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Causes of nontraumatic chest pain in children and adolescents

Causes of nontraumatic chest pain in children and adolescents
Literature review current through: Jan 2024.
This topic last updated: Apr 08, 2022.

INTRODUCTION — Chest pain is a common presenting complaint in children. Although the etiology is benign in most cases, this symptom may lead to school absences and/or restriction of activities and causes considerable anxiety in patients and their families or caregivers. A thorough history and physical examination usually can determine the cause and identify patients who require acute intervention and those who can be managed with reassurance and continued follow-up. Laboratory testing is necessary only in a small number of patients [1]. In the absence of associated symptoms of illness, positive findings on physical examination related to the cardiac or respiratory systems, or symptoms during exertion, a serious organic cause is unlikely.

This topic will discuss the causes of nontraumatic chest pain in children and adolescents. The approach to nontraumatic pediatric chest pain, pediatric thoracic trauma, and the emergent evaluation of respiratory distress in children and adolescents, with or without chest pain, is discussed separately:

(See "Nontraumatic chest pain in children and adolescents: Approach and initial management".)

(See "Overview of intrathoracic injuries in children".)

(See "Thoracic trauma in children: Initial stabilization and evaluation".)

(See "Chest wall injuries after blunt trauma in children".)

(See "Pulmonary contusion in children".)

(See "Acute respiratory distress in children: Emergency evaluation and initial stabilization".)

EPIDEMIOLOGY — Nontraumatic chest pain is a common symptom in children and adolescents and is a frequent complaint in patients seeking primary, emergent, or subspecialty care [2-6]. In the majority of pediatric patients, chest pain is not caused by a serious medical condition. However, potentially life-threatening cardiac conditions (eg, hypertrophic cardiomyopathy, myocarditis, or myocardial ischemia) and serious pulmonary conditions (eg, acute chest syndrome in patients with sickle cell disease, spontaneous pneumothorax, or pulmonary embolus) are found in 1 to 6 percent of pediatric patients with chest pain depending upon the setting.

Chest pain causes considerable anxiety in patients and their families or caregivers. Because of its association with fatal heart disease in adults, this symptom is viewed as a harbinger of serious cardiac disease in approximately half of patients seeking medical attention [3,7,8]. This interpretation is more common after the occurrence of sudden death involving an athlete in the community or at the professional level. As an example, in a series of 100 adolescent patients seen in a general pediatric clinic, nearly all of whom had no serious illness, 44 percent thought they were having a heart attack or were worried about heart disease (12 percent) or cancer (12 percent) [7].

Pediatric chest pain also has important functional consequences because it may result in restriction of activities and school absences. In the review of 100 adolescents noted above, restriction of activities was reported in 69 percent of patients and 41 percent had absences from school because of pain [7]. In another pediatric emergency-based survey of 336 children younger than 18 years of age with chest pain, 27 percent reported missing school because of the pain [9]. Thus, it is important for clinicians to address patient and caregiver concerns during evaluation.

ETIOLOGY — Causes of chest pain in children vary among reports and depend in part upon whether patients were seen in an emergency department with acute symptoms or in a pediatric or cardiology setting with a more chronic complaint [1-4,7,8,10-16]. In all settings, patients typically have no serious underlying condition (table 1) [8,10,17,18]. However, chest pain can arise from serious and life-threatening illness in some patients.

LIFE-THREATENING CONDITIONS — Life-threatening causes of pediatric chest pain, primarily consist of cardiac conditions and, depending upon the clinical setting, are found in 1 to 6 percent of children (table 1) [1-4,7,8,10-16]. Pulmonary embolism, pulmonary hypertension, and, in children with sickle cell disease, acute chest syndrome, are potentially life-threatening conditions but occur rarely (<1 percent of pediatric patients with chest pain).

Cardiac disease — Heart disease is more likely if chest pain occurs during exertion or is associated with palpitations, syncope with exertion, or decreased exercise tolerance [4]. Patients with known congenital heart disease, heart transplant, substance abuse, or prior Kawasaki disease are at heightened risk for myocardial ischemia. A positive family history of cardiomyopathy, cardiac arrhythmia, or sudden death in close relatives before the age of 50 years should also raise suspicion. In addition to a suggestive history, most patients with heart disease will have an abnormal cardiac examination or electrocardiogram (table 2). In patients with known heart disease, chest pain may indicate progression of the underlying condition. All patients with concerning finding warrant prompt consultation with a pediatric cardiologist.

Heart conditions that may present with chest pain in children include:

Congenital heart disease with left ventricular outflow tract obstruction — Hypertrophic cardiomyopathy, aortic stenosis (subvalvar, valvar, or supravalvar), or coarctation of the aorta may cause decreased coronary blood flow and angina. (See "Hypertrophic cardiomyopathy: Clinical manifestations, diagnosis, and evaluation", section on 'Chest pain' and "Clinical manifestations and diagnosis of coarctation of the aorta", section on 'Older infants and children' and "Valvar aortic stenosis in children", section on 'Clinical features'.)

