critical" period of adolescence is over, the child should eat regularly (especially have a "stronger" breakfast), drink enough fluids - preferably fresh water (2-3 l/day), avoid abruptly standing up from a sitting/lying position, standing too long in stuffy and overheated rooms, unpleasant scenes, be physically active, and in case of loss of consciousness lie down with legs raised under a slope. This maneuver will lead to quick return to consciousness.