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 heart 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.
I. Cause and Prevalence
Cardiac causes of chest pain are found in less than 5% of children with complaint of chest pain. Noncardiac causes of chest pain are found in 56% to 86% of reported cases.
Among 3700 patients who presented to a large children’s hospital with a complaint of chest pain, cardiac pathology or arrhythmias was found in only 1% of these patients, of whom 38% had SVT and 27% had pericarditis (Saleeb et al., 2011).
Table 20.1 lists the frequency of the causes of chest pain in children according to organ systems based on published data from six pediatric emergency departments and four pediatric cardiology clinics. According to the table, the three most common causes of chest pain in children are (a) costochondritis, (b) chest wall trauma or muscle strain, and (c) respiratory diseases, especially those associated with coughing.
Pediatric Emergency Department or Pediatric Clinic (Data from 6 Reports) (%)
Cardiology Clinic (Data from 4 Reports) (%)
Gastrointestinal/gastroesophageal reflux disease
Gastrointestinal and psychogenic causes are identified in fewer than 10% of cases.
Even after a moderately extensive investigation, no cause can be found in up to 50% of patients (idiopathic chest pain).
In children with chronic chest pain, a cardiac cause is less likely to be found.
Box 20.1 is a partial list of possible causes of noncardiac and cardiac chest pain in children.
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
Slipping rib syndrome
Precordial catch (Texidor’s twinge or stitch in the side)
Reactive airway disease (exercise-induced asthma)
Pneumonia (viral, bacterial, mycobacterium, fungal, or parasitic)
Pleural irritation (pleural effusion)
Pneumothorax or pneumomediastinum
Pleurodynia (devil’s grip)
Foreign bodies in the airway
Peptic ulcer disease
Foreign bodies (such as coins)
Life stressor (death in family, family discord, divorce, failure in school, nonacceptance from peers, or sexual molestation)
Bulimia nervosa (esophagitis, esophageal tear)
Sickle cell disease (vaso-occlusive crisis)
Ischemic Ventricular Dysfunction
Structural abnormalities of the heart (severe AS or PS, hypertrophic obstructive cardiomyopathy, Eisenmenger syndrome)
Mitral valve prolapse
Coronary artery abnormalities (previous Kawasaki disease, congenital anomaly, coronary heart disease, hypertension, sickle cell disease)
Aortic dissection and aortic aneurysm (Turner, Marfan, or Noonan syndromes)
Pericarditis (viral, bacterial, or rheumatic)
Myocarditis (acute or chronic)
Arrhythmias (and Palpitations)
Frequent PVCs or ventricular tachycardia (possible)
A. Noncardiac Causes of Chest Pain
Costochondritis is found in up to 80% of children with chest pain. It is more common in girls than boys and may persist for several months. It is characterized by mild to moderate anterior chest pain, usually unilateral but occasionally bilateral. The pain may radiate to the remainder of the chest and back, and may be exaggerated by breathing or physical activities. Physical examination is diagnostic; the clinician finds a reproducible tenderness on palpation over the chondrosternal or costochondral junctions. It is a benign condition.
Tietze 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 second and third costochondral junctions.
Musculoskeletal . There is a history of vigorous exercise, weight lifting, acute or chronic trauma to the chest wall from sports, fights, or accidents as well as continuous muscle strain from video gaming. Physical examination reveals tenderness of the chest wall or pectoralis muscles.
Respiratory . Lung pathology, pleural irritation, or pneumothorax account for 10% to 20% of the cases. A history of severe cough, tenderness of intercostal or abdominal muscles, and crackles or wheezing on examination suggests a respiratory cause of chest pain.
Exercise-induced asthma . Exercise-induced asthma is not that uncommon. The response of the asthmatic patient to exercise is quite characteristic. The intensity of exercise is important. Strenuous exercise for 3 to 8 minutes’ duration causes bronchoconstriction in virtually all asthmatic subjects, especially when the heart rate rises to 180 beats/min. On the other hand, jogging or slow running for 1 to 2 minutes often causes bronchodilatation. Symptoms range from mild to severe and may include coughing, wheezing, dyspnea, and chest congestion, constriction, or pain. Patients also complain of limited endurance during exercise. Environmental factors, such as cold temperature, pollen, and air pollution, as well as viral respiratory infection can worsen exercise-induced asthma. Exercise-induced bronchospasm provocation test is diagnostic (discussed under “Stress Tests” in Chapter 5 ).
