What are the differential diagnoses for chest pain in children?

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Differential Diagnoses for Chest Pain in Children

In children presenting with chest pain, the vast majority of cases (>90%) are benign and non-cardiac in origin, with musculoskeletal causes being most common, followed by pulmonary, gastrointestinal, and psychogenic etiologies—cardiac causes account for only 1-8% of cases 1, 2, 3, 4.

Approach to Differential Diagnosis

The evaluation should immediately prioritize life-threatening conditions first, then systematically work through benign causes. Age significantly influences the differential: younger children are more likely to have cardiorespiratory problems, while adolescents (>12 years) more commonly have psychogenic pain 3.

Life-Threatening Causes (Rare but Critical)

These require immediate recognition and intervention:

  • Cardiac emergencies:

    • Myocarditis (fever, heart failure signs, S3 gallop)
    • Pericarditis (fever, pleuritic pain worse when supine, friction rub)
    • Arrhythmias, particularly supraventricular tachycardia (7% in referred patients) 2
    • Acute coronary complications (extremely rare, but consider in youth with predisposing conditions like Kawasaki disease, anomalous coronary arteries)
    • Aortic dissection (in patients with Marfan syndrome or connective tissue disorders)

  • Pulmonary emergencies:

    • Pneumothorax (especially in predisposed youth—tall, thin males; Marfan syndrome)
    • Pulmonary embolism (rare, but consider with risk factors)
    • Severe pneumonia/pleuropneumonia

Common Non-Cardiac Causes (>90% of Cases)

Musculoskeletal (most common: 64-89% in emergency settings) 2:

  • Costochondritis/chest wall pain
  • Tietze syndrome
  • Muscle strain
  • Key finding: Reproducible chest wall tenderness on palpation

Pulmonary (12-24%) 1:

  • Exercise-induced asthma (12% in one study, 4% in another) 2, 5
  • Asthma exacerbation
  • Pneumonia with pleuritic component
  • Key findings: Wheezing, dyspnea, pain with inspiration

Gastrointestinal (4-7%) 1, 5:

  • Gastroesophageal reflux disease (GERD)
  • Esophagitis (especially in inflammatory/infectious contexts) 6
  • Peptic ulcer disease
  • Key finding: Epigastric tenderness, relationship to meals

Psychogenic (9-19%) 1, 2:

  • Anxiety/panic disorder
  • Stress-related pain
  • Conversion disorder
  • Key associations: Family history of heart disease or chest pain, chronic pain pattern, absence of organic findings 3

Idiopathic (21-59%) 1, 3:

  • No identifiable cause despite thorough evaluation
  • Diagnosis of exclusion

Cardiac (1-8%) 1, 2, 4:

  • Structural abnormalities (mitral valve prolapse found in 12/139 echocardiograms in one study) 3
  • Hypertrophic cardiomyopathy
  • Aortic stenosis/regurgitation
  • Coronary anomalies

Clinical Features Predicting Organic vs. Non-Organic Disease

Features suggesting ORGANIC disease 3:

  • Acute onset (<48 hours)
  • Abnormal physical examination
  • Pain awakening child from sleep
  • Presence of fever
  • Pain causing school absence (30% of cases)

Features suggesting NON-ORGANIC disease 3:

  • Chronic duration (>6 months)
  • Family history of heart disease or chest pain
  • Normal physical examination
  • Reproducible with palpation

Age-Specific Considerations

Preschool and school-age children:

  • Higher likelihood of cardiorespiratory causes 3
  • Consider infectious/inflammatory contexts (esophagitis, pleuropneumonia, pericarditis) 6

Adolescents (>12 years):

  • Higher likelihood of psychogenic causes 3
  • Consider exercise-induced asthma
  • Rare but possible: conditions predisposing to aortic dissection, pneumothorax, or pulmonary embolism 6

Critical Pitfall

The most important pitfall is over-testing in benign cases while missing rare life-threatening conditions. History and physical examination alone can identify or strongly suspect organic causes in the vast majority of cases 2, 5. In one study, ECGs were abnormal in 31/191 cases, but only 4/191 abnormalities were actually related to the diagnosis 3. Chest radiography, ECG, and blood analysis performed in suspected non-organic chest pain diagnosed no organic diseases 2.

Diagnostic Efficiency

For children with cardiac chest pain, the most common concomitant symptom is chest tightness (67%) 4. A targeted approach using pertinent history, physical examination, and selective ECG/echocardiography can effectively reduce unnecessary testing while capturing all cardiac diagnoses 4. In the elective outpatient setting for teenagers with long-lasting chest pain, relevant cardiovascular disease is rarely found, and the physician's main role is providing reassurance with minimal but appropriate testing 6.

References

1
Research

Chest pain in children: an update.

Mymensingh medical journal : MMJ, 2011

5
Research

Chest pain in children: diagnosis through history and physical examination.

Journal of pediatric health care : official publication of National Association of Pediatric Nurse Associates & Practitioners, 2000

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