by Dr. Koay Han Siang
Consultant Paediatrician & Paediatric Cardiologist

Chest pain in children and adolescents is a common reason for visits to both general practitioners and paediatric specialists. This experience can be particularly distressing for both the child and their parents, fueled by concerns about its association with heart attacks in adults.

The causes of chest pain in this age group can be categorised as either non-cardiac or cardiac in origin. The reassuring news is that non-cardiac causes are the primary culprits, accounting for the majority of cases. Only a small percentage, ranging from 1% to 4%, is attributed to cardiac issues.

What Will the Doctor Do?

Parents typically seek help by bringing their child to a clinic or casualty. The doctor’s initial approach involves obtaining a detailed medical history. Questions will cover the nature, location, timing, and factors influencing the pain, along with a review of the child’s previous medical and family history. This is followed by a thorough physical examination, which includes assessing the child’s general condition, blood pressure, saturation levels, breathing, heart rate, chest wall palpation, and listening to the lungs and heart. Often, the cause of chest pain can be identified through these evaluations alone.

Common Non-Cardiac Causes

The most frequently identified non-cardiac cause is of musculoskeletal origin, involving muscles, bones, and related structures of the chest wall. A history of injury, excessive or new physical activity, vigorous coughing, aggravation by certain maneuvers, and/or localised tenderness during examination may point to this category.

Reflux esophagitis (inflammation of the food passage) is another common non-cardiac cause. This is suggested by the timing of pain in relation to meals, intake of spicy foods, and/or a burning sensation resembling heartburn.

Asthma, chest infections, or inflammation of the lung covering layers are also common culprits, often accompanied by difficulty in breathing, audible wheezing, fever, and/or cough. Additionally, psychogenic chest pain in adolescents should not be overlooked, and certain stressors may require professional counselling or psychological intervention. A significant proportion of cases fall into the idiopathic group, where no identifiable cause for chest pain is found.

Cardiac Chest Pain

When the origin of chest pain remains uncertain or there is suspicion of cardiac involvement, your GP or Paediatric Specialist may refer your child to a Paediatric Cardiologist. Certain findings during history-taking or physical examination, such as episodes of near fainting or fainting, racing heartbeats, sweatiness, pain on exertion, known cardiac disease or connective tissue disorders, and positive family history, may warrant this referral.

Different heart-related issues can manifest as chest pain. These may encompass a range of conditions such as myocarditis (inflammation of the heart muscle), arrhythmias (disruptions in heart rhythm), abnormal coronary artery origin, pulmonary hypertension, cardiomyopathy (a dysfunction in the heart muscle’s performance), aortic or pulmonary valve stenosis, pericarditis (inflammation affecting the layers enveloping the heart), and Marfan syndrome, among others.

Fortunately, Paediatric Cardiologists can often diagnose these conditions through non-invasive evaluations such as electrocardiogram (ECG) and echocardiogram (heart ultrasound scan). In rare cases, additional tests like blood tests, exercise stress tests, 24-hour electrocardiogram recordings, cardiac MRI, or diagnostic cardiac catheterisation may be needed.

Treatment Approaches

The treatment of chest pain depends on its underlying cause. Simple analgesia and rest are often sufficient for musculoskeletal pain, while diet and lifestyle modifications may be recommended for reflux esophagitis. Cases with psychogenic origins may require referral to a counsellor or psychologist. Reassurance through detailed explanations to both parents and the child is crucial in alleviating anxiety, enabling the child to resume normal activities, including school and sports. For cardiac chest pain, specific management by a Paediatric Cardiologist will depend on the identified causes.

In Conclusion

Chest pain is a common occurrence in children and adolescents, with the majority of cases being non-cardiac, self-limited, and benign. Seeking early medical evaluation from a doctor is recommended to rule out serious medical conditions and provide peace of mind to both the child and their parents.