Chest pain is a frequent complaint in children, with the highest incidence in the early teenage years. Musculoskeletal structures of the chest wall are the common culprits; cardiac reasons are rarely the cause but should always be considered.
Causes of chest pain in children
- Nonspecific (idiopathic) chest pain is the most common. It is described as a sharp, localized, non-radiating chest pain that lasts for a nonspecific period of time (few seconds to a few hours). It may be exacerbated by deep breathing and by pressure on the chest. The costochondral junctions are not tender to palpation.
- Costochondritis usually presents as unilateral chest pain involving a few costochondral junctions; these are tender to deep palpation.
- Pericarditis causes severe chest pain that often intensifies when the patient lies down in a supine position and lessens when the patient leans forward. The EKG may show ST segment elevation and PR depression. The patient is usually very sick and has other symptoms of inflammation.
- Herpes zoster chest pain is severe and is frequently associated with a typical skin eruption that has a specific dermatomal distribution.
- Pneumothorax causes abrupt severe chest pain.
- Other noncardiac causes of chest pain in children include pneumonia, bronchitis, sickle cell crisis, trauma, muscle strain and asthma.
- Cardiac causes of chest pain in children include hypertrophic cardiomyopathy, aortic stenosis, pericarditis, arrhythmias, mitral valve prolapse and coronary insufficiency. The causes of coronary insufficiency include Kawasaki disease, Williams syndrome, anomalous origin of the coronary arteries and coronary arterio-venous fistulas.
Evaluation of chest pain in children
A good history, including a family history, may help exclude serious causes of chest pain. Benign chest pain is not associated with other symptoms. Chest pain with exercise should raise the suspicion of potentially serious causes and warrants further investigations especially if associated with lightheadedness or presyncope. Exercise induced asthma should also be suspected.
An EKG should be done for any patient with chest pain. Further investigations, including echocardiography or other imaging modalities depend on the history and physical examination. An exercise stress test may be done if the chest pain is associated with physical activities.
The management is directed to the underlying cause. Musculoskeletal chest pain and costochondritis are managed by reassurance and non-steroidal anti-inflammatory medications. Exercise induced asthma is managed with bronchodilators. Cardiac causes of chest pain are managed according to the specific etiology.