Coronary artery abnormalities — Although uncommon, a variety of coronary artery abnormalities occur in children, including congenital and acquired conditions (eg, coronary artery aneurysm or stenosis caused by Kawasaki disease) (table 3 and image 1) and may present with chest pain on exertion. Anomalous origin of the left coronary artery from the main pulmonary artery usually presents in infancy, but can become symptomatic later in childhood. In that disorder, left ventricular ischemia usually results in cardiomyopathy and mitral regurgitation. Origin of a coronary artery from the contralateral sinus of Valsalva and coursing of the anomalously positioned coronary artery between the aorta and pulmonary artery can be associated with exertional chest pain. In these patients, the pain is caused by compression of the coronary artery between the distended great arteries with the increased cardiac index associated with exercise with the following anatomic variants (see "Congenital and pediatric coronary artery abnormalities" and "Kawasaki disease: Clinical features and diagnosis", section on 'Cardiovascular findings'):

Slit-like coronary orifice

Acute angle of take-off of the coronary artery

Presence of an intramural segment

Classic angina — Although uncommon, children and adolescents with predisposing conditions, such as hyperlipidemia, prior Kawasaki disease with coronary artery aneurysms or stenoses, or collagen vascular disease (eg, systemic lupus erythematosus) can develop classic angina consisting of crushing or squeezing substernal chest pain with radiation to the jaw or left arm and associated with diaphoresis, nausea and vomiting, difficulty breathing, or altered mental status. An electrocardiogram (ECG) obtained while the patient has pain often shows ST wave elevation or depression (table 4 and waveform 1). Measurement of cardiac troponins can aid the diagnosis in patient for whom the chest symptoms or ECG are equivocal. However, reperfusion therapy should not await the results of troponin testing in patients with clear findings of an acute myocardial infarction on ECG. (See "Electrocardiogram in the diagnosis of myocardial ischemia and infarction" and "Troponin testing: Clinical use", section on 'Diagnosis of acute MI'.)

Variant angina — Coronary vasospasm (variant angina) and myocardial infarction are rare causes of chest pain in children and adolescents. Coronary vasospasm is associated with angina, transient ischemic changes on ECG during episodes of pain, cardiac enzyme elevation, and ST-segment elevation on ambulatory ECG monitoring. Variant angina with myocardial infarction has been described after recreational use of cocaine, amphetamines, bath salts (methcathinones), marijuana, and synthetic cannabinoids in adolescents. (See "Cocaine: Acute intoxication", section on 'Cardiovascular' and "Acute amphetamine and synthetic cathinone ("bath salt") intoxication", section on 'Cardiovascular system' and "Synthetic cannabinoids: Acute intoxication", section on 'Clinical manifestations'.)

The clinical presentation, diagnosis, and management of variant angina is discussed in detail separately. (See "Vasospastic angina".)

Pericarditis — The major clinical manifestations of acute pericarditis include (see "Acute pericarditis: Clinical presentation and diagnosis", section on 'Clinical features'):

Chest pain that is typically sharp, increased with inspiration, improved by sitting up and leaning forward, worsened by lying down, and occasionally radiates to the left shoulder

Pericardial friction rub described as a superficial scratchy or squeaking sound best heard with the diaphragm of the stethoscope over the left sternal border during the systolic, diastolic or both phases of the cardiac cycle

Electrocardiographic (ECG) changes such as new widespread ST elevation or PR depression; later in the course there is T wave inversion

Distant heart sounds and/or pulsus paradoxus suggesting pericardial effusion

Pericarditis may be of infectious origin (eg, nonspecific viral, bacterial, tuberculous, or secondary to human immunodeficiency virus), associated with open heart surgery (postpericardiotomy syndrome), or complicate an underlying condition such as collagen vascular disorder, uremia, neoplasm, or trauma. The diagnosis of acute pericarditis is usually suspected based upon a history of characteristic pleuritic chest pain, and confirmed if a pericardial friction rub is present. Pericarditis should also be suspected in a patient with persistent fever and new, unexplained cardiomegaly. Additional testing, which typically includes blood work, chest radiography, electrocardiography, and echocardiography, can support the diagnosis. The electrocardiogram is usually the most helpful test in the evaluation of patients with suspected acute pericarditis. Echocardiography can identify the presence and size of a pericardial effusion, potential presence of cardiac tamponade, and assess coexisting myocarditis by determining myocardial function. (See "Acute pericarditis: Clinical presentation and diagnosis", section on 'Diagnosis'.)

Myocarditis — Viral myocarditis in children, which is usually painless, may occasionally cause chest pain when concomitant pericarditis is present (table 5). Children with myocarditis also may display tachycardia that is out of proportion to fever or persistent while quiet or asleep, respiratory distress, signs of heart failure, poor perfusion, and atrial or ventricular arrhythmias. (See "Clinical manifestations and diagnosis of myocarditis in children".)

In 2020, a new cause of myocarditis was associated with coronavirus disease 2019 (COVID-19) as a finding in multisystem inflammatory syndrome in children (MIS-C) (table 6 and table 7). Clinical manifestations of this syndrome have similarities to those associated with Kawasaki disease (table 8). (See "COVID-19: Multisystem inflammatory syndrome in children (MIS-C) clinical features, evaluation, and diagnosis".)

