Major features of the principal causes of chest pain in children and relevant investigation/treatment
| Signs and symptoms | Diagnosis | Prognosis/management |
|---|---|---|
| Musculoskeletal | ||
| • Sharp, anterior chest wall pain over multiple costochondral/costosternal junctions • Usually first to fifth ribs • Pain on palpation. No swelling | Costochondritis | Pain resolves with NSAIDs and rest. May last many months, very rarely needs intra-articular steroids7 |
| • Sharp localised pain at one costochondral junction • Tender, swollen (1–4 cm mass), not hot • Most frequently 2nd or 3rd costochondral junction | Tietze's syndrome | Pain resolves with NSAIDs and rest. Lasts up to 2 months 7 |
| • Aching pain after new or intense exercise • Can appear up to 2 days later • Pain reproduced by palpation and range of movement testing | Muscular strain | Pain resolves with NSAIDs and rest11 |
| • Sudden sharp chest pain • Occurs mainly at rest • Usually left sided • Lasts a few seconds to 3 min • Exacerbated by deep inspiration • No signs/associated symptoms | Precordial catch | Reassurance12 |
| • Pain under 8th–10th ribs anteriorly when medial fibrous attachments are inadequate or ruptured • Exacerbated by sudden upward movement (eg, horse riding) and flexing of trunk • Sometimes popping sensation at onset of pain • Rare—more common in athletes • Hooking manoeuvre reproduces | Slipping rib syndrome | Resolves with rest and NSAIDS11 |
| Gastrointestinal/respiratory | ||
| • Wheeze ± dyspnoea • Exercise-induced asthma can often cause chest pain with exercise even in the absence of wheeze | Asthma/wheeze | Spirometry Consider exercise test spirometry Trial of bronchodilator2 13 |
| • Retrosternal burning • Water brash/ascending pain • Pain associated with posture, eating • Epigastric tenderness • Associated dysphagia suggests oesophageal origin | Gastro-oesophageal reflux, oesophagitis, gastritis | Trial of reflux treatment Consider pH/impedance study14 |
| • Sharp, sudden onset chest pain with significant dyspnoea • Pain diffuse on the affected side with radiation to ipsilateral shoulder • Risk factors include a tall, thin body habitus, asthma, cystic fibrosis, inhalation of cocaine or marijuana | Pneumothorax | CXR Conservative/interventional management |
| Non-organic | ||
| • Breathlessness without exertion, inability to obtain a satisfying breath, frequent yawning or sighing • Rapid, shallow or deep breathing during acute episode • Lightheadedness or dizziness | Disordered breathing/hyperventilation | Physiotherapy15 |
| • Pain often fleeting or vague or localised over precordium +/or left arm • History of stressful events • Other recurrent somatic complaints, including headache or abdominal or extremity pain | Psychogenic | Reassurance ± psychological input16 |
| Cardiac | ||
| • Sharp (anterior/precordial) • Exacerbated by leaning forward • ± systemic upset | Pericarditis | ECG to assess for widespread ST elevation Inflammatory markers Cardiology referral |
| • Palpitations • Dyspnoea | Arrhythmia | ECG (± prolonged ECG monitoring such as Holter Monitor) ± cardiology referral |
| • Syncopal episodes (especially on exercise) • ± abnormal cardiac examination findings • ± family history of hereditary heart disease | HOCM/aortic stenosis/long QT, etc | ECG reviewing QTc and PR intervals, delta waves, T wave changes Cardiology referral |
| • Central crushing chest pain ± radiating to jaw and arm • Associated sweating, nausea and pallor | Myocardial ischaemia | ECG for signs of ischaemia Cardiology referral |
| Miscellaneous | ||
| • Acutely painful vesicular rash • Pain may precede rash | Herpes zoster (shingles) | Analgesia |
HOCM, hypertrophic obstructive cardiomyopathy; MI, myocardial infarction; NSAIDS, non-steroidal anti-inflammatory drugs.