Introduction
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:

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:

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:

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:

 

References

For further reading about this subject and a more complete list of all possible etiologies of chest pain in pediatrics, try:

Kocis, Keith C.: Chest Pain in Pediatrics. Pediatric Clinics of North America Volume 46 (2): 189-201, 1999