Dilated cardiomyopathy — Children with dilated cardiomyopathy can develop chest pain in association with syncope, decreased exercise tolerance, and heart failure symptoms (eg, orthopnea or dyspnea on exertion). From 20 to 50 percent of patients with dilated cardiomyopathy have an inherited form. A family history of heart failure before the age of 60 years or sudden death suggests a genetic cause. (See "Heart failure in children: Etiology, clinical manifestations, and diagnosis", section on 'Etiology and pathophysiology' and "Familial dilated cardiomyopathy: Prevalence, diagnosis and treatment", section on 'Diagnosis of familial DCM'.)

Tachyarrhythmias — Tachyarrhythmias (eg, supraventricular tachycardia with or without underlying Wolff-Parkinson-White syndrome, ventricular tachycardia) are usually painless, but, if sustained, may cause angina. Some children may also experience the sensation of palpitations associated with tachyarrhythmias or premature beats and report this sensation as chest pain. (See "Clinical features and diagnosis of supraventricular tachycardia (SVT) in children", section on 'Signs and symptoms'.)

Aortic root dissection — Aortic root dissection causes an abrupt onset of severe sharp or tearing pain that may be localized to the anterior chest (ascending aortic dissection) or posterior chest (descending aortic dissection) with radiation to other parts of the chest, back or abdomen. It is associated with Marfan syndrome, Turner syndrome, type IV Ehlers-Danlos syndrome, homocystinuria, rare familial aortopathies, or cystic medial necrosis. (See "Epidemiology, risk factors, pathogenesis, and natural history of thoracic aortic aneurysm and dissection", section on 'Prior aortic dissection' and "Epidemiology, risk factors, pathogenesis, and natural history of thoracic aortic aneurysm and dissection", section on 'Genetic predisposition' and "Clinical manifestations and diagnosis of Turner syndrome", section on 'Aortic dissection'.)

Ruptured sinus of Valsalva aneurysm — Ruptured sinus of Valsalva aneurysm is a rare condition caused by congenital absence of media in the aortic wall behind the sinus of Valsalva. The aneurysm typically ruptures into the right ventricle or right atrium but can affect the other chambers or pulmonary artery and cause a continuous murmur and heart failure. (See "Clinical manifestations and diagnosis of thoracic aortic aneurysm", section on 'Symptomatic TAA'.)

Etiologies other than cardiac disease — Other serious causes of nontraumatic chest pain consist of rare but important conditions of the lung and esophagus.

Spontaneous pneumothorax — Spontaneous pneumothorax typically occurs in older male adolescents and is associated with a tall, thin body habitus. Other important underlying causes include drug use (eg, snorting cocaine or methamphetamines, bong use, and smoking marijuana cigarettes) scuba diving, airway disease (eg, asthma or cystic fibrosis), congenital lung disease, foreign body aspiration, menstruation in postmenarcheal females (catamenial pneumothorax), and connective tissue disease (eg, Marfan syndrome or Ehlers-Danlos syndrome (table 9)). (See "Spontaneous pneumothorax in children", section on 'Risk factors'.)

Pneumothorax typically causes acute onset of sharp chest pain that is worsened by inspiration. A large pneumothorax may present with decreased chest excursion, diminished breath sounds, hyperresonant percussion, and decreased vocal fremitus on the affected side. Other signs of respiratory compromise may include tachypnea, increased work of breathing, and cyanosis. (See "Spontaneous pneumothorax in children", section on 'Physical examination'.)

Because the mediastinum is less mobile in older adolescents in whom spontaneous pneumothorax is most common, tension pneumothorax does not typically occur. When present, signs suggestive of tension pneumothorax include deviation of the trachea towards the contralateral side, tachycardia, hypotension, and cyanosis (figure 1). Heart sounds may be diminished and the apical impulse shifted to the contralateral side. Tension pneumothorax is a respiratory emergency and requires urgent decompression. (See "Thoracostomy tubes and catheters: Indications and tube selection in adults and children", section on 'Tension pneumothorax'.)

The diagnosis of pneumothorax is established by anteroposterior and lateral chest radiographs in the upright position, when possible or by bedside ultrasound. Characteristic findings consist of air in the pleural space outlining the visceral pleura (pleural line) and hyperlucency and an attenuation of vascular and lung markings on the affected side (image 2). Spontaneous pneumothorax occurs more commonly on the left side (image 3). However, obtaining a chest radiograph should not delay needle or chest tube decompression in patients with life-threatening signs of tension pneumothorax. (See "Spontaneous pneumothorax in children", section on 'Diagnosis'.)

Pulmonary embolism — As in adults, pulmonary embolism (PE) or infarction can manifest with pleuritic chest pain, tachypnea, cough, tachycardia, acute dyspnea, and sudden collapse. Most commonly, however, the clinical manifestations of PE in children, especially younger ones, are not specific and often mimic the clinical symptoms of the underlying disease. For this reason and because infants and young children cannot verbalize their symptoms, PE should be considered in the differential diagnosis of cardiorespiratory deterioration in all critically ill children. Risk factors for PE in children include immobility, oral contraceptive use, pregnancy termination, ventriculoatrial shunts for hydrocephalus, central venous catheters, solid tumors, heart disease, infection, dehydration, hypercoagulable states, low cardiac output, and obesity. Tachycardia, hypoxia, and an abnormal ECG may be present. (See "Venous thrombosis and thromboembolism (VTE) in children: Risk factors, clinical manifestations, and diagnosis", section on 'Pulmonary embolism'.)

