Table 2

Major features of the principal causes of chest pain in children and relevant investigation/treatment

Signs and symptomsDiagnosisPrognosis/management
• Sharp, anterior chest wall pain over multiple costochondral/costosternal junctions
• Usually first to fifth ribs
• Pain on palpation. No swelling
CostochondritisPain 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 syndromePain 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 strainPain 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 catchReassurance12
• 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 syndromeResolves with rest and NSAIDS11
• Wheeze ± dyspnoea
• Exercise-induced asthma can often cause chest pain with exercise even in the absence of wheeze
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, gastritisTrial 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
Conservative/interventional management
• 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/hyperventilationPhysiotherapy15
• 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
PsychogenicReassurance ± psychological input16
• Sharp (anterior/precordial)
• Exacerbated by leaning forward
• ± systemic upset
PericarditisECG to assess for widespread ST elevation
Inflammatory markers
Cardiology referral
• Palpitations
• Dyspnoea
ArrhythmiaECG (± 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, etcECG 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 ischaemiaECG for signs of ischaemia
Cardiology referral
• 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.