Gastroesophageal reflux disease (GERD) may cause chest pain. In addition to chest pain, children with GERD may complain of abdominal pain, frequent sore throat, gagging or choking, frequent respiratory problems (such as bronchitis, wheezing, asthma), and poor weight gain. The onset and relief of pain in relation to eating and diet may help clarify the diagnosis.
In young children, ingested foreign bodies (such as coins or caustic substances) may cause chest pain.
Cholecystitis presents with postprandial pain referred to the right upper quadrant of the abdomen and part of the chest.
Psychogenic . Psychogenic disturbances account for 5% to 17% of cases and are seen in both boys and girls at equal rates. Psychogenic causes are less likely to be found in children younger than 12 years. Often a recent stressful situation parallels the onset of the chest pain: a death 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 be indicated.
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.
Slipping rib syndrome (resulting from excess mobility of the eighth to tenth 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.
Mastalgia in some male and female adolescents.
Pleurodynia (devil’s-grip) is an unusual cause of chest pain caused by coxsackievirus infection.
Herpes zoster is another unusual cause of chest pain.
Spontaneous pneumothorax and pneumomediastinum are rare respiratory causes of acute chest pain. Children with asthma, cystic fibrosis, or Marfan syndrome are at risk. Inhalation of cocaine can provoke pneumomediastinum and pneumothorax.
Hyperventilation can produce chest discomfort and is often associated with paresthesia and lightheadedness.
B. Cardiac Causes of Chest Pain
Cardiac chest pain may be caused by ischemic ventricular dysfunction, pericardial or myocardial inflammatory processes, or arrhythmias, occurring in less than 5% of cases ( Box 20.1 ). A typical anginal pain in adults is located in the precordial or substernal area and radiates to the neck, jaw, either or both arms, back, or 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 as above but young children may not. Exercise, cold stress, emotional upset, or a large meal typically precipitates anginal pain. Table 20.2 summarizes important clinical findings of cardiac causes of chest pain in children.
Ischemic myocardial dysfunction
Congenital heart defects. Severe AS, subaortic stenosis, severe PS, and pulmonary hypertension (Eisenmenger syndrome) may cause ischemic chest pain. The pain is usually associated with exercise and is a typical anginal pain.
MVP. Chest pain associated with MVP is usually a vague, nonexertional pain of short duration, located at the apex, without a constant relationship to effort or emotion. Occasionally, supraventricular or ventricular arrhythmias may result in cardiac symptoms, including chest discomfort. Nearly all patients with Marfan syndrome have MVP. A midsystolic click with or without a late systolic murmur is the hallmark of the condition.
Cardiomyopathy. Hypertrophic and dilated cardiomyopathies can cause chest pain from ischemia, with or without exercise, or from rhythm disturbances.
CAD. Coronary artery anomalies, either congenital (aberrant or single coronary artery, coronary artery fistula) or acquired (aneurysm or stenosis of the coronary arteries as a result of Kawasaki disease or as a result of previous cardiac surgery involving the coronary arteries) can rarely cause chest pain.
Cocaine abuse. Even children with normal hearts are at risk of ischemia and myocardial infarction if cocaine is used. Cocaine blocks the reuptake of norepinephrine with an increase in circulating levels of catecholamines causing coronary vasoconstriction. Cocaine also induces the activation of platelets, increases endothelin production, and decreases nitric oxide production. These effects collectively produce anginal pain, infarction, arrhythmias, or sudden death. History and drug screening help physicians in the diagnosis of cocaine-induced chest pain.
Pericardial or myocardial disease
Pericarditis. Older children with pericarditis may complain of a sharp, stabbing precordial pain that worsens when lying down and improves after sitting and leaning forward. Echo examination is usually diagnostic.
Myocarditis. Acute myocarditis often involves the pericardium to a certain extent and can cause chest pain.
Arrhythmias . Chest pain may result from a variety of arrhythmias, especially with sustained tachycardia resulting in myocardial ischemia. Even without ischemia, children may consider palpitation or forceful heartbeats as chest pain. In this situation, chest pain may be associated with dizziness and palpitation.