Pulmonary hypertension — Pulmonary hypertension can be secondary to lung disease, congenital heart disease, or other systemic disorders (eg, systemic lupus erythematosus), or have no identified cause (idiopathic pulmonary arterial hypertension) (table 10). It may rarely cause chest pain but more often causes other symptoms, such as fatigue, lethargy, and dyspnea or syncope with exertion. The mechanism of chest pain is uncertain. An electrocardiogram shows signs of right ventricular hypertrophy and right axis deviation. The ECG may show right ventricular strain (abnormal T waves in the anterior leads).

Acute chest syndrome — Acute chest syndrome is a serious and potentially fatal cause of chest pain in patients with sickle cell disease. It occurs in almost one-half of patients with the disorder. In addition to chest pain, acute chest syndrome is characterized by the presence of a new pulmonary infiltrate involving at least one complete lung segment (not atelectasis), temperature >38.5ºC, and tachypnea, wheezing, or cough. (See "Acute chest syndrome (ACS) in sickle cell disease (adults and children)", section on 'Diagnostic criteria'.)

Airway foreign body — Although most airway foreign bodies are painless, children with an acute airway foreign body can present with severe respiratory distress, cyanosis, altered mental status, and occasionally with chest pain. A history of choking may or may not be reported. Complete obstruction should be managed according to the American Heart Association recommendations for choking (algorithm 1). (See "Airway foreign bodies in children", section on 'Life-threatening foreign body aspiration'.)

In the more common, less emergent situation, the physical examination may reveal generalized wheezing or localized findings, such as focal monophonic wheezing or decreased air entry. Regional variation in aeration is an important clue to the diagnosis, and often is detected only if the clinician takes the time to do a thorough examination when the child is quiet and with minimal ambient noise. Nonspecific findings of cough and generalized wheezing are often present. Diagnosis and management of less acute pediatric patients with an airway foreign body is discussed separately. (See "Airway foreign bodies in children", section on 'Suspected foreign body aspiration'.)

Tumor — Malignant masses of the breast, chest wall, lung cavity, or mediastinum can rarely cause pain due to impingement on adjacent structures, spontaneous hemorrhage into the tumor, or when the tumor rapidly outgrows its blood supply. Depending upon the specific type of tumor, associated findings may include weight loss, bone pain or limp, recurrent fevers, excessive bruising or bleeding, abdominal or neck masses, fatigue, or pallor. Pediatric cancers that may involve the thorax include soft tissue sarcomas, primitive neuroectodermal tumors, Ewing sarcoma, neuroblastoma, lymphomas, and leukemias. Breast masses in adolescent females may rarely be caused by primary or metastatic breast cancer. All patients with possible neoplasms involving the chest or breast warrant prompt consultation with a pediatric oncologist to guide further evaluation and management. (See "Breast masses in children and adolescents", section on 'Breast cancer' and "Overview of common presenting signs and symptoms of childhood cancer", section on 'Mediastinal masses'.)

Esophageal rupture (Boerhaave syndrome) — Nontraumatic esophageal rupture in association with excessive vomiting or retching, coughing, asthma exacerbation, or marked straining (eg, childbirth or severe constipation) occurs rarely in children and adolescents [19]. Affected patients typically report severe retrosternal chest pain, pain with swallowing, and hematemesis. Shortness of breath and, in patients with mediastinitis, signs of septic shock (eg, fever, tachycardia, and/or widened pulse pressure) may also be evident on physical examination. Subcutaneous emphysema is variably present. Chest radiography demonstrates pneumomediastinum or free peritoneal air (image 4 and image 5). Prevertebral air in the soft tissues may be present on plain neck images in patients with cervical esophageal perforations. When esophageal rupture is suspected based upon clinical findings or plain radiographs, patients should promptly undergo esophagram or contrast computed tomography of the chest and surgical consultation. Further management is determined by the size and location of the perforation and whether mediastinitis is present (algorithm 2). (See "Boerhaave syndrome: Effort rupture of the esophagus", section on 'Clinical manifestations'.)

COMMON CONDITIONS — Common causes of pediatric chest pain are found in 94 to 99 percent of children, depending upon the clinical setting [1-4,7,8,10-16]. Specific diagnoses, from most to least frequent, include the following:

Musculoskeletal conditions (eg, costochondritis, muscle strain, or trauma)

Psychogenic conditions (eg, panic attack, hyperventilation syndrome, or psychosomatic complaints)

Respiratory conditions (eg, asthma, pneumonia, or pleuritis)

Gastrointestinal disease (eg, gastroesophageal reflux, esophagitis, or gastritis)

Breast disease

Skin infections

A specific diagnosis cannot be established in a substantial proportion of cases (21 to 52 percent); these are considered idiopathic. Similar to most patients with chest pain, those with idiopathic pain usually have no serious underlying medical condition. As an example, in one cohort study of approximately 1800 pediatric patients presenting for evaluation of chest pain to a specialty clinic whose etiology was idiopathic, none had a missed diagnosis resulting in cardiac death during 18,000 patient-years of follow-up [16].

