Chest Pain

Dear Lisa,

My son is 9 years old and has been complaining of pains in his chest. They are not continuous or everyday. They come and go and happen at different times of the day. He can be in the middle of an activity or doing something calm. He also has dark circles under his eyes and his coloring in his face has been a little pale lately. Is this something that could be serious or is it possibly growing pains?

“Son with Chest Pain”

Dear “Son with Chest Pain”,

Growing Pains are the pains that children experience in their arms and legs, not in the chest. Pains in the joints or the chest are due to other conditions. Growing pains usually occur in the calves or shins of both legs.(1) Children typically complain of pain in the evening or in the middle of the night. The story of a child who has Growing Pains goes like this; the child goes to sleep at night and suddenly awakes due to pain in the calf. After applying warm compresses or administering a pain medication the child goes back to sleep. By the next morning the child is absolutely fine with no complaint of pain, no limp and no rash. The child proceeds to run and jump on the leg all day with no noticeable problems.

On the other hand, pain in the chest can be due to a variety of reasons. Most people become alarmed when a child complains of Chest Pain, associating this symptom with a heart problem. In reality, cardiac defects are rarely the cause of chest pain in children. Only 4 to 6% of childhood complaints of chest pain are attributed to cardiovascular lesions.(2)

Acute Pericarditis is one of the potential cardiac causes for Chest Pain. Pericarditis occurs when the lining of the heart or the pericardium becomes inflamed. This inflammation is usually caused by an infection. The signs of Pericarditis include a stabbing, sharp chest pain that occurs when a patient lies down. The symptoms improve when the patient sits up.

Hypertrophic Obstructive Cardiomyopathy is a life threatening cardiac condition that occurs in children. adolescents and young adults. The symptoms include angina like chest pain, fatigue, shortness of breath, palpitations or passing out; usually occurring during exercise.(3) It is a familial condition and a known cause of sudden cardiac death.(3) Many times there is a history of a family member who had a sudden unexplained death.

Luckily, musculoskeletal conditions are the most common cause of Chest Pain in the pediatric population.(4) Muscles strains or injuries to the pectoral, shoulder or back muscles due to trauma or physical activity are the leading cause of Chest Pain in children. Costochondritis is a common childhood musculoskeletal disorder. It occurs when the cartilage between the ribs becomes inflammed. The point of inflammation occurs at the point where the sternum (breastbone) meets the ribs on a chid's anterior chest.

The symptoms of Costochondritis include a chronic sharp pain of the anterior chest wall that typically radiates to the back or abdomen. The pain can be worsened by deep breathing and physical activity. Application of pressure to the area where the ribs meet the sternum elicits chest pain in patients with Costochondritis.(5) The pain from Costochondritis can last for months. The children that tend to develop Costochondritis are those who participate in sports that involve swinging of the arms; such as tennis or swimming.

Conditions of the upper gastrointestinal tract such as gastritis, esophagitis or Gastroesophageal reflux can also present with chest pain. The pain from gastritis usually occurs behind the breastbone and is aggravated when the child leans forward. Children taking oral steroids or Non steroidal anti-inflammatory drugs such as Ibuprofen are at greater risk for developing gastritis.

Gastroesophageal Reflux Disease (GERD) is a common gastrointestinal disorder experienced by both children and adults. Signs and symptoms of GERD in an older child include heartburn, vomiting, difficulty swallowing, and chronic cough. GERD symptoms occur more frequently after meals and at night.(6) The older children that I cared for with GERD often complained of a bad taste in their mouth or a feeling like food was coming up their throat. It is important that GERD is diagnosed and treated because untreated GERD can lead to Esophagitis, throat disease and Barrett’s esophagus.(7)

Chest pain due to a respiratory origin is also a common finding in children. A respiratory infection can cause acute chest pain due to Pleurisy. Pleurisy occurs when the pleural membrane or the lining of the lungs becomes inflamed. Certain respiratory infections can cause this membrane to become inflamed. When the pleural membrane becomes inflamed it causes friction during breathing which can be quite painful. A patient with Pleurisy experiences such sharp pain that it causes him to catch his breath. Pleuritic pain can also refer to the abdomen and shoulder due to a common sensory nerve supply.(5)

Chest pain is also a common finding in children with Asthma.(5) Asthma is the most common chronic disorder in childhood. It affects approximately 5 million children in the United States.(8) Because the symptoms vary from child to child and different triggers affect different children, Asthma tends to be a challenge to diagnose. There is no one diagnostic test that determines whether a child has Asthma or not.(8) The diagnosis is made through a careful evaluation of a child’s clinical history as well as his family history.(8)

Airway inflammation is the hallmark of Asthma. This inflammation can remain “silent” and not cause any noticeable symptoms. The emergence of Asthma symptoms develops long after the inflammatory cascade causes changes in the airway.(8) By the time a child develops symptoms their disease is out of control. Therefore, many times the diagnosis of Asthma is more of a subjective decision rather than a measure of objective findings. That is why a detailed history of symptoms is necessary in order to make the diagnosis.

Children with Asthma can go undetected or undiagnosed for months or years before a diagnosis is made. Many Asthma related Emergency Department visits and hospitalizations can be attributed to the Doctor’s failure to recognize and correctly classify the severity of disease in a timely manner.(9) It takes an astute practitioner with extensive experience to identify Asthma in the early stages.

