Pediatric Chest Pain

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Chest pain has a variety of sources, and virtually any structure in the chest can cause pain. This includes the lungs, the ribs, the chest wall muscles, the diaphragm, and the joints between the ribs and breastbone.

Injury, infection or irritation to any of these tissues can be responsible for chest pain.

Occasionally, pain can be referred from another area (such as the abdomen).

Chest pain may also be a manifestation of stress or anxiety.

Rarely, the heart is the source of chest pain in children.

Chest pain may be a symptom of a serious underlying disease. Fortunately, most chest pain in children is caused by benign or self-limited illnesses. Listed below are some common illnesses that can cause chest pain.

Costochondritis

Costochondritis occurs secondary to inflammation of the "joint" between the breastbone and the ribs. It is particularly common in adolescent and pre-adolescent females, but can occur in anyone at any age.

Frequently caused by viral illness or by frequent coughing, upper respiratory symptoms often accompany this illness. It may last for several weeks.

There may be pain when inhaling or exhaling deeply, but true difficulty in breathing is rare and should generate concern for other diagnoses.

The hallmark of costochondritis is tenderness to pressure over the costochondral joint, which corresponds to the depression on the sides of the breastbone.

Treatment typically consists of a one- to two-week course of an over-the-counter anti-inflammatory medicine such as ibuprofen.

Injury

Injury to the muscles and bones of the chest wall can have many causes. Some are obvious such as a direct blow during a sporting event or a fall. Other less obvious causes include heavy lifting, frequent coughing or intense aerobic exercise that can all cause strain to the rib muscles.

Treatment is usually supportive with rest and over-the-counter pain relievers. Consult a physician when injury causes chest pain that is severe, persistent, or associated with difficulty breathing.

Stress or Anxiety

Although few people are willing to believe that stress can elicit such a worrisome symptom, stress-related chest pain is really no different than a stress-related headache. The pain is often dull or non-specific and worsens with stress or anxiety.

Common underlying stressors include loss of a relative, school examinations, and "breaking up" with a boyfriend or girlfriend.

Often stress can make chest pain from another cause seem worse. It is important to decipher whether chest pain is the cause of anxiety or the result.

Precordial Catch Syndrome

A benign illness of unknown cause. It occurs most commonly in adolescents and is characterized by sudden onset of intense, sharp pain along the chest or back.

The pain occurs exclusively with inspiration (inhaling). A typical episode lasts several minutes and resolves spontaneously.

The pain can also be "broken" with a forced deep inspiration. Several episodes may occur per day.

Although its cause remains uncertain, precordial catch syndrome has no significant side effects. There is no specific treatment, and the frequency of events usually declines through adolescence.

Acid Reflux

Can cause stomach or chest pain. It sometimes manifests as a burning sensation below the sternum, though children may not be capable of accurately describing this symptom.

The pain may vary in relation to meals. There are now many prescription and over-the-counter medicines available to treat acid reflux.

Unlike adults, chest pain due to a cardiac cause is extremely uncommon in children. Keep in mind that the following conditions are rare as you review the causes of chest pain.

Pericarditis

An inflammation of the heart lining. It is usually caused by a treatable or self-limited infection, but can have other more serious causes. Typical pericarditis pain is sharp and mid-sternal and may radiate to the shoulders.

Assuming a sitting position or leaning forward frequently alleviates pain. Cough, troubled breathing and fever are common.

Coronary Artery Abnormalities

May limit the heart's oxygen supply and cause symptoms similar to adults with cardiac chest pain. This can be due to congenital abnormalities of the position of the arteries or acquired diseases like Kawasaki disease.

Extreme thickening of the heart muscle and prolonged episodes of fast heart rate can also limit the heart's blood supply. Children may experience a "typical" crushing mid-sternal chest pain that radiates to the neck and chin or to the left shoulder and arm. More likely, children will have less specific complaints.

Troubled breathing and sweating may also occur. Anyone with these symptoms should promptly consult a physician.

Mitral Valve Prolapse

A minor abnormality of the valve that fills the main pumping chamber of the heart (the left ventricle). It occurs in up to 6 percent of women and is less frequent in men.

Although mitral valve prolapse is reportedly associated with an increased incidence of chest pain, the exact cause remains unclear.

In the absence of other worrisome signs and symptoms, chest pain in patients with mitral valve prolapse tends to run an uncomplicated course.

Arterial Aneurysm

An arterial aneurysm is a stretching and out-pouching of the vessel that can lead to rupture. In children, chest pain from an aortic aneurysm is extremely rare, and it occurs almost exclusively in the setting of other uncommon diseases, particularly Marfan syndrome.

Other Causes of Chest Pain

Other relatively common causes include inappropriate accumulation of air, fluid, or inflammation in the chest as well as lung infections and asthma. Look for other worrisome symptoms to determine if your child needs prompt evaluation.

What should I do if my child has chest pain?

Don't panic. Remember, chest pain is usually due to a benign or self-limited illness. Heart disease or other serious illness is an unlikely cause.

However, if your child has severe chest pain or chest pain associated with troubled breathing, fever, sweating, or a heart rate greater than 200, you should promptly consult with a physician.

In the absence of these symptoms, most chest pain can wait for a convenient time to be evaluated. Call your doctor if you are unsure.

If I think my child needs to be evaluated, what kind of doctor should I see?

It is usually better to start with your pediatrician or family doctor rather than a specialist. Most children with chest pain do not require the services of a specialized physician.

Additionally, different causes of chest pain fall under the expertise of different types of specialists. If you do need to see a specialist, your doctor can decide which type of doctor is most appropriate.

What should I expect at the physician's office if my child is seen for chest pain?

The evaluation usually starts with a thorough history of the problem and a physical evaluation. After that, the evaluation may vary markedly depending on the initial findings.

Many children will require no further testing to establish a diagnosis and start treatment. In some cases, chest X-ray, electrocardiograms, breathing studies, or consultation with a specialist may be necessary.

What if my child specifically says that his or her "heart hurts"?

For many young children, the heart is the most identifiable organ in the chest, so they use this phrase to denote chest pain of any kind.

The good news is that children are rarely able to distinguish between cardiac and non-cardiac chest pain, so they are unlikely to be correct in laying blame on the heart.

The bad news is that once parents and other caregivers hear this phrase, it can be extremely difficult to persuade them that the heart is not the culprit.

Children who complain of "heart pain" should be evaluated like other children with chest pain, with attention paid to severity and associated symptoms.


Last Updated 07/2014