1 How common is chest pain in children?

Chest pain is a common pediatric complaint. It is not nearly as frequent as abdominal pain or headache, but it is perhaps the third leading pain syndrome in children. Chest pain has been reported to occur in 6 of 1000 children who visit an urban pediatric emergency department (ED).

Selbst SM, Ruddy R, Clark BJ, et al: Pediatric chest pain—a prospective study. Pediatrics 82:319–323,1988.

2 What is the peak age for pediatric chest pain?

Most studies report the mean age of children with chest pain to be 12–14 years. It affects children of all ages, and half of children with chest pain are younger than 12 years of age.

3 How does the etiology of chest pain in children differ from that in adults?

Children with chest pain are far less likely to have a cardiac etiology for their pain. Most children with chest pain have a self-limited, “benign” etiology.

Massin MM, Bourguignont A, Coremans C, et al: Chest pain in pediatric patients presenting to an emergency department or to a cardiac clinic. Clin Pediatr 43:231–238, 2004.

4 Which diagnoses are most common in children who present to an ED with chest pain?

In many studies, up to 45% of cases of chest pain in children are labeled “idiopathic.” That is, after a careful history and physical examination, the etiology is still uncertain. When a diagnosis can be found, musculoskeletal injury is most common. Active children frequently strain chest wall muscles while carrying heavy books, exercising, or engaging in rough play. Many other children suffer chest pain from a direct blow to the chest that results in a mild contusion or, in rare cases, a rib fracture. Costochondritis accounts for about 10–20% of cases of chest pain. This musculoskeletal disorder produces tenderness over the costochondral junctions and is often bilateral. It is exaggerated by physical activity or breathing. Musculoskeletal pain is often reproducible by palpation of the chest wall or moving the arms and chest through a variety of positions. Table 8-1 lists the most common etiologies for pediatric chest pain.

Table 8-1 Most Common Causes of Pediatric Chest Pain

Selbst SM: Chest pain in children—consultation with the specialist. Pediatr Rev 18:169–173, 1997.

5 How is the etiology of chest pain related to the child’s age?

Young children are more likely to have chest pain related to a cardiorespiratory condition (cough, asthma, pneumonia, or heart disease). Children over the age of 12 years are more likely to have a psychogenic disturbance as the cause of their pain.

6 What common gastrointestinal condition causes chest pain?

Gastroesophageal reflux, which is very common in children and accounts for at least 7% of pediatric chest pain. Some feel it is underdiagnosed. The pain is usually worse in the recumbent position. History may reveal that the pain is “burning” in quality and may have developed after eating spicy foods. A trial of antacids is often diagnostic and therapeutic.

7 What is Texidor’s twinge?

In 1955, Miller and Texidor described a syndrome of left-sided chest pain that is brief (less than a 5-minute 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 sometimes one deep breath, and assumes a straightened posture. It is believed that the pain arises from the parietal pleura or from pressure on an intercostal nerve, but the etiology remains unclear. Others refer to this pain syndrome as “precordial catch” or “stitch in the side.”

Gumbiner CH: Precordial catch syndrome. South Med J 96:38–41, 2003.

8 What is “slipping rib syndrome”?

This is a rare sprain disorder caused by trauma to the costal cartilages of the eighth, ninth and tenth ribs, which do not attach to the sternum. Children with slipping rib syndrome report pain under the ribs or in the upper abdominal quadrants. They also hear a clicking or popping sound when they lift objects, flex the trunk, or even walk. It is believed that the pain is caused by one of the ribs hooking under the rib above and irritating the intercostal nerves. The pain can be duplicated and the syndrome confirmed by performing the “hooking maneuver,” whereby the affected rib margin is grasped and then pulled anteriorly. Intercostal block has been tried for pain relief. Surgery to resect the involved costal cartilage may provide long-term relief, though most patients are treated satisfactorily with oral analgesics.

Mooney DP, Shorter NA: Slipping rib syndrome in childhood. J Pediatr Surg 32:1081–1082, 1997.

9 How can ingestion of tetracycline lead to chest pain?

Tetracycline, doxycycline, and other pill medications can cause acute esophagitis (pill-induced esophagitis). The pain is especially likely if the patient takes the medication with a minimal amount of water and then lies down. A history of esophageal dysmotility or stricture makes the pain more likely. However, many normal teenagers also report this pain. Because of the pH of the drug, doxycycline produces an acidic solution or gel as it dissolves, and thus it is caustic when it remains in the esophagus. Symptoms may be noted several days after the start of therapy with the medication, but frequently they occur after the first dose is taken.