Musculoskeletal — Among children with a primary complaint of chest pain, conditions affecting the chest wall account for up to 31 percent of all patients and two-thirds of patients with an identified condition. Thus, it is the most frequent specific diagnosis for chest pain in children [2,4,7]. Musculoskeletal pain can be traumatic or nontraumatic, although nontraumatic chest pain as an isolated complaint is more common. Occasionally, the clinician elicits a recent history of strenuous exercise of the chest muscles (eg, weightlifting or push-ups) that has subsequently resulted in muscle soreness. Serious thoracic trauma is readily identified by history and physical examination in most patients and may result in chest wall or lung injury. (See "Chest wall injuries after blunt trauma in children" and "Overview of intrathoracic injuries in children" and "Pulmonary contusion in children".)

Isolated nontraumatic musculoskeletal chest wall pain syndromes in children include:

Costochondritis – Costochondritis is associated with point tenderness of the costal cartilages along the sternal border [20]. Provocative maneuvers such as horizontal arm traction (figure 2) or the "crowing rooster" (figure 3) typically reproduces the pain. Lifting a heavy school bag and carrying it over one shoulder can be a precipitating factor, which may also produce strain of chest wall muscles and ligaments. In one classic series of 100 adolescents with chest pain, costochondritis was the cause in 79 percent of patients [21]. It typically was unilateral and occurred more frequently on the left side.

Slipping rib syndrome – Slipping rib syndrome involves the 8th, 9th, and 10th ribs, which are not attached by costal cartilage to the sternum but are attached to each other by fibrous tissue [22-25]. If these fibrous connections are weakened or ruptured by trauma, the ribs can slip and impinge on the intercostal nerve, producing pain. The hooking maneuver, in which the examiner takes curled fingers, hooks them under the costal margin, and gently pulls the ribs forward, is often positive in these patients (figure 4).

Precordial catch – Precordial catch, also known as Texidor twinge, is an uncommon and benign etiology of musculoskeletal chest pain in children [11,14,15,26,27]. This condition consists of brief episodes (seconds to a few minutes) of sharp pain that can be localized with the fingertip to one interspace at the left sternal border or cardiac apex. The pain has a sudden onset, typically at rest or during mild activity, and increases with inspiration. The cause is unknown.

Other conditions, such as fibromyalgia, may also present with a complaint of isolated chest pain. However, complete physical examination of the musculoskeletal system reveals pain at other sites indicating a more general process. (See "Fibromyalgia in children and adolescents: Clinical manifestations and diagnosis", section on 'Clinical features'.)

Both pectus excavatum ("funnel chest", characterized by sternal depression from the midpoint of the manubrium to the xiphoid process) and pectus carinatum ("pigeon chest" characterized by protrusion of the anterior chest wall) can be associated with chest pain, but are rarely the cause, so clinicians must be wary of attributing chest pain to these deformities. The approach to patients depends on the specific type of pectus as follows:

Pectus excavatum – Chest pain is a more frequent symptom in children with pectus excavatum than pectus carinatum and may be associated with connective tissue abnormalities with potential for concerning causes of chest pain (eg, Marfan syndrome [pneumothorax or aortic dissection] or Turner syndrome [aortic stenosis or coarctation of the aorta). Thus, these patients frequently warrant a screening electrocardiogram and chest radiograph and, if normal, referral to a pulmonologist and cardiologist for additional testing. (See "Pectus excavatum: Etiology and evaluation", section on 'Evaluation'.)

Pectus carinatum – The chest pain associated with pectus carinatum is typically mild and associated with a prone position [28]. Most patients have no physiologic abnormalities. Cosmetic appearance is the primary patient concern. (See "Pectus carinatum and arcuatum", section on 'Evaluation'.)

Psychiatric — Chest pain may have a psychiatric etiology in as many as 30 percent of cases [3,7,12]. This cause is more common in children older than 12 years of age [1,2]. The pain may reflect a psychiatric disorder triggered by stressful events and may be a presenting feature of panic disorder, anxiety, depression, or hypochondriasis as well as cardiac, cancer, or other phobias [12,29,30]. In one series, approximately one-third of children with chest pain seen in a general pediatric clinic had a history of stressful events, including recent death, illness or accident in the family, family separations, or school changes [7]. Most children with psychiatric chest pain have other recurrent somatic complaints, including headache or abdominal or extremity pain [31,32]. Approximately one-third have significant sleep disturbances [31]. The physical examination in these patients is normal.

Hyperventilation can result in chest pain that frequently is accompanied by lightheadedness or paresthesias. The mechanism is uncertain. Possibilities include spasm of the diaphragm resulting from rapid, repetitive use, gastric distension arising from aerophagia, or coronary artery vasoconstriction caused by hypocapnic alkalosis (the last tested in adults with ischemic coronary disease) [33]. (See "Approach to the child with palpitations", section on 'Hyperventilation'.)

Respiratory — Respiratory disorders, including pneumonia and asthma, are common causes of acute pediatric chest pain. Children with pneumonia usually have fever, cough, and tachypnea. Rales or tubular breath sounds may be present on lung examination. Less commonly, the chest pain can arise from sites of pleuritis or pleural effusion. (See "Community-acquired pneumonia in children: Clinical features and diagnosis", section on 'History and examination'.)

