Children frequently present to a pediatric office or emergency department with the complaint of chest pain. Between 0.3% and 0.6% of visits to a pediatric emergency department are for chest pain. Unlike adult patients with chest pain, most studies have shown that children with chest pain rarely have serious organic pathology. Infrequently, a child with chest pain will present with significant distress and require immediate resuscitation. Most children with chest pain are not in extremis, and for many, the pain is not acute in nature.
Children frequently present to a pediatric office or emergency department (ED) with the complaint of chest pain. Between 0.3% and 0.6% of visits to a pediatric emergency department are for chest pain. Unlike adult patients with chest pain, most studies have shown that children with chest pain rarely have serious organic pathology. Infrequently, a child with chest pain will present with significant distress and require immediately resuscitation. Most children with chest pain are not in extremis and for many the pain is not acute in nature.
Treat the complaint of chest pain seriously, because underlying heart disease or other serious pathology can sometimes exist. Many patients and their families associate chest pain with heart disease. Dramatic media accounts of sudden deaths in young athletes have focused attention on chest pain as a sign of serious heart disease. Also, young people are aware of risk factors for cardiac disease because the medical community has emphasized the prevalence of hypertension and atherosclerotic cardiovascular disease in adults. Although serious, fatal heart disease is extremely rare in the pediatric population, families seek reassurance when they bring their child to the pediatric office or ED with the complaint of chest pain.
Furthermore, treat this complaint seriously because the symptom of chest pain often disturbs a child’s daily routine. About one-third of children with this complaint are awakened from sleep by the pain and one-third miss school because of the pain. In one study, 16% of children with chest pain made more than 1 visit to an ED with this same complaint. Chest pain often becomes a chronic problem, lasting more than 6 months in 7% to 45% of children. About 8% of children have chest pain for more than 1 year.
Because there are occasional children with serious pathology related to chest pain, the pediatrician and ED physician must carefully contemplate an extensive differential diagnosis when evaluating a child with chest pain ( Box 1 ).
Cardiac-related causes
Coronary artery disease-ischemia/infarction
Anomalous coronary arteries
Kawasaki disease (coronary arteritis)
Diabetes mellitus (long standing)
Arrhythmia
Supraventricular tachycardia
Ventricular tachycardia
Structural abnormalities of the heart
Hypertrophic cardiomyopathy
Severe pulmonic stenosis
Aortic valve stenosis
Infection
Pericarditis
Myocarditis
Noncardiac-related causes
Musculoskeletal disorders
Chest wall strain
Direct trauma/contusion
Rib fracture
Costochondritis
Respiratory disorders
Severe cough
Asthma
Pneumonia
Pneumothorax/pneumomediastinum
Pulmonary embolism
Psychological disorders
Stress-related pain
Gastrointestinal disorders
Reflux esophagitis
Pill-induced esophagitis
Esophageal foreign body
Miscellaneous disorders
Sickle cell crises
Abdominal aortic aneurysm (Marfan syndrome)
Pleural effusion (collagen vascular disease)
Shingles
Pleurodynia (coxsackievirus)
Breast tenderness (pregnancy, physiologic)
Tietze syndrome
Texidor’s twinge/precordial catch syndrome
Chest mass
Idiopathic
Age is a factor in the etiology of pediatric chest pain. Young children are more likely to have a cardiorespiratory cause for their pain, such as cough, asthma, pneumonia, or heart disease; whereas, adolescents are more likely to have pain associated with stress or a psychogenic disturbance.
Differential diagnosis
There are numerous causes of chest pain in children (see Box 1 ). The following articles in this issue of Pediatric Clinics of North America will address these etiologies in detail. Keep a broad differential diagnosis in mind while assessing the child with chest pain. Cardiac Disease that was previously undiagnosed is a rare cause of chest pain in children. Some children may have an underlying medical condition that results in a higher likelihood of angina or myocardial infarction. For instance, children who have long-standing diabetes mellitus, past history of Kawasaki disease, chronic anemia, or use of cocaine are at risk for cardiac pathology. In many cases, exercise induces the chest pain with these disorders because coronary blood flow is limited. Pain with exertion should therefore be given careful consideration. Syncope may also be associated.
In addition, some children may have an arrhythmia that causes symptoms, such as palpitations or an abnormal cardiac examination. Supraventricular tachycardia is the most common of these arrhythmias, but ventricular tachycardia can also lead to brief, sharp, chest pain.
