Chest pain in children is a symptom that causes considerable alarm for parents, but it is rarely a sign of a serious underlying condition. Unlike in adults, where chest discomfort often suggests a heart issue, the vast majority of cases are benign, especially in children and adolescents. Studies show that cardiac causes account for a very small fraction, often less than 4%, of all chest pain complaints in this age group. The primary goal of medical evaluation is to differentiate the common, harmless causes from the extremely rare, serious ones.
Common Non-Cardiac Origins
The most frequent source of chest pain in children is the chest wall itself, stemming from musculoskeletal structures like the ribs, muscles, and cartilage. These benign causes are so common that they account for a substantial majority of all pediatric chest pain presentations. A defining feature of these pains is that they can often be reproduced or worsened by pressing on the affected area of the chest.
One of the most diagnosed causes is costochondritis, an inflammation of the cartilage that connects the ribs to the breastbone. This inflammation typically causes a sharp, aching, or stabbing sensation, and the pain intensifies with deep breaths, coughing, or direct pressure on the costosternal joints. The condition is generally self-limiting and resolves on its own over time.
Another frequent non-cardiac complaint is Precordial Catch Syndrome (PCS), sometimes referred to as Texidor’s twinge. PCS is characterized by a sudden onset of very sharp, stabbing pain, usually localized to a small area beneath the left breast. The pain is short-lived, typically lasting from a few seconds to a couple of minutes, and is often exacerbated by taking a deep breath. Although the pain can feel intense, it is harmless and is thought to be caused by a temporary spasm or pinched nerve in the chest wall lining. Additionally, muscle strain from vigorous physical activity, coughing fits, or even poor posture can cause tenderness and soreness in the chest muscles.
Respiratory and Gastrointestinal Causes
Chest pain can also be a referred symptom from issues within the respiratory or gastrointestinal systems. Respiratory conditions can lead to pain when the lungs or the surrounding structures become inflamed or irritated. One such condition is pleurisy, which is the inflammation of the pleura, the thin membranes lining the lungs and the chest cavity.
Pleurisy typically produces a sharp, stabbing pain that becomes worse with inhalation, coughing, or sneezing, due to the inflamed membranes rubbing against each other. Asthma, a chronic inflammatory airway disease, can also manifest as chest discomfort, often described as a feeling of tightness or pressure. In some children, chest pain or tightness may be the primary symptom of an asthma exacerbation, particularly when it is triggered by exercise or occurs during the night.
Gastroesophageal Reflux Disease (GERD) is the most common gastrointestinal cause of chest pain in children, especially in older adolescents. This occurs when stomach acid flows back up into the esophagus, causing a burning sensation behind the breastbone. The pain from GERD is sometimes confused with cardiac pain, but it is often worse after eating, when lying down, or when bending over. Inflammation of the esophageal lining, or esophagitis, can also result from chronic acid exposure or other causes, leading to generalized chest pain and difficulty or pain when swallowing food.
Rare but Critical Cardiac Concerns
Though rare in healthy children, cardiac conditions that cause chest pain are the most serious. These conditions usually involve inflammation, structural abnormalities, or problems with the heart’s electrical system. Inflammatory conditions include myocarditis and pericarditis, which are most often triggered by a viral infection.
Myocarditis, the inflammation of the heart muscle, can present with nonspecific symptoms like fatigue, shortness of breath, and flu-like illness, but in severe cases, it can cause chest pain and lead to heart failure or abnormal heart rhythms. Pericarditis is the inflammation of the sac surrounding the heart and often causes a sharp chest pain that is characteristically worse when lying flat and may be relieved by sitting up and leaning forward. This pain may also radiate to the neck or shoulder.
Structural heart issues are another concern, particularly when chest pain is associated with physical activity. Hypertrophic cardiomyopathy (HCM) is an inherited condition that causes the heart muscle to thicken, making it difficult for the heart to pump blood effectively. Chest pain in HCM is a serious symptom, often occurring during exertion due to the heart muscle not receiving enough oxygen relative to its size. Similarly, anomalous coronary arteries are a concern. These anomalies can restrict blood flow during periods of high demand, making them the second most common cause of sudden cardiac death in young athletes and often presenting with chest pain during exercise.
When Immediate Medical Attention is Needed
While most pediatric chest pain is harmless, certain accompanying symptoms are considered “red flags” and necessitate immediate medical evaluation at an emergency department. Any complaint of chest pain that occurs during or immediately following intense physical exertion requires urgent attention, as this is a common presentation for serious cardiac issues like hypertrophic cardiomyopathy or coronary artery anomalies. Pain accompanied by fainting or near-fainting episodes is a serious warning sign that the heart may not be adequately supplying the brain with blood.
Other symptoms that should prompt an immediate call for emergency services include:
- Difficulty breathing, which can indicate a severe respiratory or cardiac problem.
- Pain described as crushing or pressure-like that is not relieved by rest.
- Pain that radiates to the arm, jaw, or back.
- The presence of cold sweats, pale or clammy skin, or a noticeably racing or irregular heartbeat.