Chest pain in pediatric patients is a common complaint, yet less than 5% of cases are due to cardiac disease. However, providers always should conduct a broad differential diagnosis and remain aware of red-flag symptoms indicating possible cardiac involvement, referring patients to cardiology for further testing and evaluation as needed.

Common causes of pediatric chest pain

“Studies show that idiopathic, musculoskeletal [issues], and costochondritis are by far the most common causes of pediatric chest pain,” said Joshua D. Kurtz, M.D., pediatric and adult congenital interventional cardiologist with Norton Children’s Heart Institute, affiliated with the UofL School of Medicine. “However, conducting a thorough workup and patient/family history is necessary to rule out conditions and help inform next steps in diagnostics.”

Idiopathic chest pain:  The most common type in kids. Sharp pain lasting seconds to minutes, worse with deep breathing, can be at rest or with exercise. Can easily play through the pain. It is usually not reproducible.

Costochondritis: Pain in two to four contiguous costochondral or costosternal joints, often reproducible on palpation and worsened with deep breaths. Brief, sharp pain lasts seconds to minutes. Usually inflammatory in nature, but without visible inflammation.

Precordial catch syndrome: Sudden, sharp, localized pain in the area of the chest just below the heart; can take a child’s breath away but resolves quickly, within seconds.

Muscle strain or trauma: Typically linked to history of trauma, movement or certain positions and is reproducible on examination.

Asthma or pneumonia: Accompanied by shortness of breath, cough, congestion or fever.

GI causes: Often linked to food ingestion or dysphagia.

Sickle cell disease: Disease includes a higher risk of acute chest syndrome (ACS).

Psychogenic causes: Diagnosis of exclusion that may be tied to emotional stress. More common in children with a family history of serious cardiac disease.

Red-flag symptoms of possible cardiac etiology

Although cardiac-related chest pain is rare, the following signs could indicate possible cardiac disease:

• Chest pain exclusively with exertion
• Syncope or near-syncope during exercise
• Chest pain associated with palpitations, sweating or dizziness
• A strong family history of sudden unexplained death, cardiomyopathy or premature coronary artery disease
• A history of Kawasaki disease, Williams syndrome or congenital heart conditions

Patients exhibiting any red-flag symptoms should be referred to cardiology; however, referrals should not be limited to these symptoms alone. Comprehensive evaluation can help identify overlooked symptoms or underlying conditions, ultimately improving patient outcomes.

Diagnostic tools

Based on findings, additional diagnostic tools include:

Electrocardiogram (ECG) First-line testing. Not always necessary if history is consistent with noncardiac chest pain. Is appropriate for exertional chest pain, abnormal physical exam findings or strong family history.

Chest X-ray can evaluate any pulmonary causes.

Echocardiogram is appropriate for exertional pain, nonexertional chest pain with abnormal ECG or strong family history of sudden cardiac death.

Stress testing can be very effective in cases of exertional chest pain to identify ECG changes during exercise.

Criteria for ordering an echocardiogram

An echocardiogram is recommended in the following situations:

• Exertional chest pain
• Nonexertional chest pain with an abnormal ECG
• Chest pain plus a strong family history of sudden unexplained death or cardiomyopathy
• Chest pain with other cardiac signs or symptoms, despite a benign family history and normal ECG
• Chest pain in patients with a history of fever, illicit drug use, or suspected myocarditis or endocarditis

Treatments for noncardiac patients

For noncardiac chest pain, treatment often involves giving patients plenty of reassurance, according to Dr. Kurtz.

“With a negative workup it is likely not cardiac in origin, but having recurrent chest pain is scary. We have to let them know that having recurrent chest pain is OK, and that just because there’s a recurrence doesn’t mean that something really bad has suddenly happened,” he said.

Other treatment options include nonsteroidal anti-inflammatory drugs, which are used for inflammatory causes such as costochondritis, with scheduled dosing for anti-inflammatory effect; or treatment of underlying etiology, such as asthma, pneumonia or GERD, as appropriate.

Clear communication with families about the nature of noncardiac chest pain can reduce anxiety and help improve outcomes. When necessary, a referral to pediatric cardiology can help rule out other conditions.