Chest Pain in Children and Adolescents

Chest pain is a common complaint in children and adolescents. Chest pain is often perceived as “heart pain” both to children and their parents, and it can cause a lot of emotional and physical upset. However, chest pain in children is very rarely due to a heart problem and most often arises from a less worrisome source.

Jennifer S. Li, MD, MHS, explains causes of chest pain in children.

-- Dennis Clements MD, PhD, MPH

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Chest pain in children and adolescents is common, but is generally benign. Cardiac (heart-related) causes of chest pain are uncommon. Chest pain with exercise or that associated with fast heart beat, dizziness, or fainting can indicate a cardiac cause.

What causes chest pain?

Many organs located in the chest can cause or contribute to chest pain. Among these are the muscles, tendons, cartilage or bones of the chest, the lungs, the heart, the gastrointestinal system, and the nerves. A problem in any one of these areas can cause chest pain.

How often is chest pain found to be due to a heart problem?

In older adults, chest pain is frequently due to a heart problem. This is because heart disease mostly strikes older people.

In kids, chest pain is very rarely due to a heart problem. A prospective study in 50 children referred to a cardiology clinic showed that 76 percent had pain from the muscles, bones, or cartilage; 12 percent had exercise-induced asthma; 8 percent had pain from gastrointestinal causes; and 4 percent had pain due to psychogenic causes. (Evangelista JA et al: J Pediatr Health Care 2000 14(1); 3-8)

But what about the kid who dies on the playing field?

While these cases receive a lot of media attention, the kid who experiences sudden cardiac death is an extremely rare event among the millions of children and adolescents who participate in athletics.

In many cases, this is related to a previously undiagnosed underlying heart condition. Because of this, a sports physical prior to participation in competitive athletics with your child’s regular health care provider is important and necessary.

Sometimes underlying conditions related to sudden cardiac death have genetic factors, so a careful family history is also an important part of the pre-sports evaluation.

What are some common causes of chest pain?

Some common causes include:

• Musculoskeletal -- this is usually related to muscle strain or heavy lifting
• Costrochondritis -- inflammation of the cartilage around the junction of the ribs to the breastbone
• Precordial catch syndrome -- sharp stabbing chest pain below the breast that lasts a few seconds and is worsened by taking a deep breath. It may be due to a pinched nerve
• Asthma -- this is frequently a cause of exercise-induced chest pain
• Gastroesophageal reflux -- usually burning pain worsened while lying down after eating
• Anxiety -- typically related to stress or excessive worry

What are some heart-related causes of chest pain?

Several cardiac problems have the potential to cause chest pain. Some of these include:

• Left ventricular outflow tract obstruction (blockage of the outflow of the heart to the body) -- a heart murmur is present
• Hypertrophic cardiomyopathy -- usually an inherited condition causing a thickened heart muscle
• Anomalous coronary arteries -- coronary artery arising off the wrong sinus causing chest pain with exercise
• Rhythm disturbances -- chest pain is typically associated with the feeling of the heart beating too fast
• Pericarditis -- inflammation of the lining of the heart often preceded by a viral illness

What are some worrisome symptoms of a heart-related cause of chest pain?

• Chest pain with exercise, associated with irregular or fast heart beat, or associated with dizziness or syncope (fainting) are symptoms that can indicate a serious heart problem.
• Chest pain that occurs at rest without other associated symptoms is not typically due to a heart problem.

What is the usual evaluation that is performed?

A careful history and physical examination are necessary and can usually identify the cause for the chest pain. Sometimes laboratory studies may be needed such as an electrocardiogram, an echocardiogram, or an exercise stress test.

-- Jennifer S. Li, MD, MHS, is chief of cardiovascular research at the division of cardiology in Duke's Department of Pediatrics.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.