Chest pain is a worrisome symptom that often causes parents to bring their child to the emergency department (ED) for evaluation. The rate of children presenting to the ED with a complaint of chest pain is 3 to 6 for every 1000 patient visits.^1,2

In the majority of cases, the etiology of the chest pain is benign, but symptoms are distressing enough to cause 27% to 30% of children to miss school.^2,3

The clinical presentation of children with chest pain varies greatly. The average age of presentation is 10 to 12 years, with an equal distribution between genders.^1–4 Younger children are more likely to have a cardiorespiratory source for their chest pain, whereas the chest pain of an adolescent patient is more likely to be of psychogenic origin.^1,3

The duration of the chest pain in the majority of patients is either acute or subacute in onset.^1,3 Patients that present with a complaint of chronic chest pain (>6 months’ duration) usually have idiopathic or psychogenic chest pain.^3,4

Children often have difficulty localizing and qualifying their pain. In instances where the child is able to indicate a location for their chest pain (e.g., right-sided, left-sided, and sternal), no specific relationship to a particular diagnosis or diagnostic category has been found.^1–3 The description of the pain (e.g., sharp, dull, and aching) also shows no relationship to the actual diagnosis.³

The differential diagnosis for pediatric chest pain is extensive (Table 7-1).

CARDIAC

A cardiac cause for pediatric chest pain is found in 0.6% to 5% of cases presenting to the ED.^1,3,5 Myocardial infarction is rare in children, but has been reported in the literature in previously healthy adolescents.⁶ These patients usually present with the classic severe, substernal chest pain with radiation to the left arm or jaw; however, it is important to note that the location and severity of a child’s chest pain is not specific to myocardial infarction or a cardiac etiology.^1–3,6 Patients are at greater risk for myocardial ischemia if they have a history of congenital heart disease, acquired heart disease (e.g., Kawasaki disease), or drug abuse (e.g., cocaine), thus a thorough history and physical examination is imperative.

Pericarditis and myocarditis are cardiac diseases that cause chest pain. Both conditions can present with fever and chest pain, although myocarditis usually has a more insidious onset. Pericarditis usually presents with sharp, substernal chest pain that is alleviated by leaning forward. On physical examination, the patient classically has distant heart sounds, a friction rub, and signs of congestive heart failure (CHF). Myocarditis patients often have vague symptoms including chest pain, dyspnea, dizziness, nausea, vomiting, and fatigue. Physical examination usually reveals a gallop, signs of CHF, and tachycardia unresponsive to fluids. A concerning history and physical examination should prompt the practitioner to consider myocarditis and pericarditis.

Structural abnormalities of the heart and vessels can cause chest pain. Hypertrophic cardiomyopathy patients usually have a history of increased chest pain with exertion. Aortic stenosis, pulmonary stenosis, abnormal coronary arteries, and mitral valve prolapse, depending on the severity, can lead to ischemia of the heart and papillary muscles. History and physical examination of these patients typically reveal a heart murmur associated with the lesion.