10 How can I diagnose pill-induced esophagitis?

The diagnosis is made by taking a careful history. Physical examination generally is unremarkable. These medications are often taken by adolescents for treatment of acne, and since they are used long-term, teens may fail to reveal that they take the medication unless asked specifically. Some physicians prefer to perform endoscopic evaluation to document esophageal ulcers (midesophageal ulcers are most common, as the tablets are most likely to lodge in that region). Others prefer not to perform the endoscopy and, instead, discontinue use of the tetracycline medications and treat with sucralfate. This approach can be both diagnostic and therapeutic, if the patient responds well.

Palmer KM, Selbst SM, Shaffer S, et al: Pediatric chest pain induced by tetracycline ingestion. Pediatr Emerg Care 15:200–201, 1999.

11 When should a pneumothorax be suspected in a child with chest pain?

Suspect a pneumothorax if a child develops acute onset of sharp chest pain associated with some degree of respiratory distress. The pain is usually worsened by inspiration and may radiate to the shoulder, neck, or even the abdomen. Children with this condition do not have long-standing pain and almost all present for care within 48 hours of developing the pneumothorax. The patient will usually have dyspnea, tachycardia, and, perhaps, decreased breath sounds on the affected side, or even cyanosis. However, these signs and symptoms depend on the size of the pneumothorax and whether it is under tension (Fig. 8-1). A small pneumothorax may produce minimal findings on examination.

Figure 8-1 Tension pneumothorax on a frontal chest radiograph. Note the thin, sharply defined visceral pleural “white” line between radiolucent lung (L) and radiolucent “black” free air (A) in the peripheral pleural space in addition to rightward mediastinal shift and inferior left hemidiaphragmatic shift due to air under tension.

Reproduced from Torigian DA, Miller Jr WT: Pleural diseases. In Pretorius ES, Solomon JA [eds]: Radiology Secrets, 2nd ed. Philadelphia, Mosby, 2006, Fig. 66-3, p 541.

History of trauma may increase your suspicion of pneumothorax, but many cases occur spontaneously or with exercise or cough. In those cases, a small, unrecognized, subpleural bleb ruptures, leading to the air leak. Some underlying conditions increase the risk of “spontaneous” pneumothorax. Those with asthma, cystic fibrosis, and Marfan’s syndrome are particularly prone to chest pain secondary to pneumothoraces. Also, several cases have been reported in teenagers who smoke crack cocaine.

Uva JL: Spontaneous pneumothoraces, pneumomediastinum, and pneumoperitoneum: Consequences of smoking crack cocaine. Pediatr Emerg Care 13:24–26, 1997.

12 How can anxiety or emotional stress lead to chest pain in children?

The relationship of pain to emotional stress is not quite clear. However, we assume children get headaches and abdominal pain from stress. It is reasonable to conclude that chest pain can also be related to stress. Studies have shown that stress is the cause (psychogenic pain) in about 10% of children with chest pain who present to a pediatric ED. Possible stressors include school failure, recent death or illness in the family, recent loss of friends from moving to a new city or school, and school phobia. It is important to consider stress as an etiology of chest pain in all children who present with the complaint. This should not be a diagnosis of exclusion, but if significant stress is temporally related to the pain, it is a reasonable diagnosis.

13 Why do some adolescents who present with hyperventilation also have chest pain?

Hyperventilation may be associated with psychogenic chest pain, and may lead to pain by producing a hypocapnic alkalosis. Prolonged hyperventilation can lead to coronary artery vasoconstriction and chest pain. Also, stomach distention due to concomitant aerophagia can occur with hyperventilation and produce chest pain. Lightheadedness, headache, and paresthesias may also be found.

Sawni A, Wright K, Ragothaman R: Hyperventilation and chest pain in an adolescent female: Index of suspicion. Clin Pediatr 43:663–666, 2004.

