Chest pain at its most basic level is the body warning itself about injury or possible
injury to a structure in the chest. The chest contains many different structures so
pinning down the source of the pain can be difficult. Parents and patients are usually
very upset about this common symptom because they know that in adults chest pain often
signifies myocardial infarction (heart attack). However, cardiac causes of chest pain are
among the least likely causes in pediatric patients. Symptoms are chronic in over half of
the patients seen, but 81% of these resolve over time.
There are two main types of pain that can help the doctor to decide where the symptom
is coming from. The first type is somatic pain, which is usually described as sharp,
burning, stabbing, and is often easy to point to. Somatic pain arises from the skin or
just under it, or may come from muscle and bones. The second type is visceral pain, which
originates in organs and body cavity linings. It is frequently described as dull, pressure
or vice-like, and it can be difficult to point out a specific area affected. Armed with
knowledge of which of these pain types is affecting the patient, the doctor can
significantly narrow down the number of possible diagnoses.
1) Idiopathic Chest Pain
The most common cause of chest pain is idiopathic, meaning that no organic or
psychological cause for the pain is ever found by medical work up, accounting for 12-85%
of all pediatric chest pain. This cause is most common in adolescent females during
periods of rapid growth. This is a diagnosis of exclusion, being made only when all other
tests have been inconclusive, and most often resolves on its own over time.
2) Musculoskeletal Chest Pain
Diagnosed in 15-30% of cases, musculoskeletal pain is usually the result of muscle
strain or overuse. Symptoms often follow physical exercise like weight lifting, pushups or
school sports, especially if the patient is not used to such activity. Musculoskeletal
chest pain is generally somatic pain and can be reproduced in the office by the physician
in the majority of cases. The following are causes other than muscle strain:
- CostochondritisAn inflammation of the cartilage connecting the ribs to the
sternum. This syndrome is most common in females, and the pain can be easily reproduced in
- Tietze SyndromeSimilar to costochondritis, but has a noticeable swelling of
the affected cartilage to bone junction.
- Slipped Rib SyndromeThis syndrome is caused by an increased mobility of the
8th to 10th ribs (which are not attached to the sternum like the other 7 pairs). Patients
often feel a clicking or slipping movement in the chest with movement or lifting. Doctors
can reproduce the pain by using the "hooking maneuver" and pulling the lower
ribs toward the front of the body.
- Breast MassesBreast masses can be found in males and females during puberty
and are a source of chest pain. After menstruation begins, girls often have breast pain
that changes with menstrual cycle. Breast masses in children and adolescents are nearly
3) Pulmonary Chest Pain
Chest pain originating in the lung explains 12-21% of cases, and is more common in
children under 12 years old. Most pulmonary causes can be diagnosed by chest x-rays and
listening with the stethoscope. The three most common sources are asthma, pneumonia and
chronic cough. The majority of pulmonary chest pain is made worse with deep breathing or
coughing and is often sharp in character; this is called "pleuritic" pain. In
addition to these three, other, rarer causes follow:
- AsthmaA reactive airway disease often found in children. The spasm of airways
may cause difficulty breathing, wheezing and pain.
- PneumoniaA lung infection caused by virus or bacteria that may cause shortness
of breath, cough and chest pain. Usually accompanied by fever.
- Chronic CoughPain is from either strain on the muscles between the ribs or
from irritation of airways, both from overuse in coughing fits.
- PleurodyniaA pain syndrome caused by Coxsackie virus that causes spasms of
sharp pain in the chest, often with fever.
- Pulmonary EmbolusPain caused by a blood clot in the lung circulation that
causes death of lung tissue. Pain is sudden and is often associated with difficulty
breathing. This occurrence is very rare in children unless they are already predisposed to
blood clotting disorders or are adolescent females on birth control pills.
- PneumothoraxAir enters the space around the lung, which may lead to a collapse
of the lung and inability to breath adequately. It may happen spontaneously in teenagers,
or after trauma and can be a medical emergency. Symptoms vary based on the extent of the
pneumothorax and may include pain with breathing, difficulty breathing and even loss of
- Acute Chest SyndromeOnly found in patients with sickle cell disease. This pain
syndrome is caused by an acute sickling crisis of the pulmonary blood supply.
