• Chest wall strain
• Costochondritis
• Direct chest trauma
• Slipping rib syndrome

• Arrhythmia (supraventricular tachycardia, premature ventricular contractions)
• Coronary-artery anomalies
• Coronary-artery aneurysms (Kawasaki syndrome)
• Infections (myocarditis, pericarditis
• Myocardial infarction/ischemia
• Structural abnormalities
  • Aortic stenosis
  • Hypertrophic cardiomyopathy
  • Pulmonic stenosis
  • Mitral valve prolapse
  • Severe coarctation of the aorta

• Caustic ingestions
• Esophageal foreign bodies
• Esophagitis (sometimes tetracycline, “pill,” induced)

• Anxiety
• Hyperventilation

• Asthma
• Cough (prolonged)
• Pleural effusion
• Pneumonia
• Pneumothorax—spontaneous, trauma-related, drug-related (cocaine)
• Pneumomediastinum
• Pulmonary embolism

• Breast mass
• Cigarette smoke
• Pleurodynia
• Precordial catch syndrome
• Shingles
• Sickle cell crises
• Thoracic tumor

Question: How severe, how often is the pain?
Significance: Constant, frequent severe pain is more likely to be distressing, interruptive of daily activity. Serious etiology is not well correlated with frequency, severity of pain.

Question: What is the type of pain? Its location?
Significance: Burning pain is associated with esophagitis. Sharp, stabbing pain relieved by sitting up or leaning forward is typical of pericarditis. Young children do not describe or localize chest pain well.

Question: When was the onset of pain?
Significance: Acute pain (<48 hours) is more likely to have an organic etiology. Chronic pain (>6 months) is more likely to be psychogenic, idiopathic.

Question: Is the pain induced by exercise?
Significance: Exercise-induced chest pain may be related to serious cardiac disease or asthma.

Question: Recent trauma or muscle overuse?
Significance: Musculoskeletal (chest wall) pain

Question: Eaten spicy foods? Taken tetracycline or other pills?
Significance: Esophagitis

Question: Recent use of cocaine?
Significance: Hypertension, tachycardia, myocardial ischemia, or pneumothorax.

Question: Use of oral contraceptives or recent leg trauma?
Significance: Pulmonary embolism

Question: Recent significant stress (e.g., move, death of loved one, serious illness)?
Significance: Psychogenic pain

Question: Associated complaints?
Significance: Fever may imply pneumonia, myocarditis, pericarditis. Syncope, palpitations may imply cardiac arrhythmias or severe anemia. Joint pain, rash may relate chest pain to collagen vascular disease. Pain that resolves with parental attention may indicate an emotional etiology.

Question: Positive familial history?
Significance: Hypertrophic cardiomyopathy is often familial. Those with a familial history positive for heart disease and chest pain may be concerned about the symptom in a child. Chest pain in such children often has a non-organic etiology.

Question: Past medical history?
Significance: Previous Kawasaki syndrome, long-standing insulin-dependent diabetes mellitus, and sickle cell disease may have serious cardiac or pulmonary complications leading to chest pain. Marfan syndrome has increased risk for aortic dissection, pneumothorax. Asthma has increased risk for pneumonia, pneumothorax. Collagen vascular disease has increased risk for pleural effusion, pericarditis. Most underlying structural cardiac lesions rarely produce chest pain.

Finding: Child is in significant distress.
Significance: Requires emergency care; stabilization, consider pneumothorax, arrhythmia.

Finding: Child appears chronically ill.
Significance: Chest pain may be found in serious illness such as malignancy (Hodgkin lymphoma).

Finding: Skin bruising present
Significance: Chest pain may be related to unrecognized trauma.

Finding: Abdominal pathology
Significance: Pain may be referred to the chest

Finding: Arthritis present
Significance: Collagen vascular disease may manifest as pleural effusion, chest pain.

Finding: Unusually anxious child
Significance: Underlying stress may lead to pain.

