What are the common disorders of the xiphoid bone in young children and how should they be managed?

Disorders of the Xiphoid Bone in Young Children

The xiphoid process in young children is highly variable in its development and rarely causes clinical problems, but when symptomatic, xiphodynia (xiphoid pain) is the primary disorder to consider, though it is uncommon in the pediatric population.

Normal Development and Anatomical Variations

The xiphoid process undergoes significant developmental changes during childhood that should not be confused with pathology:

• Ossification is highly variable: In children under 10 years, the xiphoid is absent on CT imaging in 67% of cases 1. When present, it shows wide variation in appearance and timing of ossification.

• Anatomical variants are common: The xiphoid can be bifid (split), trifid, curved, deflected anteriorly or posteriorly, contain foramina, or appear broad or thin 2. Bifid xiphoid occurs in approximately 1% of children 1.

• Age-related progression: The xiphoid typically begins ossifying later than other sternal segments and may not be visible radiographically until later childhood or adolescence.

Critical point: These variations are normal developmental findings and should not be mistaken for pathology or trigger unnecessary investigations 1, 2.

Xiphodynia (Xiphoid Syndrome)

While extensively documented in adults, xiphodynia is rare in young children but should be considered when:

Clinical Presentation

• Pain radiating from the xiphoid process to the chest, abdomen, throat, or arms 3
• Tenderness on palpation of the xiphoid process
• Anterior displacement or prominence of the xiphoid may be palpable 4

Diagnostic Approach

Look specifically for:

• Direct tenderness: Palpate the xiphoid process specifically—this is the key diagnostic finding
• History of trauma: Repeated microtrauma to the anterior chest wall (less common in young children than adults) 5
• Exclusion of cardiac/GI causes: The anterior chest location often misleads clinicians toward cardiac or gastrointestinal workup 3

Plain radiographs can confirm anterior displacement or unusual positioning of the xiphoid 4.

Management Algorithm

1. Conservative management first (majority of cases):

   • NSAIDs for pain control
   • Avoid pressure/trauma to the anterior chest wall
   • Observation for spontaneous resolution 3, 5

2. Local injection therapy (if conservative fails):

   • Corticosteroid injection to the xiphisternal joint
   • Consider in persistent cases after 4-6 weeks of conservative treatment 3

3. Surgical intervention (xiphoidectomy):

   • Reserved for severe, refractory cases only
   • Results in complete symptom resolution in documented cases 4
   • Rarely necessary in the pediatric population

Important Caveats

Avoid these pitfalls:

• Do not over-investigate: Normal xiphoid variations on imaging do not require treatment or further workup 1, 2

• Do not confuse with CPR technique: During pediatric CPR, compressions should be performed on the lower half of the sternum, specifically avoiding the xiphoid process to prevent injury 6. Proper hand placement is just below the intermammary line for infants and on the lower sternum for children—never directly on the xiphoid.

• Consider differential diagnoses: Epigastric masses or prominence may represent xiphoid variants rather than true pathology 2. However, rule out more serious conditions (cardiac, GI) before attributing symptoms solely to the xiphoid.

• Recognize occupational/activity patterns: In older children and adolescents, repetitive anterior chest trauma from sports or activities can precipitate xiphodynia 5.

The key clinical message: Most xiphoid "abnormalities" in young children represent normal developmental variation requiring only reassurance. True xiphoid disorders causing symptoms are rare in this age group, and when present, respond well to conservative management in the vast majority of cases.