• Chest pain is common in children and adolescents.
• Despite the degree of concern that it generates, the
symptom is rarely associated with a serious cardiac
• The epidemiology of chest pain in youth is not well
understood, although available data suggest more
cases are classified as idiopathic than are attributed to
a more specific etiology (e.g., cardiac, respiratory).
• Studies approximate between 1% and 10% of pediatric
chest pain cases are due to cardiac etiologies.
history and physical Examination
• A properly done history and physical are often
the only tools required in the evaluation of
pediatric chest pain.
• Screening tests are not considered helpful
unless specifically indicated.
• Eliciting the patient’s or family’s concerns
about their complaint may be useful.
• A medical history of asthma, sickle cell disease,
collagen vascular disease, or a recent coughing
illness may be helpful.
• Long-standing diabetes mellitus and chronic
anemias are risk factors for ischemic chest pain.
• Inquire about a history of Kawasaki disease,
including the possibility of an undiagnosed case.
• The review of systems should include inquiries
about associated acute and chronic symptoms
and any precipitating factors.
• Inquire about choking episodes, recent trauma,
and exercise or activities that could cause pain
from muscle strain or overuse.
• It is critical to distinguish a history of exercise
(that could cause muscular chest wall pain) from
exercise as a precipitating factor (which may be
consistent with ischemic pain and mandates an
urgent cardiac evaluation).
• Associated syncope is very worrisome and also
mandates a cardiac evaluation.
• A medication history could provide clues to a potentially causative
etiology (oral contraceptives) or the possibility of mucosal injury
(e.g., tetracycline, NSAIDs); also investigate the possibility of
substance abuse, especially cocaine and methamphetamine.
• Evaluation of psychosocial factors in the child’s life is very
• Ask about school attendance and performance, relationships with
friends and family, and any current stresses or conflicts.
• The family history should inquire about hypercholesterolemia,
Marfan syndrome, and cardiomyopathy.
• A family history of recurrent syncope or unexplained sudden death
may suggest hypertrophic cardiomyopathy or long QT syndrome.
• Heart disease in an adult family member may provoke anxiety-
related chest pain in a younger person.
• A complete thorough physical exam is
necessary; focusing on the chest exam may
miss findings pertinent to a noncardiac
underlying cause of chest pain.
• Costochondritis is pain due to inflammation of the
costochondral joints (where the bony rib meets the
• It is a common cause of chest pain in children and is
usually unilateral, sharp, transient in nature, and can
be reproduced by palpation on examination.
• Tietze syndrome, a rare form of costochondritis,
affects a single chostochondral, costosternal or
sternoclavicular joint and causes notable swelling,
tenderness, and warmth localized to the affected joint.
• Other skeletal causes of chest pain include
traumatic injury, spondyloarthritis, and stress
fractures. The latter should be considered in
athletes with repetitive upper extremity motions,
especially in the absence of a recognized acute
traumatic event; a bone scan should be
considered if suspicion is high and x-rays are
• Chest wall deformities (pectus carinatum, pectus
excavatum) are rare causes of pediatric chest
• Muscular chest wall pain is common in weight-lifters, but
carrying heavy back packs, severe coughing, and sports
involving rotation or twisting can also be causative.
• Sharp pain in the intercostal muscles can occur with
infection due to coxsackie and other enteroviruses.
• This pain (historically called pleurodynia or Bornholm
disease) is sudden in onset, paroxysmal, and accompanied
by fever and other systemic signs of enteroviral infection
(e.g., vomiting, headache, sore throat).
• Sometimes the illness exhibits a biphasic pattern with a
recurrence of the chest pain and fever several days after
the initial presentation.
• Early puberty may cause chest pain related to
breast nodule development in males and
• Other breast disorders including infections,
cystic disorders, pregnancy, and menstrual
swelling may cause chest pain in females.
Shingles (herpes zoster)
• Pain related to shingles (herpes zoster) may
precede the appearance of the rash.
• Children affected by hypersensitivity pain
syndromes may complain of pain with light
touch to their chest wall, or even with wearing
certain clothing; other somatic complaints are
typically present as well.
• Chest pain is occasionally the initial presentation of
• A history of nocturnal cough, atopy or a remote history of
bronchospasm may support the diagnosis.
• Bronchoconstriction is often reported by children as chest
• Prolonged cough (due to acute exacerbations or poor
control of asthma) can lead to soreness of chest wall
• Asthma also sometimes presents with a complaint of chest
pain with running or exertion (with or without coughing).
• Chest x-ray findings are often normal, but may reveal
hyperinflation, atelectasis, or peribronchial thickening.
Psychogenic chest pain
• It is difficult to clearly define the role of psychological
disorders in cases of pediatric chest pain because of
inconsistent use of valid psychological assessment tools and
differences in research terminology in this area.
• Stress, anxiety, mood disorders, somatoform disorders,
depression, and psychotic disorders have all been
associated with chest pain; the validity of these diagnoses
is impacted by the use (or misuse or nonuse) of appropriate
• The psychological impact of organic causes of chest pain on
patients is also poorly defined, even though it is likely very
relevant to patients and families dealing with a serious
• Providers must be cognizant of the importance of
using valid assessments to diagnose psychological
disorders; psychogenic chest pain should never
be a diagnosis of exclusion.
• Hyperventilation typically presents with rapid
breathing, dyspnea, anxiety, and sometimes with
palpitations, chest pain, paresthesias,
lightheadedness, and confusion.
• Careful evaluation often reveals anxiety or
underlying psychological concerns.
Psychogenic chest pain
Precordial catch syndrome
• Precordial catch syndrome (Texidor twinge) is
classically described as a benign condition
characterized by brief paroxysms of sharp, well-
localized pains in the midsternal or precordial
• Episodes are brief (30 seconds to 3 minutes), self-
resolving, and exacerbated by deep breathing.
