A complaint of chest pain is frequently encountered in children in the office and emergency department (ED). Although chest pain does not indicate serious disease of the heart or other systems in most pediatric patients, in a society with a high prevalence of atherosclerotic cardiovascular disease, it can be alarming to the child and parents. Physicians should be aware of the differential diagnosis of chest pain in children and should make every effort to find a specific cause before making a referral to a specialist or reassuring the child and the parents of the benign nature of the complaint. Making a routine referral to a cardiologist is not always a good idea; it may increase the family’s concern and may result in a prolonged and costly cardiac evaluation.
Cause and Prevalence
Chest pain occurs in children of all ages and equally in male and female patients, with an average age of presentation at 13 years. Most of the data on the frequency of causes of chest pain in children come from studies performed in pediatric ED and cardiology clinics. Chest pain accounts for approximately 0.3% to 0.6% of pediatric ED visits. Table 30-1 lists the frequency of the causes of chest pain in children according to the organ systems based on data from 6 published reports from pediatric emergency departments or pediatric clinics and data from 4 pediatric cardiology clinics (Thull-Freedman, 2011). According to the table, trauma or muscle strain of the chest wall, costochondritis, and respiratory illness are the three most frequent causes of the pain. Gastrointestinal and psychogenic causes are identified in fewer than 10% of cases, and a cardiac cause is found infrequently (5% or less). In another report, chest wall pathology, including costochondritis, was the cause of the pain in 64% of patients seen in an ED and in 88% of the patients seen in cardiology clinic ( Massin et al, 2004 ). Whereas children younger than 12 years of age were two times more likely to have an organic cause, adolescents were 2.5 times more likely to have a psychogenic cause. Box 30-1 is a partial list of possible causes of noncardiac and cardiac chest pain in children.
| Causes | Pediatric Emergency Department or Pediatric Clinic (Data from Six Reports) (%) | Cardiology Clinic (Data from Four Reports) (%) |
|---|---|---|
| Idiopathic or cause unknown | 12–61 | 37–54 |
| Musculoskeletal or costochondritis | 7–69 | 1–89 |
| Respiratory or asthma | 13–24 | 1–12 |
| Gastrointestinal or gastroesophageal reflux disease | 3–7 | 3–12 |
| Psychogenic | 5–9 | 4–19 |
| Cardiac | 2–5 | 3–7 |
Noncardiac Causes
Musculoskeletal
Costochondritis
Trauma to chest wall (from sports, fights, or accident)
Muscle strains (pectoral, shoulder, or back muscles)
Overused chest wall muscle (from coughing)
Abnormalities of the rib cage or thoracic spine
Tetze’s syndrome
Slipping rib syndrome
Precordial catch (Texidor’s twinge or stitch in the side)
Respiratory
Reactive airway disease (exercise-induced asthma)
Pneumonia (viral, bacterial, mycobacterium, fungal, or parasitic)
Pleural irritation (pleural effusion)
Pneumothorax or pneumomediastinum
Pleurodynia (devil’s grip)
Pulmonary embolism
Foreign bodies in the airway
Gastrointestinal
Gastroesophageal reflux
Peptic ulcer disease
Esophagitis
Gastritis
Esophageal diverticulum
Hiatal hernia
Foreign bodies (e.g., coins)
Cholecystitis
Pancreatitis
Psychogenic
Life stressor (death in family, family discord, divorce, failure in school, nonacceptance from peers, sexual molestation)
Hyperventilation
Conversion symptoms
Somatization disorder
Depression
Bulimia nervosa (esophagitis, esophageal tear)
Miscellaneous
Sickle cell disease (vaso-occlusive crisis)
Mastalgia
Herpes zoster
Cardiac Causes
Ischemic Ventricular Dysfunction
Structural abnormalities of the heart (severe aortic or pulmonary stenosis, hypertrophic obstructive cardiomyopathy, Eisenmenger syndrome
Mitral valve prolapse
Coronary artery abnormalities (previous Kawasaki disease, congenital anomaly, coronary heart disease, hypertension, sickle cell disease)
Cocaine abuse
Aortic dissection and aortic aneurysm (Turner’s, Marfan’s, and Noonan’s syndromes)
Inflammatory Conditions
Pericarditis (viral, bacterial, or rheumatic)
Postpericardiotomy syndrome
Myocarditis (acute or chronic)
Kawasaki disease
Arrhythmias (and Palpitations)
Supraventricular tachycardia
Frequent premature ventricular tachycardia or ventricular tachycardia (possible)
Clinical Manifestations
Idiopathic Chest Pain
No cause can be found in 12% to 85% of patients even after a moderately extensive investigation. In many children with chronic chest pain, an organic cause is less likely to be found. In some of these children, chest pain is resolved spontaneously, and some of them are eventually referred for specialty evaluation.
