Chest Pain in Children

Chest pain is a common complaint among children of all ages. It rarely is due to cardiac disease, but deserves careful evaluation. (See also SHA June, 1996, p. 7) The most common heart problems leading to chest pain in children are listed in the accompanying table.

Coronary artery disease-Ischemia/Infarction

• Anomalous coronary arteries

• Coronary arteritis (Kawasaki disease)

• Long-standing diabetes mellitus

Arrhythmia Structural abnormalities

• Supraventricular tachycardia • Hypertrophic cardiomyopathy

• Ventricular tachycardia • Severe pulmonic stenosis

Infection • Aortic valve stenosis

• Pericarditis • Mitral valve prolapse

• Myocarditis

Musculoskeletal Pain

This is one of the most common diagnoses in children who have chest discomfort. Active children frequently strain chest wall muscles while wrestling, carrying heavy books, or exercising. Direct trauma to the chest may result in a mild contusion of the chest wall or, with more significant force, a rib fracture, hemothorax, or pneumothorax. In most cases, there is a straightforward history of trauma, and the diagnosis is clear.

Respiratory Conditions

Children who have severe, persistent cough, asthma, or pneumonia may complain of chest pain due to overuse of chest wall muscles. Some children may complain of chest pain with exercise due to exercise-induced asthma.

Psychogenic Disturbances

Stress or anxiety can precipitate chest pain in both boys and girls. Often the stress that results in somatic complaints is not readily apparent and not all of these children present with hyperventilation or an anxious appearance. However, 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, it is reasonable to conclude that the symptoms are related to the event.

Gastrointestinal Disorders

Such conditions as reflux esophagitis often cause chest pain in young children and adolescents. The pain is described classically as burning, substernal in location, and worsened by reclining or eating spicy foods. Likewise, some young children will complain of chest pain following the ingestion of a coin or other foreign body that lodges in the esophagus. In general, the child or parent gives a clear history of recent foreign body ingestion.

Miscellaneous Causes

Some instances of chest pain are related to underlying disease. For instance, sickle cell disease may lead to vaso-occlusive crises or acute chest syndrome. Marfan syndrome may result in chest pain and fatal dissection of an abdominal aortic aneurysm. Collagen vascular disorders may lead to pleural effusions. Shingles may result in severe chest pain that precedes or occurs simultaneously with the classic rash. Likewise, infection with coxsackie virus may lead to pleurodynia with sharp pain in the chest or abdomen. Children also may complain of chest pain when there is breast tenderness from physiologic changes of puberty or from early changes of pregnancy. A careful history and physical exam will often sort these out.

Unfortunately, in 20% to 45% of cases of pediatric chest pain, no diagnosis can be determined with certainty and the child’s pain is labeled as idiopathic.

Musculoskeletal disorders

• Chest wall strain

• Direct trauma/contusion

• Rib fracture

• Costochondritis

Respiratory disorders Psychologic disorders

• Severe cough • Stress-related pain

• Asthma

• Pneumonia

• Pneumothorax/

pneumomediastinum

• Pulmonary embolism

Gastrointestinal disorders

• Reflux esophagitis

• Esophageal foreign body

Miscellaneous disorders

• Sickle cell crisis

• Abdominal aortic aneurysm (Marfan syndrome)

• Pleural effusion (collagen vascular disease)

• Shingles

• Pleurodynia (coxsackie virus)

• Breast tenderness (pregnancy, physiologic)

Idiopathic

(Selbst S. Chest pain in children. Pediatrics in Review 1997; 18(5):169-173)

COMMENT: The child who has pain of acute onset, that interferes with sleep, is precipitated by exercise, or is associated with dizziness, palpitations, syncope, or shortness of breath should be evaluated. Usually diagnostic tests will include at least a chest x-ray and ECG.  R. A.