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Child With Chest Pain


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

  • 1.

    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.

  • 2.

    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).

  • 3.

    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.

    Table 20.1
    Frequency of Causes of Chest Pain in ChildreN
    From Thull-Freedman, J. (2010). Evaluation of chest pain in the pediatric patients. Medical Clinics of North America, 94(2) :327-347.
    Causes Pediatric Emergency Department or Pediatric Clinic (Data from 6 Reports) (%) Cardiology Clinic (Data from 4 Reports) (%)
    Idiopathic/cause unknown 12-61 37-54
    Musculoskeletal/costochondritis 7-69 1-89
    Respiratory/asthma 13-24 1-12
    Gastrointestinal/gastroesophageal reflux disease 3-7 3-12
    Psychogenic 5-9 4-19
    Cardiac 2-5 3-7

  • 4.

    Gastrointestinal and psychogenic causes are identified in fewer than 10% of cases.

  • 5.

    Even after a moderately extensive investigation, no cause can be found in up to 50% of patients (idiopathic chest pain).

  • 6.

    In children with chronic chest pain, a cardiac cause is less likely to be found.

  • 7.

    Box 20.1 is a partial list of possible causes of noncardiac and cardiac chest pain in children.

    Box 20.1
    Selected Causes of Chest Pain

    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

    • Tietze 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 (such as coins)

    • Cholecystitis

    • Pancreatitis

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