Most Likely Cause: Exercise-Induced Laryngeal Dysfunction (EILD) or Dysfunctional Breathing
In patients under 18 years with chest pain and breathing difficulties but normal cardiac workup, the most common causes are exercise-induced laryngeal dysfunction (EILD), exercise-induced hyperventilation, musculoskeletal pain, or idiopathic chest pain—NOT cardiac disease. 1
Understanding the Clinical Picture
When cardiac evaluation is normal in pediatric patients with chest pain and dyspnea, you're dealing with a fundamentally different diagnostic landscape than adults. Cardiac causes account for only 1-4% of pediatric chest pain cases 2, 3. The evidence shows:
- Musculoskeletal causes: 46.2% (most common identifiable cause)
- Idiopathic: 24.9% (second most common)
- Respiratory/dysfunctional breathing: 18.8%
- Psychogenic: 5.8%
- Gastrointestinal (GERD): 2.8%
- Cardiac: only 2.2% 3
Key Diagnostic Consideration: EILD and Hyperventilation
The combination of chest pain AND breathing difficulties in adolescents with normal cardiac workup strongly suggests exercise-induced laryngeal dysfunction or exercise-induced hyperventilation 1. The guidelines specifically describe this as an "epidemic" among adolescents.
Critical Distinguishing Features:
- Inspiratory stridor is the signature feature of EILD (not wheezing) 1
- Chest discomfort with dyspnea during vigorous exercise associated with hypocapnia without bronchoconstriction 1
- Symptoms often misdiagnosed as asthma but don't respond to bronchodilators
Recommended Diagnostic Approach
Perform cardiopulmonary exercise testing to determine if exercise-induced dyspnea and hyperventilation are masquerading as asthma 1. This is a moderate-strength recommendation from the 2016 guidelines.
Additional Workup to Consider:
Laryngoscopy if EILD suspected—can identify:
- Vocal cord dysfunction (VCD)
- Laryngomalacia (arytenoid redundancy and prolapse)
- GERD-related laryngeal changes
- Concurrent laryngeal abnormalities 1
Trial of bronchodilator 15-20 minutes before exercise if exercise-induced asthma suspected 2
Consider GERD evaluation if symptoms suggest reflux, as laryngopharyngeal reflux commonly coexists with EILD 1
Treatment Algorithm
For EILD/Vocal Cord Dysfunction:
A multidisciplinary approach is required, including speech therapy and addressing psychophysiologic stress 1. This is the guideline-recommended treatment strategy.
- Speech therapy (primary intervention for VCD)
- Breathing retraining techniques
- Address psychological stressors
For GERD-Associated Symptoms:
Empiric pharmacologic treatment of GERD is recommended in juveniles with VCD because posterior laryngeal changes associated with GERD are common 1
For Musculoskeletal Pain:
- Non-steroidal anti-inflammatory medication 2
For Idiopathic/Benign Chest Pain:
Explanation and reassurance can reduce anxiety and decrease symptom severity 2. This is particularly important since most pediatric chest pain is benign.
Critical Pitfalls to Avoid
Don't assume asthma and treat with bronchodilators without proper testing—exercise-induced hyperventilation and EILD are commonly misdiagnosed as asthma 1
Don't over-investigate—in patients without red-flag features (exertional syncope, abnormal ECG, family history of sudden cardiac death, abnormal cardiac exam), additional cardiac testing has very low yield 3
Don't dismiss obesity—dyspnea on exertion in obese patients can present with chest pain and has increased oxygen cost of breathing 1
Don't ignore the "poorly conditioned" diagnosis—physiologic limitation without bronchospasm is perhaps the most common reason for exercise-induced dyspnea in children 1
When to Reconsider Cardiac Causes
Only 0.3% of patients WITHOUT red-flag features have cardiac diagnoses, versus 13.5% WITH red-flag features 3. Red flags include:
- Exertional chest pain with syncope
- Palpitations
- Abnormal cardiac examination
- Abnormal ECG
- Family history of sudden cardiac death
If red flags are present despite initial normal workup, pursue echocardiography and consider cardiology referral 3.