Chest Pain in Children and Adolescents

Chest pain in children and adolescents is a common complaint that, understandably, often causes significant worry for both the child and their family, since chest pain is widely associated with heart problems in adults. In children, however, the relationship between chest pain and the heart is quite different: the large majority of pediatric chest pain, typically well over ninety percent of cases evaluated in a clinical setting, has a cause unrelated to the heart, most often involving the muscles, cartilage, and bones of the chest wall, the lungs and airways, digestive system, or, particularly in adolescents, stress and anxiety.

Cardiac causes of chest pain do exist in children and are the focus of careful evaluation whenever a child presents with this symptom, but they represent a distinct minority of cases. Because it is not possible to reliably tell a benign cause from a rare, more serious one based on the pain alone, the specific pattern of the pain, its relationship to exercise, and any accompanying symptoms are what guide a physician's evaluation.

• Musculoskeletal causes — the most common; include muscle strain from physical activity or heavy lifting, and costochondritis, an inflammation of the cartilage connecting the ribs to the breastbone that typically produces pain that can be reproduced by pressing on the affected area
  
  
• Precordial catch syndrome — a distinctive, sharp, brief stabbing pain lasting only a few seconds, sometimes worsened by a deep breath; a common and harmless cause seen particularly in school-age children
  
  
• Respiratory causes, including asthma, are a frequent source of chest pain that occurs specifically with exercise
  
  
• Digestive causes, particularly gastroesophageal reflux, tend to produce a burning sensation that is often worse after eating or when lying down
  
  
• Anxiety or panic, in adolescents especially, sometimes accompanied by rapid breathing or a racing heart sensation
  
  
• Cardiac causes — uncommon but include structural problems that obstruct normal blood flow out of the heart, certain rare coronary artery abnormalities that can cause pain specifically with exertion, inflammation of the heart muscle or its surrounding lining, and, in some cases, an underlying arrhythmia
  
  
• Elevated risk indicators — a family history of sudden unexplained death, cardiomyopathy, or a known inherited heart condition raises the level of concern for a cardiac cause even when the pain itself seems otherwise typical of a benign source

• Any child with chest pain should be evaluated by a pediatrician, both to address the symptom and to provide reassurance, even though the great majority of cases turn out to have a straightforward, non-cardiac explanation
  
  
• Certain features warrant more urgent or specialized evaluation by a pediatric cardiologist:
  • Pain that occurs specifically during exercise or physical exertion rather than at rest
  • Pain accompanied by a racing or irregular heartbeat, dizziness, or fainting
  • Pain associated with a previously undetected heart murmur or other abnormal findings on physical examination
  • Pain occurring in a child with a personal history of heart disease or a family history of sudden unexplained death, cardiomyopathy, or an inherited arrhythmia syndrome

• In general, chest pain that occurs only at rest, is reproducible by pressing on the chest wall, or is brief and sharp lasting only a few seconds is more typical of a benign, non-cardiac cause, while pain triggered consistently by exertion deserves closer scrutiny

When cardiac evaluation is warranted, it typically includes a detailed history, physical examination, and an electrocardiogram, with further testing such as an echocardiogram added if any of these initial findings raise specific concern.