Chest pain is a common symptom in pediatrics. It often causes significant anxiety and concern for patients and families. Although cardiac etiologies are often the principal concern for families, pediatric chest pain is rarely caused by cardiac disease (0%–5%).^1-3 More common causes involve the pulmonary, gastrointestinal, or musculoskeletal systems. Hospitalists caring for patients with chest pain must be able to utilize a thorough history and physical to determine benign from organic disease among the long list of differential diagnoses (Table 20-1).

Acute chest pain is much more likely to have an organic etiology than chronic pain, which is more likely to be musculoskeletal, psychogenic, or idiopathic. Table 20-2 outlines some of the common findings and their associated diagnoses in pediatric chest pain. It is often difficult for younger children to accurately articulate the location, severity, or quality of chest pain. For example, younger children may complain of chest pain when what they’re likely experiencing are palpitations. It is important to consider the gastrointestinal organs due to the proximity of the epigastric area to the sternum. Modifying factors such as relationship to exercise, positional change, effect with inspiration, and relationship to eating or swallowing can be helpful in discerning which organ system may be involved.

Associated symptoms are particularly helpful in identifying the cause of pediatric chest pain. Fever is often associated with conditions such as lower respiratory tract infections, pericarditis, or myocarditis. Dyspnea in pediatrics is most commonly associated with disorders that involve the airway, the lung parenchyma, or the pulmonary vasculature. However, cardiac conditions such as myocarditis, dilated cardiomyopathy, and cardiac tamponade can raise the left atrial pressure, resulting in pulmonary edema and dyspnea. Patients hospitalized for trauma or other surgical procedures that result in immobilization remain at risk for venous thromboembolic disease.

Patients with acute chest pain should be evaluated for current and past medical conditions that may predispose them to important underlying pathology. Any patient with a previous history of a cardiomyopathy or congenital heart disease should be closely evaluated for cardiac disease and should be examined by or discussed with a pediatric cardiologist. Asthma is an important chronic medical condition that would raise the probability of an acute pulmonary process. Patients with a previous history of Kawasaki disease may have had coronary artery aneurysms that would increase their risk of myocardial ischemia. Inflammatory conditions such as systemic lupus erythematosus, inflammatory bowel disease, or other rheumatologic conditions increase the possibility of pericarditis, pleuritis, or a pulmonary embolus. Patients with central venous catheters are at particular risk for venous thromboembolic complications. Also, patients with a malignancy who have been exposed to chemotherapeutic agents such as anthracyclines should be evaluated for a cardiomyopathy or a pericardial effusion. Sickle cell patients with chest pain need to be quickly evaluated and treated for possible acute chest syndrome.

Substance abuse, medications, or toxin exposures can predispose patients to develop certain conditions that can cause chest pain in pediatrics. Cocaine could potentially induce coronary or systemic vasoconstriction resulting in myocardial ischemia or systemic hypertension, respectively.⁴ Methamphetamines and other stimulant medications could increase the possibility of an arrhythmia. Caustic ingestions or foreign body aspiration can lead to esophageal injury or upper airway obstruction.

Family historical data regarding cardiomyopathies, sudden unexplained death, Marfan syndrome, and hypercoaguable conditions should be obtained.