Asthma exacerbations are often associated with chest tightness and wheezing. However, exercise-induced bronchoconstriction appears to be a frequent cause of chest discomfort even in patients without audible wheezing. This was illustrated by a study of pulmonary function testing before and after exercise in 88 otherwise healthy children and adolescents with chest pain [34]. Exercise decreased forced expiratory volume in one second or peak expiratory flow rate in 72.7 percent of the children. Subjective or objective improvement occurred in 97 and 70 percent, respectively, of 36 children given inhaled albuterol. In this condition, air hunger typically precedes the chest pain. (See "Asthma in children younger than 12 years: Initial evaluation and diagnosis" and "Exercise-induced bronchoconstriction", section on 'Clinical manifestations'.)

Any respiratory condition associated with chronic cough may also cause chest pain due to muscle strain or, in instances of severe cough (eg, pertussis or cystic fibrosis), rib fracture. (See "Causes of chronic cough in children".)

Spontaneous pneumomediastinum, the presence of gas in the mediastinum in the absence of trauma, is an uncommon cause of pediatric chest pain that is usually benign and self-limited. It may occur in the presence of acute asthma, respiratory tract infections, vigorous vomiting or coughing, intense physical effort, illicit drug use, or a Valsalva maneuver (table 11). Physical findings include subcutaneous emphysema in the neck or precordial region, dyspnea, and Hamman sign, a crunching, rasping sound that is synchronous with the heartbeat and heard over the precordium. (See "Spontaneous pneumomediastinum in children and adolescents", section on 'Evaluation'.)

Gastrointestinal — Chest pain may arise from several gastrointestinal conditions as follows:

Gastroesophageal reflux disease (GERD) – Based upon small observational studies, GERD and/or esophagitis represents the most frequently identified gastrointestinal disorder associated with pediatric chest pain [35,36]. In older children, chest pain typically is described as squeezing or burning, located substernally and sometimes radiating to the back. The pain lasts anywhere from minutes to hours, and resolves either spontaneously or with antacids. It usually occurs after meals, awakens patients from sleep, and may be exacerbated by emotional stress. GERD-related chest pain is not well described by young children. Young or nonverbal children may be observed pounding their chest. GERD is common in children with autism, and may be manifested only by unexplained or self-injurious behaviors. (See "Clinical manifestations and diagnosis of gastroesophageal reflux disease in children and adolescents", section on 'Clinical manifestations'.)

Medication-induced ("pill") esophagitis – Medication-induced or "pill" esophagitis can cause abrupt onset of retrosternal pain, heart burn, pain with swallowing, and difficulty swallowing in older children and adolescents taking the pill form of certain medications (eg, doxycycline, iron supplements, aspirin, or other nonsteroidal antiinflammatory drugs). Often history reveals that the patient takes the pill without water, commonly at bedtime. The typical injury consists of a discrete ulcer in the proximal esophagus near the aortic arch (picture 1). (See "Pill esophagitis", section on 'Etiology' and "Pill esophagitis", section on 'Clinical manifestations'.)

Esophageal foreign body – Although many children with esophageal foreign bodies are asymptomatic, some patients may have retrosternal pain associated with dysphagia, drooling, or, less commonly, respiratory distress (eg, wheezing, stridor, or choking). A careful history and physical examination are essential to diagnosing an esophageal foreign body and preventing complications. Initial imaging consists of anteroposterior and lateral chest radiographs to confirm the findings and to localize the site of radio-opaque foreign bodies. The diagnostic steps and treatment depend upon the patient's symptoms, the shape and location of the foreign body, whether it is radio-opaque, and whether it is a strong magnet (algorithm 3 and algorithm 4). (See "Foreign bodies of the esophagus and gastrointestinal tract in children", section on 'Clinical manifestations' and "Foreign bodies of the esophagus and gastrointestinal tract in children", section on 'Approach to management'.)

Urgent and sometimes emergent intervention to remove a foreign body is provided in the algorithm and discussed separately (algorithm 3). (See "Foreign bodies of the esophagus and gastrointestinal tract in children", section on 'Indications for urgent removal'.):

Other esophageal disorders – Esophageal endoscopy and manometry may detect abnormalities in children with chronic chest pain, even when typical gastrointestinal symptoms are not present. This was demonstrated in a study of 83 children with chest pain who underwent these procedures [37]. Esophageal histology and motility were normal in 47 patients (57 percent). Among the others, 15 (18 percent) had esophagitis with normal motility, 13 (16 percent) had normal histology and dysmotility, and 8 (9 percent) had both esophagitis and dysmotility. The most common motility disorders were diffuse esophageal spasm and achalasia, which occurred in seven and four patients, respectively. Thus, referral to a gastroenterologist may be indicated in selected children with chronic chest pain (eg, children whose pain is not due to another etiology, is causing significant distress, and does not resolve or improve with presumptive treatment).

Less commonly, disorders of the stomach, pancreas, small intestine, gall bladder, or biliary tract may present with chest pain. Conditions affecting the stomach and bowel include ulcer and irritable bowel. Cholecystitis may cause symptoms that suggest angina in adults, but is rare in healthy children. Biliary (eg, gallstones) and pancreatic disorders are also uncommon. In these conditions, abdominal pain or tenderness usually accompanies the chest pain. Refer to appropriate topics.

Breast — The breast can be a source of chest pain in adolescent patients, although it typically accounts for less than 5 percent of complaints. Pain may be a presenting symptom in males with gynecomastia. These patients also may have anxiety about the size of their breasts. (See "Clinical features, diagnosis, and evaluation of gynecomastia in adults", section on 'Clinical features'.)