Noncardiac Causes of Chest Pain
Most cases of pediatric chest pain originate in the organ systems other than the cardiovascular system. Identifiable noncardiac causes of chest pain are found in 56% to 86% of reported cases. Causes of chest pain are found most often on the thorax and respiratory system.
Costochondritis . Costochondritis causes chest pain in 9% to 22% of children with such pain. A single study reported rates as high as 79%. It is more common in girls than boys. Pain is generally sharp, anterior chest pain and usually unilateral but occasionally bilateral. Pain is usually exaggerated by physical activity or breathing. A specific position may also cause the pain. The pain may radiate to the remainder of the chest, back, and abdomen. The pain may be preceded by exercise, an upper respiratory infection, or physical activity. Physical examination is diagnostic; the clinician finds a reproducible tenderness on palpation over the chondrosternal or costochondral junctions. It is a benign condition, but the pain may persist for several months.
Tietze’s syndrome is a rare form of costochondritis characterized by a large, tender, fusiform (spindle-shaped), nonsuppurative swelling at the chondrosternal junction. It usually affects the upper ribs, particularly the second and third costochondral junctions.
Musculoskeletal . Musculoskeletal chest pain is also common in children. The pain is caused by strains of the pectoral, shoulder, or back muscles after exercise; overused chest wall muscle for coughing; or because of trauma to the chest wall from sports, fights, or accidents. A history of vigorous exercise, weightlifting, or direct trauma to the chest and the presence of tenderness of the chest wall or muscles clearly indicate muscle strain or trauma. Abnormalities of the rib cage or thoracic spine can cause mild, chronic chest pain in children.
Respiratory . Respiratory problems are responsible for about 10% to 20% of cases of pediatric chest pain, which may result from lung pathology, pleural irritation, or pneumothorax. A history of severe cough, with tenderness of intercostal or abdominal muscles, is usually present. The presence of crackles, wheezing, tachypnea, retraction, or fever on examination suggests a respiratory cause of chest pain. Pleural effusion may cause pain that is worsened by deep inspiration. Radiographic examination may confirm the diagnosis of pleural effusion, pneumonia, or pneumothorax.
Exercise-induced asthma . The prevalence of exercise-induced asthma is probably underestimated. Exercise triggers bronchospasm in up to 80% of individuals with asthma. The response of the patient with asthma to exercise is quite characteristic. Running for 1 to 2 minutes often causes bronchodilatation in patients with asthma, but strenuous exercise for 3 to 8 minute’s duration causes bronchoconstriction in virtually all subjects with asthma, especially when the heart rate rises to 180 beats/min. Symptoms range from mild to severe and may include coughing; wheezing; dyspnea; and chest congestion, constriction, or pain. They also complain of limited endurance during exercise. Environmental factors such as cold temperature, pollens, and air pollution, as well as viral respiratory infection, can worsen exercise-induced asthma. Exercise-induced bronchospasm provocation test is diagnostic, which is described under Stress Tests in Chapter 6 .
