Chest Pain in Children¶

Learning Objectives¶

Core Knowledge & Clinical Reasoning¶

[ ] Recognize that cardiac causes account for <5% of pediatric chest pain
[ ] Identify the common non-cardiac causes (musculoskeletal, GI, anxiety)
[ ] Apply red flag criteria to identify the rare cardiac causes requiring urgent evaluation
[ ] Formulate appropriate workup based on history and exam findings

Communication & Counseling¶

[ ] Reassure families when evaluation suggests benign etiology
[ ] Educate on when to seek re-evaluation

Key Concept¶

Cardiac causes account for <5% of pediatric chest pain Most chest pain in children is benign musculoskeletal or idiopathic

Quick Reference: Chest Pain Evaluation Algorithm

Etiology of Pediatric Chest Pain¶

Category	Prevalence	Examples
Musculoskeletal	30-40%	Costochondritis, muscle strain, precordial catch
Idiopathic	20-40%	No identifiable cause
Pulmonary	10-20%	Asthma, pneumonia, pneumothorax
GI	5-10%	GERD, esophagitis
Psychogenic	5-15%	Anxiety, panic, hyperventilation
Cardiac	<5%	Pericarditis, arrhythmia, structural

Common Benign Causes¶

Precordial Catch Syndrome (Texidor's Twinge)¶

Age: Adolescents, young adults
Character: Sharp, sudden, well-localized to left chest
Duration: Seconds to minutes
Trigger: Often at rest, may worsen with breathing
Resolution: Resolves spontaneously
Management: Reassurance only

Costochondritis¶

Character: Sharp or aching anterior chest pain
Exam: Reproducible with palpation of costochondral junctions
Management: NSAIDs, reassurance

Musculoskeletal Strain¶

History: Often after exercise, lifting, new activity
Exam: Reproducible with movement or palpation
Management: Rest, NSAIDs

RED FLAGS: Cardiac Chest Pain¶

Red Flag	Concern
Exertional chest pain	Ischemia (AAOCA, HCM, AS)
Associated syncope	Arrhythmia, structural
Palpitations with pain	Arrhythmia
Family history of SCD <50y	Inherited cardiac disease
Family history of cardiomyopathy	HCM, ARVC
Known heart disease	Disease-related
Fever + chest pain	Pericarditis, myocarditis
Recent viral illness + new pain	Myocarditis, pericarditis
Marfanoid habitus	Aortic dissection
Abnormal exam (murmur, rub, abnormal pulses)	Structural disease

Cardiac Causes to Know¶

Pericarditis¶

Sharp, pleuritic pain improved by leaning forward
Friction rub on exam
ECG: diffuse ST elevation, PR depression
Echo: effusion

Myocarditis¶

Often preceded by viral illness
May have heart failure symptoms
Troponin elevated
ECG changes variable

Arrhythmia¶

Palpitations prominent
Pain during episodes
ECG may capture rhythm

Structural (Rare)¶

AAOCA: Exertional pain, may have syncope
HCM: Exertional, family history
Severe AS: Exertional

Coronary (Very Rare in Children)¶

Kawasaki disease with CAA
Anomalous left coronary from PA (infants)

Clinical Approach¶

CHEST PAIN
    │
    ▼
HISTORY & EXAM
    │
    ├── RED FLAGS present?
    │        │
    │        YES → ECG + Cardiology referral
    │              Consider: Echo, Troponin, CXR
    │
    └── NO RED FLAGS
             │
             ├── Reproducible with palpation?
             │        │
             │        YES → Musculoskeletal
             │              Reassurance, NSAIDs
             │
             ├── Sharp, brief, at rest?
             │        │
             │        YES → Precordial catch
             │              Reassurance
             │
             ├── GI symptoms?
             │        │
             │        YES → Consider GERD
             │              Trial PPI
             │
             └── Anxiety features?
                      │
                      YES → Psychogenic
                            Address anxiety

When to Get an ECG¶

ECG INDICATED¶

Any red flag present
Exertional symptoms
Palpitations
Syncope or near-syncope
Family history of SCD or cardiomyopathy
Abnormal cardiac exam

ECG NOT ROUTINELY NEEDED¶

Classic musculoskeletal pain
Precordial catch syndrome
Clear non-cardiac etiology
Normal exam, no red flags

When to Refer to Cardiology¶

Exertional chest pain
Chest pain with syncope
Abnormal ECG
Elevated troponin
Pericardial friction rub
Significant murmur
Family history of SCD/cardiomyopathy
Known structural heart disease

Board Pearls¶

Pearl: Cardiac causes = <5% of pediatric chest pain

Most is musculoskeletal or idiopathic

Pearl: Exertional chest pain = RED FLAG

Requires cardiac evaluation (ECG, consider echo)

Pearl: Precordial catch = Sharp, brief, at rest, self-limited

Classic benign cause in adolescents

Pearl: Reproducible with palpation = Musculoskeletal

Reassurance and NSAIDs appropriate

Self-Assessment¶

Q1: A 14-year-old has sharp left chest pain that started suddenly while sitting in class. It lasts 30 seconds, worsens with deep breath, then resolves completely. Exam is normal. What is the most likely diagnosis?

Answer

**Answer**: Precordial catch syndrome (Texidor's twinge) **Rationale**: Classic features - sudden onset at rest, sharp, brief, may worsen with breathing, completely resolves. No workup needed.

Q2: A 16-year-old athlete has chest pain during basketball practice. He has no syncope but feels his heart "racing." Family history reveals his uncle died suddenly at age 35. What is the most appropriate next step?