4) Psychological Chest Pain
Psychological causes in the absence of organic causes account for 5-17% of chest pain
in pediatrics. There is an increased frequency in females. Most often the patient has one
or more significant life stressors that precede the pain, such as death of a family
member, school problems, divorce in the family, fights or problems with peers, abusive or
violent families, etc. Hyperventilation also falls into this category of problems.
5) Gastrointestinal Pain
Pain coming from the esophagus, gut and liver is only implicated in 4-7% of chest pain
cases. The two most common causes are as follows:
- Esophageal refluxThis is common heartburn, caused by a reflux of acid stomach
contents back up into the esophagus. Usually described as a burning pain in the center of
the chest, sometimes with the feeling of acid or liquid in the back of the throat.
Symptoms are increased or decreased by different foods, and by body position.
- CholecystitisGallstones are occasionally a cause of lower right sided chest
pain, most common after meals. Gallstones are uncommon in pediatric patients, but not
6) Cardiac Chest Pain
The heart is the cause of chest pain in only 4-6% of cases. Even of those patients
referred to cardiologists only 5-15% had a cardiac cause for their pain. Of course, though
they are rare, cardiac causes are important because they tend to be the most dangerous of
all the causes of chest pain. A history of syncope (fainting), palpitations, previous
cardiac surgery or a family history of unexplained early deaths all raise suspicion of
cardiac problems. The tests used for working up cardiac pain are careful listening with
the stethoscope, ECG, and occasionally an echocardiogram.
Another type of pain that is found predominantly in heart causes of chest pain is
"ischemic" or "angina"described as crushing or pressure on left
side of chest or on center of chest sometimes radiating to left arm. Ischemic pain is
usually felt with or after exertion, builds to a peak then subsides, lasting only minutes.
This type of pain is due to decreased oxygen reaching the muscle cells of the heart
itself. The following are the most common sources of cardiac pain:
- Hypertrophic Obstructive CardiomyopathyThis is a structural abnormality of the
heart with a genetic transmission in families. Symptoms include ischemic pain, shortness
of breath, fatigue, difficulty breathing while lying flat, fainting, and heart
palpitations. This abnormality carries a risk of sudden death.
- Severe aortic and pulmonic valve stenosisThese valve abnormalities may cause
ischemic chest pain because the heart is not receiving enough oxygenated blood to keep it
- Mitral Valve ProlapseThe mitral valve in some people is floppy and is
sometimes associated with a heart murmur and a clicking noise heard with the stethoscope.
The cause of the chest pain in these patients is not very well known.
- PericarditisThis is an infection or inflammation of the sack that surrounds
the heart. Found often with autoimmune disorders or after a viral illness.
- MyocarditisThis is inflammation of the heart muscle itself and is similar to
- Kawasaki syndromeAn infectious illness that may lead to small aneurysms of the
arteries to the heart which then may get plugged or ruptures, thereby reducing blood flow
to the heart.
- Drug useAdolescents using cocaine may have spasm of the arteries to the heart
leading to chest pain and possibly heart attack. Nicotine from cigarettes can also cause
- ArrhythmiasThese heart rhythm disturbances are common in children, most being
harmless. A few of these arrhythmias can be dangerous, such as ventricular and
supraventricular tachycardias. Symptoms are usually the feeling of palpitations (the
uncomfortable feeling of the heart beating, possibly in an irregular fashion), feeling
that the heart is skipping beats, and chest pain. ECG is often diagnostic in these cases,
but sometimes patients are put on a Holter monitor for 24 hours to watch for unexplained
changes in rhythm.
- Angina and myocardial infarctionAnginal or ischemic pain is not terribly
common in children, but can occur, usually coming from several of the above problems.
Myocardial infarction (heart attack) is very rare in children. When it does occur, the
pain is crushing, constricting or heavy, behind the sternum, and lasts from half an hour
to hours. The pain of a heart attack can be similar to anginal pain, but lasts longer than
a few minutes and may not follow exercise.