The complaint of chest pain in a child, known medically as pediatric chest pain (PCP), often raises immediate fears about heart health. However, data consistently show that the vast majority of these cases are benign and non-cardiac in origin. Over 95% of all chest pain complaints in children and adolescents are related to issues outside of the heart, such as the chest wall, lungs, or digestive system. Understanding the true causes helps parents approach the symptom with informed concern. Recognizing the characteristics of the pain can help isolate the true source, as the heart is rarely the cause of the discomfort.
Musculoskeletal and Respiratory Sources
The most frequent source of pediatric chest pain originates from the chest wall itself, involving the bones, cartilage, or muscles. A common diagnosis in this category is costochondritis, an inflammation of the cartilage that connects the ribs to the breastbone. This inflammation causes a sharp, localized pain that is often reproducible when pressure is applied directly to the affected area, a key diagnostic feature distinguishing it from other causes. The discomfort can also be worsened by deep breathing, coughing, or moving the upper body, and it may sometimes follow a viral illness or physical strain.
Muscle strain is another frequent cause, often resulting from intense physical activity like sports or heavy lifting. Muscle soreness can also be caused by the forceful contractions from a persistent, deep cough associated with a respiratory infection. This type of pain is generally localized and feels sore or tight, improving with rest and over-the-counter pain relievers. The pain’s specific location and its direct relationship to movement or palpation are reliable indicators of a musculoskeletal origin.
Respiratory conditions also frequently present as chest pain, with asthma being a notable example. For children with asthma, the sensation of chest tightness and discomfort is a direct result of bronchoconstriction, the narrowing of the small airways within the lungs. This pain is often accompanied by classic symptoms like wheezing, persistent coughing, and shortness of breath, particularly during or immediately following exercise (exercise-induced asthma). Additionally, infections like pneumonia can cause pleurisy, which is the inflammation of the lung lining, leading to a sharp, stabbing pain that intensifies with every deep breath or cough.
Digestive and Stress-Related Pain
Pain arising from the digestive tract is another common non-cardiac etiology that can mimic heart discomfort. Gastroesophageal Reflux Disease (GERD) occurs when stomach acid backs up into the esophagus, causing a burning sensation known as heartburn. This discomfort is typically felt behind the breastbone and is often worse after eating a large meal, or when the child lies down or bends over.
In older children and adolescents, the classic GERD symptom is a burning chest pain. Younger children may present with atypical symptoms like a dry cough, trouble swallowing, or a frequent sore throat. The association of the pain with mealtimes helps distinguish it from other causes. Treatment focusing on reducing stomach acid production usually resolves this type of chest pain.
Psychological factors, specifically anxiety and stress, are recognized causes of pediatric chest pain, particularly in adolescents. This pain is a physical manifestation of the body’s “fight-or-flight” response, which releases stress hormones like adrenaline. The surge of adrenaline causes the heart rate to increase and leads to muscle tension in the chest and shoulders, which the child perceives as pain or tightness.
The physical mechanism of anxiety-related chest pain often involves hyperventilation, or rapid, shallow breathing. This altered pattern lowers the carbon dioxide level in the blood, causing light-headedness, numbness, and chest tightness. Anxiety-related pain is frequently described as sudden, brief, or stabbing, and it tends to occur when the child is at rest rather than during physical exertion.
Rare Cardiac Concerns
Although the vast majority of pediatric chest pain is harmless, the small percentage of cases that involve the heart are serious and require prompt identification. Cardiac causes often involve inflammatory conditions or structural anomalies that impair the heart’s function. These conditions are typically accompanied by distinguishing symptoms that do not occur with benign causes.
One such inflammatory condition is pericarditis, which is the swelling of the thin, two-layered sac surrounding the heart. The pain from pericarditis is often sharp, located centrally in the chest, and is typically worsened when the child lies flat and is relieved when they sit up and lean forward. Pericarditis is commonly preceded by a recent viral infection and is accompanied by a fever.
Myocarditis, an inflammation of the heart muscle, is a rare cause that typically follows a viral illness. Chest pain is generally not the sole symptom; it is usually accompanied by extreme fatigue, shortness of breath, or abnormal heart rhythms. Isolated chest pain is highly unlikely to be myocarditis without these systemic symptoms.
Structural anomalies, such as hypertrophic cardiomyopathy or abnormal coronary arteries, are serious cardiac causes. For these conditions, the chest pain is a red flag when it occurs specifically and consistently during physical exertion, not after or at rest. Pain during exercise, especially when combined with a history of fainting (syncope) or a strong family history of early sudden death, suggests a cardiac origin.
Identifying Warning Signs and Next Steps
Parents should focus on specific “red flag” symptoms that necessitate immediate medical attention. The primary concerning sign is chest pain that occurs exclusively or predominantly during periods of physical exertion or high-intensity exercise. Pain associated with fainting (syncope), near-fainting, or significant dizziness is also a serious warning sign.
If the child experiences any of the following, a medical professional should be consulted immediately:
- Pain associated with a rapid or irregular heartbeat (palpitations).
- Difficulty breathing that is not relieved by rest.
- A bluish discoloration around the lips or nail beds.
- Pain that is crushing or radiating to the neck or arm.
- Pain that is prolonged and does not resolve with rest.
A doctor’s initial assessment begins with a thorough medical history, focusing on the pain’s characteristics, timing, and any familial history of serious heart conditions. The physical exam includes checking for reproducible tenderness on the chest wall, which points toward a musculoskeletal cause. If red flags are present, the diagnostic process involves an electrocardiogram (ECG) to assess electrical activity and an echocardiogram (ultrasound) to visualize the heart’s structure. These tests rule out rare cardiac causes, confirming the benign nature of the pain in most children.