Consider a structural cardiac abnormality, such as hypertrophic obstructive cardiomyopathy, when evaluating a child with chest pain. There may be a family history of this condition, as it has an autosomal dominant pattern of inheritance. Children with this disorder have a murmur heard best when patients are standing or performing a Valsalva maneuver. These patients are at risk for ischemic chest pain, especially when exercising. Most other structural disorders of the heart rarely cause chest pain, however, severe pulmonic stenosis with associated cyanosis, coarctation of the aorta, and aortic valve stenosis can lead to ischemia. The pain in these conditions may be described as squeezing, choking, or as a pressure sensation in the sternal area. Finally, mitral valve prolapse (MVP) may cause chest pain by papillary muscle or left ventricular endocardial ischemia. With MVP, a midsystolic click and late systolic murmur are often found. MVP is not a frequent cause of pediatric chest pain and it is no more common in children with chest pain than in the general population.
Cardiac infections are important, although uncommon, causes of pediatric chest pain. For instance, pericarditis produces sharp stabbing pain that improves when patients sit up and lean forward. The child with this infection is usually febrile, in respiratory distress, has a friction rub, distant heart sounds, neck vein distention, and pulsus paradoxus. Myocarditis is a more common infection and is often difficult to diagnose because it presents as many other viral infections. Children with myocarditis may have pain for several days, albeit mild and not disruptive. After a few days of fever and other systemic symptoms, such as vomiting and lightheadedness, patients may develop chest pain with exertion and shortness of breath. Examination may reveal muffled heart sounds, fever, a gallop rhythm, tachycardia or tachypnea that is out of proportion to the degree of fever present. Patients also may have orthostatic changes in pulse or blood pressure. This is often misinterpreted as volume depletion because children with this infection may not be taking oral fluids well and may indeed have mild dehydration. However, when orthostatic changes do not improve after fluid resuscitation, cardiogenic causes, such as myocarditis, should be suspected. A chest radiograph usually shows cardiomegaly in both of these infections and an electrocardiogram will be abnormal, prompting a further evaluation, such as an echocardiogram (see the article by Durani and colleagues elsewhere in this issue for further exploration of this topic).
Musculoskeletal disorders are perhaps the most common causes of chest pain in children. Active children frequently strain chest wall muscles while wrestling, carrying heavy books, or exercising. Some children complain of chest pain after direct trauma to the chest, resulting in a mild contusion of the chest wall or, with more significant force, a rib fracture, hemithorax, or pneumothorax. In most cases, there is a straightforward history of trauma and the diagnosis is clear. Careful physical examination reveals chest wall tenderness or pain with movement of the torso or upper extremities.
Costochondritis is a common musculoskeletal disorder in children. Pain related to this condition is generally sharp, may be bilateral, and is exaggerated by physical activity or breathing. The diagnosis is made by eliciting tenderness over the costochondral junctions with palpation. Pain from costochondritis may persist for several months (see the article by Son and Sundel elsewhere in this issue for further exploration of this topic).
Respiratory Conditions frequently lead to chest pain. For instance, children with a severe, persistent cough; asthma; or pneumonia may complain of chest pain caused by overuse of chest wall muscles. Diagnosis of one of these conditions is made by history or the presence of rales, wheezes, tachypnea, or decreased breath sounds on physical examination. Some children who complain of chest pain with exercise will be found to have exercise-induced asthma, which can be determined with a treadmill test. Consider a spontaneous pneumothorax or pneumomediastinum in children with sudden chest pain, especially if they have respiratory distress. Children at high risk for these conditions are those with asthma, cystic fibrosis, and Marfan syndrome. Also, previously healthy children may develop a pneumothorax by rupture of an unrecognized subpleural bleb with minimal precipitating factors, such as cough or stretching. Examination often reveals respiratory distress, decreased breath sounds on the affected side (if the pneumothorax is significant), and possibly palpable subcutaneous air. Adolescents who snort cocaine are also at risk for barotrauma and may complain of severe, sudden chest pain with associated anxiety, hypertension, and tachycardia. Finally, consider pulmonary embolism (PE) as a cause of chest pain. This condition is rare in pediatric patients, but is occasionally diagnosed in teenage girls using birth control pills or after recent surgery/abortion, or young males with recent leg trauma. Patients with PE will experience dyspnea, fever, pleuritic pain, cough, and hemoptysis (see the article by Johnson and colleagues elsewhere in this issue for further exploration of this topic).
Psychogenic Disturbances cause chest pain in both boys and girls at equal rates. Consider this etiology if the child has had a recent major stressful event, such as separation from friends, divorce in the family, or school failure that correlates temporally with the onset of the chest pain, Often the anxiety or stress that results in somatic complaints is not easily apparent; hyperventilation or an anxious appearance are not always present (see the article by McDonnell and White elsewhere in this issue for further exploration of this topic).