• Expert opinions vary regarding whether this
phenomenon is a distinct entity, or if it should be
considered an idiopathic etiology of chest pain.
Pericarditis & Myocarditis
• Infections are rare but serious causes of chest pain in
• Chest pain is frequently a prominent symptom in
pericarditis; it is usually exacerbated by lying down or with
• Physical examination findings include a friction rub, muffled
heart sounds, tachycardia, neck vein distention, and pulsus
• Myocarditis presents with a more subtle but progressive
illness, including fever, chest pain, vomiting, and shortness
of breath. Electrocardiograms are abnormal in each of
these conditions, and cardiomegaly is evident on chest x-
• Asthma, cystic fibrosis, and connective tissue disorders
(Marfan syndrome, Ehlers-Danlos syndrome, ankylosing
spondylitis) are risk factors for pneumothoraces.
• Pneumonias due to certain pathogens (e.g., Pneumocystis
jirovecii in immunodeficient conditions or staphylococcal,
anaerobic gram negative pathogens) also predispose to the
development of pneumothoraces.
• Healthy children may also develop spontaneous
pneumothorax; cocaine use is a risk factor.
• Forceful vomiting is a rare cause of esophageal rupture
causing pneumomediastinum (Boerhaave syndrome).
• Traumatic or iatrogenic causes should also be considered.
• Movement and deep breathing often
aggravate the pain associated with pleurisy
(pleuritis) or pleural effusions.
• Bacterial pneumonias are the most common
cause of pleuritis in children; collagen vascular
disorders can also be causative.
• Risk factors for venous thrombosis (e.g., oral
contraceptives, recent abortion or surgery
[especially cardiac], the presence of a central
venous line, immobilization, sepsis,
hypercoagulable states, vascular malformations)
should raise suspicion for pulmonary emboli.
• Associated symptoms include dyspnea, cough,
hypoxia, and occasionally, hemoptysis.
• If emboli are suspected, appropriate labs and
imaging (spiral CT or pulmonary angiography)
should be performed.
Slipping rib syndrome
• Slipping rib syndrome is characterized by pain along
the lower rib margin of the upper abdomen,
sometimes associated with a slipping sensation and a
popping or clicking sound.
• Although a clear consensus on the cause of the pain is
lacking, a commonly presumed etiology is that trauma
to the eighth, ninth, or tenth rib causes a sprain-like
injury, which increases the mobility of the rib and
allows impingement on an intercostal nerve.
• Reproduction of the pain by hooking the fingers under
the anterior costal margins and pulling the ribs forward
GERD (gastroesophageal reflux
• Symptoms of GERD (gastroesophageal reflux
disease) vary by age; common symptoms in older
children and adolescents are abdominal or
substernal pain, vomiting or regurgitation,
increased pain after meals or when recumbent,
and relief with antacids.
• A trial of empiric therapy is appropriate in
children with typical symptoms, although a
positive response is not confirmatory of GERD
since spontaneous resolution of symptoms (due
to any cause) can occur.
Peptic ulcer disease (PUD)
• Peptic ulcer disease (PUD) frequently
presents with a chronic intermittent history of
dull or aching pain and often includes
• The pain may be epigastric or poorly localized
abdominal pain; it may or may not be relieved
Eosinophilic esophagitis (EoE)
• Eosinophilic esophagitis (EoE) is diagnosed by
endoscopic biopsies showing localized
eosinophilic infiltrates of the esophagus.
• The condition is being increasingly recognized in
all age groups; abdominal pain and vomiting are
more common in younger children and
dysphagia, chest pain, and food impaction are
more likely in adolescents.
• Other atopic diseases and food allergies are
• Consultation with a cardiologist is
recommended because of the potentially
serious (ischemic) nature of chest pain caused
by severe obstructive lesions; it is also
considered a more cost-effective alternative to
obtaining additional studies without
• Hypertrophic cardiomyopathy is a genetic disorder
transmitted in an autosomal dominant pattern, although a
large proportion of cases are considered de novo
• Classic physical examination findings include a left
ventricular lift and a harsh systolic ejection murmur that is
increased with any maneuver that decreases venous return
(Valsalva maneuver, rising from squatting to standing).
• As the development of hypertrophy is gradual over years,
examination findings in children may be limited to
nonspecific murmurs; cardiac evaluation is indicated
whenever there is a known family history.
• Unless suspected to be asthma, chest pain that is
precipitated by exercise or running or is associated with
syncope or palpitations warrants urgent cardiac
• Myocardial ischemia is rare in children overall, although an
increasing number of children are at risk due to advances in
care and treatment of congenital and acquired (Kawasaki)
• Unlike adults with atherosclerotic heart disease, children
do not experience classic angina-type pain (i.e., chest
pressure or squeezing sensation with radiation to neck,
jaws or arms); rather, the symptoms of myocardial ischemia
in younger patients are nonspecific and include irritability,
nausea, vomiting, abdominal pain, failure to thrive, shock,
syncope, seizures, or sudden cardiac arrest.
• The presentation of congenital coronary
artery abnormalities may be subtle or abrupt
with few identifiable risk factors.
• However, children with a history of heart
surgery (e.g., repair of tetralogy of Fallot or
transposition of the great arteries), congenital
heart conditions, or a history of Kawasaki
disease warrant a higher threshold of
awareness for risk of ischemic chest pain.
• Coronary artery anomalies are rare but can be
associated with severe ischemia.
• The physical examination may be normal or may
include tachypnea, tachycardia, pallor,
diaphoresis, distant heart tones, a murmur
consistent with mitral regurgitation, or a gallop
rhythm suggesting myocardial dysfunction.
• Echocardiogram and angiography are used in