Painful conditions of the breast in females include mastitis, fibrocystic disease, thelarche, or tenderness associated with pregnancy. Worries about cancer are often present in these patients [7]. (See "Breast disorders in children and adolescents", section on 'Breast pain'.)

Idiopathic — Many children and adolescents with chest pain (21 to 45 percent) have no obvious cause after a thorough evaluation and are diagnosed with idiopathic chest pain [2,7,8,10,17]. Although repetitive episodes of pain may occur, symptoms typically resolve over time. In one report of 31 children with idiopathic chest pain followed for an average of 4.1 years, persistent symptoms were reported by 45 percent [17]. However, pain resolved in 81 percent of patients followed for more than three years.

OTHER CONDITIONS — Pediatric chest pain is occasionally attributed to the following conditions:

Tietze syndrome – Tietze syndrome has been defined as a benign, painful, nonsuppurative localized swelling of the costosternal, sternoclavicular, or costochondral joints, most often involving the area of the second and third ribs. Only one area is usually involved, and young adults are more commonly affected. Tietze syndrome is rare and should be differentiated from more diffuse forms of myofascial chest pain (costochondritis) in which no areas of localized swelling are detected on examination. The cause of Tietze syndrome is unknown, but antecedent upper respiratory infections and excessive coughing have been described in some patients. (See "Major causes of musculoskeletal chest pain in adults", section on 'Tietze's syndrome'.)

Pleurodynia – Pleurodynia refers to an acute illness with marked paroxysmal spasms of the muscles of the chest and abdomen and fever. It most commonly occurs in association with group B coxsackie viruses. In children, characteristic vesicular stomatitis and rash on the palms and soles of the feet are often present as well (picture 2 and picture 3). Most patients are ill for four to six days. (See "Enterovirus and parechovirus infections: Clinical features, laboratory diagnosis, treatment, and prevention", section on 'Pleurodynia' and "Hand, foot, and mouth disease and herpangina".)

Neurologic disorders — Chest pain rarely is caused by a neurologic disorder that affects one or more costal nerves. As an example, herpes zoster in a dermatomal distribution on the chest can cause pain, which may be manifest before lesions appear (see "Postherpetic neuralgia"). Spinal cord compression, which may be caused by tumor or vertebral collapse, or epidural abscess is also a rare cause of radicular chest pain.

Mitral valve prolapse — Although identified as a cause of chest pain in the past, whether patients with mitral valve prolapse have chest pain more frequently than normal children is unclear. In one study of 119 children, 18 percent had atypical chest pain [38]. However, in a report of 813 children aged 9 to 14 years, 31 of whom had mitral valve prolapse, the incidence of chest pain was similar in affected and unaffected patients [39]. Appropriately controlled studies in adult patients suggest that patients with mitral valve prolapse and control subjects are equally symptomatic. Thus, we do not typically attribute chest pain to mitral valve prolapse. (See "Mitral valve prolapse: Clinical manifestations and diagnosis", section on 'MVP syndrome'.)

SUMMARY

Epidemiology and etiology – Nontraumatic chest pain is a common symptom in children and adolescents and is a frequent complaint in patients seeking primary, emergency, or subspecialty care. In the majority of pediatric patients, chest pain is not caused by a serious medical condition. (See 'Epidemiology' above and 'Etiology' above.)

Life-threatening conditions – Life-threatening conditions including cardiac disease, spontaneous pneumothorax, pulmonary embolism, and pulmonary hypertension account for 1 to 6 percent of pediatric patients with nontraumatic chest pain depending upon the setting and can frequently be identified based upon clinical findings (table 2). (See 'Life-threatening conditions' above.)

Common conditions – Common conditions are found in 94 to 99 percent of patients, with musculoskeletal conditions, psychiatric disease, and idiopathic chest pain diagnosed most frequently (table 1). (See 'Common conditions' above.)

Evaluation – A thorough history and physical examination usually can determine the cause and differentiate patients who require further diagnostic studies and acute intervention from those who can be managed with reassurance and continued follow-up. (See "Nontraumatic chest pain in children and adolescents: Approach and initial management", section on 'History' and "Nontraumatic chest pain in children and adolescents: Approach and initial management", section on 'Physical examination'.)

Diagnostic approach – An approach to nontraumatic chest pain in children and adolescents is provided in the algorithm (algorithm 5) and discussed separately. (See "Nontraumatic chest pain in children and adolescents: Approach and initial management", section on 'Evaluation' and "Nontraumatic chest pain in children and adolescents: Approach and initial management", section on 'Approach and initial management'.)