Gastrointestinal disorders , such as reflux esophagitis, frequently cause chest pain in young children and adolescents. The pain is classically described as burning, substernal in location, and worsened by reclining or eating spicy foods. This condition is diagnosed by history or with a therapeutic trial of antacids. In addition, some adolescent patients may take medications, such as doxycycline, with little water and then lie down. They may develop severe pill esophagitis as the undissolved pill lodges in the esophagus.
Also, consider the ingestion of a coin, button battery, or other foreign body that is lodged in the esophagus when a young child presents with sudden severe chest pain, perhaps with drooling or difficulty swallowing. Usually, the child or parent gives a clear history that a foreign body was recently ingested and a simple radiograph can confirm the diagnosis (see the article by Garza and Kaul elsewhere in this issue for further exploration of this topic).
Miscellaneous causes of chest pain include pain related to underlying diseases. For instance, patients with sickle cell disease may have pain related to vasoocclusive crises or acute chest syndrome. Marfan syndrome may cause chest pain because of a dissection of an abdominal aortic aneurysm. Collagen vascular disorders may lead to pleural effusions. Varicella zoster infection may cause shingles, resulting in severe chest pain that can precede the classic rash or occur simultaneously. Coxsackie virus infection may cause pleurodynia with paroxysms of sharp pain in the chest or abdomen. Children may also complain of chest pain with breast tenderness from physiologic changes of puberty or early changes of pregnancy (see the article by Cico and colleagues elsewhere in this issue for further exploration of this topic). Tietze syndrome is a rare condition that causes sternal chest pain. Suspect this condition when physical examination reveals tender, spindle-shaped swelling at the sterno-chondral junctions. Etiology of Tietze syndrome is unknown and it can last for months. Finally, Texidor’s Twinge is a syndrome of left- sided chest pain that is brief (<5 minutes duration) and sporadic. This pain may recur frequently for a few hours in some individuals and then remain absent for several months. The pain seems to be associated with a slouched posture or bending, and is not related to exercise. It is usually relieved when the individual takes a few shallow breaths, or one deep breath, and assumes a straightened posture. This pain syndrome is also referred to as precordial catch or stitch in the side . The etiology remains unclear.
Idiopathic chest pain is a label given to children when no clear etiology can be found. In 20% to 45% of cases of pediatric chest pain, no diagnosis can be determined with certainty.
Immediate approach to children with chest pain
It is rare for a child with chest pain to present in extremis. However, conditions, such as pneumothorax, trauma, cocaine toxicity, or an arrhythmia, can lead to cardiovascular compromise. Before going on with a detailed evaluation, determine if patients need immediate support. If patients have tachypnea, dyspnea, shortness of breath, or poor color attach a monitor and support the patients’ airway and breathing. Measure the patients’ oxygen saturation and give oxygen supplementation if needed.
Next, evaluate the patients’ cardiac rate and rhythm and support the patients’ circulation. Consider an intravenous (IV) line and IV fluids to restore intravascular volume. Give an IV bolus of normal saline, 20 mL/kg, if patients have signs of shock, dizziness with standing, orthostatic changes in vital signs, or if they have not been drinking well.
General approach to children with chest pain
Most children with chest pain do not need immediate management. Take a thorough history and perform a careful physical examination. These practices will guide the physician to determine when laboratory studies, specific treatments, and referral to a specialist for further evaluation are necessary.
History
A thorough history will reveal the etiology of chest pain in most cases ( Box 2 ). First, determine when the pain began. Children with acute onset of pain (within 48 hours of presentation) are more likely to have an organic etiology for the pain. The etiology is not always serious, but pneumonia, asthma, trauma, pneumothorax, and arrhythmia are more likely if the pain is recent. In a young child with sudden onset of pain, consider a foreign body (coin or button battery) in the esophagus or injury. Those with chronic pain who have gone for extended periods without a diagnosis are much more likely to be idiopathic or have a psychogenic etiology.
- 1.
Consider thoracic trauma if patients recall a specific incident.
- 2.
Consider stress or emotional upset as the cause of pain, if an important life event is temporally correlated.
- 3.
Consider esophageal foreign body (coin or button battery ingestion) in a young toddler with acute onset of chest pain.
- 4.
Consider pneumonia or viral myocarditis if the child has fever.
- 5.
Consider cardiac disease if the pain is associated with exertion, syncope, and dizziness.
- 6.
Consider serious associated conditions, such as asthma, lupus, sickle cell disease, and Marfan’s syndrome.
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