14 Which children with chest pain deserve an evaluation with an electrocardiogram and/or chest radiograph?

1 Those with worrisome historical features:

Acute onset of pain

Chest pain associated with exercise

Associated syncope, dizziness, palpitations

History of heart disease

History of a condition that can affect the heart or lungs—diabetes mellitus, Kawasaki disease, Marfan’s syndrome, asthma, anemia, systemic lupus erythematosus

History of sickle cell disease

Use of cocaine

Trauma

Foreign-body ingestion

Fever

2 Those with an abnormal physical examination:

Respiratory distress

Decreased or abnormal breath sounds

Cardiac findings (murmur, rub, click, arrhythmia)

Fever

Trauma

Palpation of subcutaneous air

15 Which children with chest pain do not need extensive evaluation with laboratory studies in the ED?

Those with chronic pain (and none of the worrisome features mentioned above) do not necessarily need laboratory studies. Management must be individualized, but most patients can be managed with analgesics, reassurance that cardiac disease is unlikely, and close follow-up. If the history and physical examination do not suggest an etiology for the pain, it is unlikely that laboratory tests will be helpful.

16 Why is chest pain of acute onset more worrisome?

Studies have shown that children with sudden onset of pain (within 48 hours of presentation) are more likely to have an organic etiology for the pain. It is not necessarily a serious etiology, but pneumonia, asthma, trauma, and pneumothorax are more likely.

Selbst SM, Ruddy R, Clark BJ, et al: Pediatric chest pain—a prospective study. Pediatrics 82:319–323, 1988.

17 Why is fever associated with chest pain of concern?

Fever is much more likely to be associated with pneumonia, myocarditis, or pericarditis. Endocarditis is a very rare condition in otherwise healthy adolescents, but it should also be considered.

18 Which cardiac conditions can cause chest pain in children?

19 How common is cardiac chest pain in children?

Pediatric chest pain is rarely due to cardiac pathology. Studies have found that only about 4% of children who present to a pediatric ED have a cardiac etiology for their pain, and some of these had known heart disease at the time of presentation.

20 Which arrhythmias can possibly cause chest pain in children?

Consider the possibility of an arrhythmia such as supraventricular tachycardia (SVT) as a cause of chest pain in an older child who reports having palpitations. Ventricular tachycardia and premature ventricular contractions are rare in children, but may also cause sharp chest pain and an irregular cardiac rhythm. They may be found in children taking various medications or drugs such as cocaine.

21 When should I be concerned about a cardiac infection as the cause of chest pain?

Children with infections such as myocarditis or pericarditis can present with chest pain and usually have fever. Those with pericarditis may report a sharp, stabbing, midsternal pain that is somewhat relieved when the patient sits up and leans forward. Distant heart sounds, neck vein distention, and a friction rub may be found. Viral myocarditis is more common and usually presents with low-grade fever and dull substernal chest pain. There is often respiratory distress as the infection progresses, and there may be muffled heart sounds or a gallop rhythm heard. Tachycardia out of proportion to the degree of fever is characteristic. Tachycardia and hypotension may be worse with standing, and this may not resolve after fluid resuscitation. A chest radiograph often reveals cardiomegaly (Fig. 8-2).

Figure 8-2 X-ray of large heart from myocarditis.

22 Which cardiac conditions can lead to ischemia and chest pain?

There are rare conditions that may lead to ischemic myocardial dysfunction in children. For instance, hypertrophic cardiomyopathy can cause pain, especially with exercise. Aortic valve stenosis can also cause ischemia and chest pain. Finally, those with underlying problems of the coronary arteries may develop chest pain. This is not common in children, but some with long-standing diabetes mellitus may have CAD, and children who had Kawasaki disease in the past may have persistent coronary artery aneurysms that can produce symptoms long after the initial illness.

Madhok AB, Boxer R, Green S: An adolescent with chest pain—sequela of Kawasaki disease. Pediatr Emerg Care 20:765–768, 2004.

23 What are the concerns in children with Marfan’s syndrome who report chest pain?

These children may report chest pain due to rupture of an aortic aneurysm, which can be fatal. They are also at risk for spontaneous pneumothorax.

24 Why is chest pain associated with exercise of concern?

Mainly, young children with sudden death had preceding chest pain with exercise. Pain related to serious conditions such as myocarditis, CAD, and hypertrophic cardiomyopathy is worsened by exertion. Such patients should be referred to a cardiologist for further testing, including echocardiography, Holter monitoring, or exercise stress tests. Exercise-induced asthma is another condition in which chest pain is precipitated or worsened by exercise.

25 What is Tietze’s syndrome?

This is a rare condition of unknown etiology that causes sternal chest pain. Physical examination may reveal tender, spindle-shaped swelling at the sternochondral junctions. The condition can last for months.

26 Why do children with asthma report chest pain?

Some possible etiologies include anxiety and overuse of chest wall muscles due to respiratory distress. Some have an associated pneumonia that could lead to diaphragmatic irritation. Others may develop a pneumothorax or pneumomediastinum.