Gastrointestinal . Some gastrointestinal disorders, including gastroesophageal reflux disease (GERD), may present as chest pain in children. In addition to chest pain, children with GERD may complain of abdominal pain, frequent sore throat, gagging or choking, extreme pickiness about foods, frequent respiratory problems (e.g., bronchitis, wheezing, asthma), and poor weight gain. The onset and relief of pain in relation to eating and diet may help clarify the diagnosis. The incidence of GERD is higher in patients with Down syndrome, cerebral palsy, and other causes of developmental delay. Esophagitis resulting from gastroesophageal reflux should be suspected in a child who complains of burning substernal pain that worsens with a reclining posture or abdominal pressure or that worsens after certain foods are eaten. Cholecystitis presents with postprandial pain referred to the right upper quadrant of the abdomen and part of the chest.
Young children sometimes ingest foreign bodies, such as coins, which lodge in the upper esophagus, or they may ingest caustic substances that burn the entire esophagus. In such cases, the history makes the diagnosis obvious.
Psychogenic . Psychogenic disturbances account for 5% to 17% of cases and are seen in both boys and girls at equal rates. Often a recent major stressful event parallels the onset of the chest pain such as a death, divorce or separation in the family, a serious illness, a disability, a recent move, failure in school, or sexual molestation. However, a psychological cause of chest pain should not be lightly assigned without a thorough history taking and a follow-up evaluation. Psychological or psychiatric consultation may reveal conversion symptoms, a somatization disorder, or even depression.
Miscellaneous
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The precordial catch (Texidor’s twinge or stitch in the side), a one-sided chest pain, lasts a few seconds or minutes and is associated with bending or slouching. The cause is unclear, but the pain is relieved by straightening and taking a few shallow breaths or one deep breath. The pain may recur frequently or remain absent for months.
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Slipping rib syndrome results from excess mobility of the 8th to 10th ribs, which do not directly insert into the sternum. In many cases, the ligaments that hold these ribs to the upper ribs are weak, resulting in slippage of the ribs, causing pain.
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Some male and female adolescents complain of chest pain caused by breast masses (mastalgia). These tender masses may be cysts (in postpubertal girls) or may be part of normal breast development in pubertal boys and girls.
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Pleurodynia (devil’s grip), an unusual cause of chest pain caused by coxsackievirus infection, is characterized by sudden episodes of sharp pain in the chest or abdomen.
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Herpes zoster is another unusual cause of chest pain.
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Spontaneous pneumothorax and pneumomediastinum are serious but rare respiratory causes of acute chest pain in children; children with asthma, cystic fibrosis, or Marfan’s syndrome are at risk. Inhalation of cocaine can provoke pneumomediastinum and pneumothorax with subcutaneous emphysema.
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Pulmonary embolism, although extremely rare in children, has been reported in female adolescents who use oral contraceptives or have had elective abortions. It has also been reported in male adolescents with recent trauma of the lower extremities and in children with shunted hydrocephalus. It may occur in children with hypercoagulation syndromes. Affected patients usually have dyspnea, pleuritic pain, fever, cough, and hemoptysis.
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Hyperventilation can produce chest discomfort and is often associated with paresthesia and lightheadedness.
Cardiovascular Causes of Chest Pain
Cardiovascular disease is identified as the cause of pediatric chest pain in 0% to 5% of cases. Cardiac chest pain may be caused by ischemic ventricular dysfunction, pericardial or myocardial inflammatory processes, or arrhythmias. A typical anginal pain in adults is located in the precordial or substernal area and radiates to the neck, jaw, either or both arms, the back, or the abdomen. The patient describes the pain as a deep, heavy pressure; the feeling of choking; or a squeezing sensation. Older adolescents are expected to describe the pain this way, but young children may not. Exercise, cold stress, emotional upset, or a large meal typically precipitates anginal pain. Table 30-2 summarizes clinical findings of cardiac causes of chest pain in children for practitioners.