The most common symptoms of Asthma include recurring cough, wheeze, shortness of breath and chest tightness or pain. Symptoms that are elicited with triggers, symptoms that worsen at night and waking at night due to respiratory symptoms are key indicators for Asthma.(10) Other more subtle signs of Asthma include exercise intolerance, allergic shiners(dark circles under the eyes) and prolonged expiratory phase during breathing. From my experience I found that many children with Asthma triggered by exercise experienced chest pain as their presenting symptom.

A viral infection can also cause Chest Pain in children. Pleurodynia also known as “The devil’s grip” can cause intense chest pain. Coxsackievirus Group B is usually the offending organism that causes the condition. The chest pain from Pleurodynia occurs in spasms and is intensified by breathing and coughing. Other symptoms include fever, sore throat and diarrhea.(11)

Psychogenic Chest Pain accounts for 5 to 17% of the cases of Chest Pain in the pediatric population. (2) Psychogenic Chest Pain is usually seen in children over 12 years old and more often found in females.(12) This diagnosis is a diagnosis of exclusion and is a only a consideration when all other causes have been ruled out. Psychosocial or social pressures in a child’s life can contribute to Psychogenic Chest Pain. Stressors including a death in the family or divorce are potential causes of Psychogenic Chest Pain.

As you can see, the causes of Chest Pain in children are many. An accurate diagnosis can only be made through a complete history and physical examination performed by a health care professional. To aide in the diagnosis it would be a good idea to keep a symptom diary. The symptom diary should include the location of the pain, its affect on activity, the time of day, relation to food intake, environmental conditions and activities (ex. coloring with markers), weather, medication use and activity level. It would also be important to record the duration of symptoms, associated findings (for example a runny nose) and measures that improve the symptoms. A symptom diary can help you determine if there are triggers that elicit the Chest Pain.

Since your child is experiencing intermittent chest pain, sometimes associated with exercise, dark circles under the eyes and pale skin color a respiratory cause should be investigated. It would be unlikely that his symptoms are due to a respiratory infection or virus because you did not mention a recent illness or fever. Instead, Asthma should be considered because it is a very common childhood disorder and because his symptoms are commonly found in children with Asthma.

If there is a family history of Asthma, Allergies or Eczema, then Asthma would be a strong consideration. It would be a good idea to have your son evaluated by a practitioner who specializes in treating childhood Asthma. An in depth review of your child’s personal history of symptoms, such as Allergies and Eczema as well as a review of the family history regarding these conditions should be investigated. This is essential because the presence of Allergies and Eczema puts a child at risk for the development of Asthma. (13,14)

If your child is presently engaged in sports, has heartburn or has a relative who experienced an unexplained sudded death you should discuss this with your doctor. These findings may represent one of the other conditions discussed.

I wish your son well.

If you are interested in reading other Pediatric Advice stories covering these topics:

Growing Pains

Asthma Treatment

Asthma Triggers

Allergic Shiners

Gastroesophageal Reflux in Infancy

Gastroesophageal Reflux

References:
(1)Graham M, Uphold C. Clinical Guidelines in Child Health. Gainsville, Florida: Barmarrae Books. 1994:566,572.
(2)Fyfe DA, Moodie DS.Chest pain in pediatric patients presenting to cardiac clinic. Clin Pediatr (Phila). 1984. 23:321-340.
(3) Walsh CA. Syncope and sudden death in the adolescent. Adolesc Med. 2001.(12)105-132.
(4)Kocis KC. Chest pain in pediatrics. Pediatr Clin North Am. 1999;46:189-203.
(5)Kundra M, Mahajan P. Pediatric Chest Pain: Key to the Diagnosis. Consultant for Pediatricians. 2006. August:460-466.
(6) Suwandhi E, Ton M, Schwarz S. Gastroesophageal Reflux in Infancy and Childhood. Pediatric Annals. (35)4:259-266.
(7)Rudolph CD, Mazur, Liptak GS. North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of Gastroesophageal reflux in infants and children: recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001. 32:S1-S31.
(8)Mahr T, Crisalida T, Hollingsworth J, Ortiz G, Senske B, Calvin M, Waldrop J. Attaining the Inside Track on Asthma Control. The Clinical Advisor. 2006. Dec:S 3-S14.
(9)Wolfenden LL, Diette GB, Krishnan JA,. Lower physician estimate of underlying asthma severity leads to under treatment. Arch Intern Med. 2003. 163:231-236.
(10)National Asthma Education And Prevention Program. Guidelines for the diagnosis and management of asthma: expert panel report 2. Bethesda, Md; US Department of Health and Human Services. Public Health Service, National Institutes of Health, National Heart, Lung and Blood Institute. 1997. NIH publication no. 97-4051.
(11)Behrman R, Kliegman R. Nelson Essentials of Pediatrics. Philadelphia ,PA: W.B.Saunders Company. 1990:345-346.
(12) Selbst SM. Chest pain in children. Pediatrics. 1985. (75):1068-1070.
(13)Kumar R. The Wheezing Infant: Diagnosis and Treatment.Pediatric Annals. 2003. (32)1:30-36.
(14 ) Hogan M, Wilson N. Asthma in the School-Aged Child. Pediatric Annals. 2003. 32(1):20-25.

Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner

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