27 What etiology should be considered in an afebrile, previously well toddler, with no injury, who reports sudden midsternal chest pain?

Foreign body in the esophagus. Many young children ingest coins, and most are asymptomatic. However, if the coin lodges in the esophagus (especially in the upper esophagus), the child may report sudden chest pain. Dysphagia may also be present. A chest radiograph or a metal detector usually confirms the diagnosis.

28 When would you suspect hypertrophic cardiomyopathy in a child with chest pain?

There may be a positive family history for this condition. It is generally inherited as an autosomal dominant disorder. A murmur may be heard best when the child is standing or performing a Valsalva maneuver. These positions and exercise may exaggerate the chest pain. Squatting or lying supine minimizes the obstruction and reduces the murmur. This condition is concerning because it is associated with sudden death among young athletes.

Washington RL: Sudden deaths in adolescent athletes caused by cardiac conditions. Pediatr Ann 32:751–756, 2003.

29 Does mitral valve prolapse (MVP) cause chest pain in children?

This is uncertain. Some postulate that MVP causes papillary muscle or left ventricular endocardial ischemia. However, in many cases, chest pain can be attributed to other causes, even in children with MVP. MVP is no more common in children with chest pain than in the general population. About 6–8% of children in the United States are believed to have MVP.

30 Name a cutaneous condition that is associated with chest pain.

Herpes zoster infection (Fig. 8-3). Shingles is often associated with distressing chest pain when the lesions involve a chest wall dermatome. The chest pain can sometimes precede the vesicular rash by several days.

Figure 8-3 Herpes zoster infection.

31 What is “devil’s grip”?

This is an unusual condition also known as pleurodynia. It is characterized by paroxysms of sharp pain in the abdomen or thorax. It is caused by coxsackievirus and may occur in mini-epidemics.

32 What are possible causes of chest pain in a teenage girl with systemic lupus erythematosus?

These patients are at risk for pericarditis, myocarditis, endocarditis, pneumonia, pleural effusion, and myocardial ischemia if they have renal disease and hypertension.

33 Should pulmonary embolism be considered as a cause of chest pain in a child?

Pulmonary embolism is a rare problem in children. Consider it in a child (usually a teenage boy) with minor trauma to a lower extremity. It is very rarely reported in teenage girls who use oral contraceptives and in those who have recently had elective abortions. A patient with a pulmonary embolism usually has accompanying shortness of breath, pleuritic chest pain, fever, cough, and hemoptysis. The finding of a swollen, tender lower extremity on physical examination increases concern about venous thrombosis and a pulmonary embolism.

34 In children with chest pain and sickle cell disease, what are the likely etiologies?

Vaso-occlusive crises may be the cause of pain. However, consider acute chest syndrome in these patients. Pneumonia due to an encapsulated organism is also of concern. Finally, ischemia due to a heart weakened by chronic anemia is possible. All such patients deserve a chest radiograph and perhaps an electrocardiogram as part of their evaluation.

35 Chest pain associated with a “crunching” sound on chest examination is found with which condition?

Pneumomediastinum. Free mediastinal air and subcutaneous emphysema are complications of asthma exacerbation. It may also occur as a result of trauma, or spontaneously. Some children with this finding have associated dyspnea and cough. Crepitation is often noted in the suprasternal notch and may extend to the neck, axilla, and face. A chest radiograph confirms the diagnosis. The condition usually has a good outcome and resolves within a few days. Hospital admission and treatment of the underlying cause (i.e., asthma) are recommended.

Kanegaye JT: An adolescent football player with chest pain. Clin Pediatr 42:471–474, 2003.

36 When should referral to a cardiologist be considered for a child with chest pain?

Chest pain associated with exercise (during or immediately after) requires an evaluation by a cardiologist. If the pediatric patient has pain associated with syncope, dizziness, or palpitations, evaluation by a cardiologist is also reasonable. Furthermore, if the child has a history of underlying heart disease or cardiac arrhythmia or has a previous condition that subjects him to heart disease (i.e., long-standing diabetes mellitus, Kawasaki disease) referral to a cardiologist seems prudent. It is also recommended to have a cardiologist evaluate the child if there is a history of premature sudden death in the family or if the child has hypertension or features of Marfan’s syndrome.

Owens TR: Chest pain in the adolescent. Adolesc Med State Art Rev 12:95–104, 2001.