  1. Selbst SM. Chest pain in children. Pediatrics 1985; 75:1068.
  2. Selbst SM, Ruddy RM, Clark BJ, et al. Pediatric chest pain: a prospective study. Pediatrics 1988; 82:319.
  3. Driscoll DJ, Glicklich LB, Gallen WJ. Chest pain in children: a prospective study. Pediatrics 1976; 57:648.
  4. Friedman KG, Alexander ME. Chest pain and syncope in children: a practical approach to the diagnosis of cardiac disease. J Pediatr 2013; 163:896.
  5. Danduran MJ, Earing MG, Sheridan DC, et al. Chest pain: characteristics of children/adolescents. Pediatr Cardiol 2008; 29:775.
  6. Gesuete V, Fregolent D, Contorno S, et al. Follow-up study of patients admitted to the pediatric emergency department for chest pain. Eur J Pediatr 2020; 179:303.
  7. Pantell RH, Goodman BW Jr. Adolescent chest pain: a prospective study. Pediatrics 1983; 71:881.
  8. Fyfe DA, Moodie DS. Chest pain in pediatric patients presenting to a cardiac clinic. Clin Pediatr (Phila) 1984; 23:321.
  9. Rowe BH, Dulberg CS, Peterson RG, et al. Characteristics of children presenting with chest pain to a pediatric emergency department. CMAJ 1990; 143:388.
  10. Selbst SM, Ruddy R, Clark BJ. Chest pain in children. Follow-up of patients previously reported. Clin Pediatr (Phila) 1990; 29:374.
  11. Kocis KC. Chest pain in pediatrics. Pediatr Clin North Am 1999; 46:189.
  12. Tunaoglu FS, Olguntürk R, Akcabay S, et al. Chest pain in children referred to a cardiology clinic. Pediatr Cardiol 1995; 16:69.
  13. Anzai AK, Merkin TE. Adolescent chest pain. Am Fam Physician 1996; 53:1682.
  14. Zavaras-Angelidou KA, Weinhouse E, Nelson DB. Review of 180 episodes of chest pain in 134 children. Pediatr Emerg Care 1992; 8:189.
  15. Selbst SM. Evaluation of chest pain in children. Pediatr Rev 1986; 8:56.
  16. Saleeb SF, Li WY, Warren SZ, Lock JE. Effectiveness of screening for life-threatening chest pain in children. Pediatrics 2011; 128:e1062.
  17. Rowland TW, Richards MM. The natural history of idiopathic chest pain in children. A follow-up study. Clin Pediatr (Phila) 1986; 25:612.
  18. Evangelista JA, Parsons M, Renneburg AK. Chest pain in children: diagnosis through history and physical examination. J Pediatr Health Care 2000; 14:3.
  19. Kundra M, Yousaf S, Maqbool S, Mahajan PV. Boerhaave syndrome--unusual cause of chest pain. Pediatr Emerg Care 2007; 23:489.
  20. Cava JR, Sayger PL. Chest pain in children and adolescents. Pediatr Clin North Am 2004; 51:1553.
  21. Brown RT. Costochondritis in adolescents. J Adolesc Health Care 1981; 1:198.
  22. Porter GE. Slipping rib syndrome: an infrequently recognized entity in children: a report of three cases and review of the literature. Pediatrics 1985; 76:810.
  23. Mooney DP, Shorter NA. Slipping rib syndrome in childhood. J Pediatr Surg 1997; 32:1081.
  24. Taubman B, Vetter VL. Slipping rib syndrome as a cause of chest pain in children. Clin Pediatr (Phila) 1996; 35:403.
  25. Heinz GJ, Zavala DC. Slipping rib syndrome. JAMA 1977; 237:794.
  26. Coleman WL. Recurrent chest pain in children. Pediatr Clin North Am 1984; 31:1007.
  27. Pickering D. Precordial catch syndrome. Arch Dis Child 1981; 56:401.
  28. Desmarais TJ, Keller MS. Pectus carinatum. Curr Opin Pediatr 2013; 25:375.
  29. Friedman SB. Conversion symptoms in adolescents. Pediatr Clin North Am 1973; 20:873.
  30. Smith MS. Psychosomatic symptoms in adolescence. Med Clin North Am 1990; 74:1121.
  31. Asnes RS, Santulli R, Bemporad JR. Psychogenic chest pain in children. Clin Pediatr (Phila) 1981; 20:788.
  32. Kashani JH, Lababidi Z, Jones RS. Depression in children and adolescents with cardiovascular symptomatology: the significance of chest pain. J Am Acad Child Psychiatry 1982; 21:187.
  33. Foster GT, Vaziri ND, Sassoon CS. Respiratory alkalosis. Respir Care 2001; 46:384.
  34. Wiens L, Sabath R, Ewing L, et al. Chest pain in otherwise healthy children and adolescents is frequently caused by exercise-induced asthma. Pediatrics 1992; 90:350.
  35. Berezin S, Medow MS, Glassman MS, Newman LJ. Chest pain of gastrointestinal origin. Arch Dis Child 1988; 63:1457.
  36. Woolf PK, Gewitz MH, Berezin S, et al. Noncardiac chest pain in adolescents and children with mitral valve prolapse. J Adolesc Health 1991; 12:247.
  37. Glassman MS, Medow MS, Berezin S, Newman LJ. Spectrum of esophageal disorders in children with chest pain. Dig Dis Sci 1992; 37:663.
  38. Bisset GS 3rd, Schwartz DC, Meyer RA, et al. Clinical spectrum and long-term follow-up of isolated mitral valve prolapse in 119 children. Circulation 1980; 62:423.
  39. Arfken CL, Lachman AS, McLaren MJ, et al. Mitral valve prolapse: associations with symptoms and anxiety. Pediatrics 1990; 85:311.
Topic 96737 Version 14.0

References

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