Finding: Breast enlargement, asymmetry, tenderness
Significance: Physiologic breast changes in young teens may be painful. Consider pregnancy in teenage girls.

Finding: Rubs, decreased breath sounds, wheezing
Significance: May suggest pneumonia, asthma with overuse of chest wall muscles.

Finding: Subcutaneous emphysema palpable on chest or neck
Significance: Pneumothorax, pneumomediastinum

Finding: Heart murmur, rub, arrhythmia
Significance: Congenital heart disease, cardiac infection such as myocarditis, pericarditis, supraventricular tachycardia, ventricular tachycardia.

Finding: Tenderness of chest wall, costochondral junctions
Significance: Musculoskeletal pain

Test: Electrocardiogram
Significance: Obtain if history suggests cardiac pathology, for instance:

• Acute onset of pain
• Pain on exertion
• Pain associated with syncope, dizziness, palpitations
• History of congenital heart disease
• Serious associated medical problems (Kawasaki syndrome, diabetes mellitus)
• Use of cocaine

• Respiratory distress
• Cardiac abnormality
• Fever
• Significant trauma

Test: Chest radiograph
Significance: Same as for electrocardiogram. Also, obtain if history suggests cardiac or pulmonary pathology, tumor, Marfan syndrome, or foreign body (coin ingestion).

Test: Holter monitor
Significance: Arrange for this study if cardiac arrhythmia suspected. Electrocardiogram may fail to detect intermittent arrhythmia.

Test: Exercise stress test, pulmonary function tests
Significance: Obtain if pain induced by exertion.

Test: Drug screen
Significance: Obtain if cocaine use suspected.

• Pneumothorax: may present with severe sudden chest pain, respiratory distress, cyanosis, hypotension.
• Cardiac arrhythmia: ventricular tachycardia or supraventricular tachycardia in an older child may progress to heart failure or a lethal rhythm.
• Cocaine intoxication: may present with pneumothorax, cardiac arrhythmia, hypertension.
• Direct chest trauma: may lead to cardiac contusion, and arrhythmia.
• Caustic ingestions or esophageal foreign bodies require prompt attention.

Q: How common is chest pain in children?
A: Chest pain is a common pain syndrome reported in 6 of 1,000 children who present to an urban emergency department. The complaint is less common than abdominal pain or headache. Although children of all ages may complain of chest pain, the mean age is about 12 years.

Q: Is follow-up important?
A: Yes. Serious pathology is unlikely to be found if not diagnosed initially. However, watch for signs of exercise-induced asthma or for emotional problems that were not obvious initially. Ensure that the child returns to normal activity when appropriate.

Q: What is the prognosis for most children with chest pain?
A: Most children with chest pain have an excellent prognosis. About 40% of children with chest pain will have continued symptoms for 6 to 24 months.

• Acute distress
• Significant trauma
• History of heart disease or related serious medical problem
• Pain with exercise, syncope, palpitations, dizziness
• Serious emotional disturbance
• Esophageal foreign body, caustic ingestion
• Pneumothorax, pleural effusion

• If the child is febrile, consider pneumonia, or viral myocarditis.
• Treat specific etiology when found.
• Over-the-counter analgesics (acetaminophen, ibuprofen) suffice for most pain.
• Antacids may be diagnostic and therapeutic for esophagitis pain.
• Rest, heat, relaxation techniques may be useful.
• Avoid expensive, invasive laboratory studies with chronic pain and normal physical examination, benign history.

Knapp JF, Dowd MD, Tarantino C, Borders J. Case 02-1994: a tall, thin 15 year old male with chest pain. Pediatr Emerg Care 1994;10:117–120.

Selbst SM. Chest pain in children, consultation with the specialist. Pediatr Rev 1997;18:169–173.

Selbst SM, Ruddy RM, Clark BJ, et al. Pediatric chest pain: a prospective study. Pediatrics 1988;82:319–323.

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;90:350–353.