Pediatric Annals

Chronic Chest Pain in Children and Adolescents

Ronald A Feinstein, MD; Willlam A Daniel, JR, MD

Abstract

When an adolescent complains of chest pain, parents and physicians may conclude that a life-threatening condition is present and immediate health care is needed. If pains have occurred for several months, most parents believe they are related to the heart. This assumption can create more problems by increasing anxiety and establishing a behavior pattern that can affect the adolescents lifestyle.

PREVALENCE

Approximately 650,000 children and youths from 10 to 21 years of age are seen by physicians each year for complaints of chest pain. This condition is exceeded only by headaches and abdominal pains as a cause for a visit to the doctor. A survey of urban black adolescents revealed that chest pain was the seventh most common health problem affecting this population group, with 32% of those affected seeking medical care.1

Very few studies have reported the incidence and etiologies of chest pains in the pediatrie population. Driscoll et al2 prospectively identified 43 patients in an outpatient setting over a nine-week period with a primary complaint of chest pain. They concluded that the majority of conditions identified were not serious, were se If- limiting, and that chest pain in pediatrie patients is rarely associated with heart disease.

Similar findings have been found in other retrospective and prospective studies.3·4 All of these reports agree on the predominant benign nature, lack of need for extensive laboratory evaluation, and the necessity for reassuring the patients and parents concerning chest pain.

ETIOLOGY

Identification of the cause of the pain depends on understanding the anatomy and physiologic functions of the contents of the chest.5 Superficial structures of the chest wall or the internal viscera of both the thoracic and abdominal cavities can be the sites of the problem. Superficial chest discomfort can usually be localized to a very specific area of the skin, subcutaneous tissues, fat, or breasts. Structures that compose the thoracic cage, the ribs, cartilage, muscles, nerves, and pleura can generate pain that is intensified by respiratory movements. Displacement of these components by breathing, laughing, coughing, or sneezing may accentuate the pain.

Dermatomes T-I to T-6 cover the thoracic surface from the neck to beneath the xiphoid process and extend down the anteromedial aspects of the arms and forearms. Fibers from T-I to T-4 supply sensory fibers to the thoracic viscera: myocardium, pericardium, aorta, pulmonary artery, esophagus, and mediastinum. Disorders of these organs can produce similar pain tending to be deep and poorly localized, most often with the greatest intensity located in the retrostemal or pericardial areas.

Fibers from T-5 and T-6 provide sensory innervation to the lower thoracic wall, diaphragmatic muscles and their peritoneal surfaces, the gallbladder, pancreas, duodenum, and stomach. Abnormality of any of these organs causes deep, poorly localized pain usually most severe in the xiphoid region or in the back, inferior to the right scapula.

DIFFERENTIAL DIAGNOSIS

Chest Wall Pain

An abnormality in the chest wall is the most common and easily identifiable cause of recurrent chest pain (see checklist). This etiologic group includes a large number of different conditions having a similar clinical presentation.

Tietze's Syndrome6·7 classically presents as a tender, unilateral swelling of the left second costal cartilage. Other cartilages may be affected and there have been reports of multiple and bilateral swellings of adjacent articulations. This condition has not shown any sex, racial, or seasonal predilection and occurs most commonly during the second and third decades of life. Onset of symptoms can be either sudden or gradual, with pains varying from slight to severe in intensity, and they are usually limited to the affected area. The pain is accentuated by deep breathing, movements that place…

When an adolescent complains of chest pain, parents and physicians may conclude that a life-threatening condition is present and immediate health care is needed. If pains have occurred for several months, most parents believe they are related to the heart. This assumption can create more problems by increasing anxiety and establishing a behavior pattern that can affect the adolescents lifestyle.

PREVALENCE

Approximately 650,000 children and youths from 10 to 21 years of age are seen by physicians each year for complaints of chest pain. This condition is exceeded only by headaches and abdominal pains as a cause for a visit to the doctor. A survey of urban black adolescents revealed that chest pain was the seventh most common health problem affecting this population group, with 32% of those affected seeking medical care.1

Very few studies have reported the incidence and etiologies of chest pains in the pediatrie population. Driscoll et al2 prospectively identified 43 patients in an outpatient setting over a nine-week period with a primary complaint of chest pain. They concluded that the majority of conditions identified were not serious, were se If- limiting, and that chest pain in pediatrie patients is rarely associated with heart disease.

Similar findings have been found in other retrospective and prospective studies.3·4 All of these reports agree on the predominant benign nature, lack of need for extensive laboratory evaluation, and the necessity for reassuring the patients and parents concerning chest pain.

ETIOLOGY

Identification of the cause of the pain depends on understanding the anatomy and physiologic functions of the contents of the chest.5 Superficial structures of the chest wall or the internal viscera of both the thoracic and abdominal cavities can be the sites of the problem. Superficial chest discomfort can usually be localized to a very specific area of the skin, subcutaneous tissues, fat, or breasts. Structures that compose the thoracic cage, the ribs, cartilage, muscles, nerves, and pleura can generate pain that is intensified by respiratory movements. Displacement of these components by breathing, laughing, coughing, or sneezing may accentuate the pain.

Dermatomes T-I to T-6 cover the thoracic surface from the neck to beneath the xiphoid process and extend down the anteromedial aspects of the arms and forearms. Fibers from T-I to T-4 supply sensory fibers to the thoracic viscera: myocardium, pericardium, aorta, pulmonary artery, esophagus, and mediastinum. Disorders of these organs can produce similar pain tending to be deep and poorly localized, most often with the greatest intensity located in the retrostemal or pericardial areas.

Fibers from T-5 and T-6 provide sensory innervation to the lower thoracic wall, diaphragmatic muscles and their peritoneal surfaces, the gallbladder, pancreas, duodenum, and stomach. Abnormality of any of these organs causes deep, poorly localized pain usually most severe in the xiphoid region or in the back, inferior to the right scapula.

DIFFERENTIAL DIAGNOSIS

Chest Wall Pain

An abnormality in the chest wall is the most common and easily identifiable cause of recurrent chest pain (see checklist). This etiologic group includes a large number of different conditions having a similar clinical presentation.

Tietze's Syndrome6·7 classically presents as a tender, unilateral swelling of the left second costal cartilage. Other cartilages may be affected and there have been reports of multiple and bilateral swellings of adjacent articulations. This condition has not shown any sex, racial, or seasonal predilection and occurs most commonly during the second and third decades of life. Onset of symptoms can be either sudden or gradual, with pains varying from slight to severe in intensity, and they are usually limited to the affected area. The pain is accentuated by deep breathing, movements that place stress on the lesion, and if pressure is placed on the area.

It is believed that the condition is most commonly due to microtrauma. Histologie reports of specimens have described normal cartilage without evidence of tumor or inflammation. The diagnosis can be made by identification of a nonsuppurative, tender, fusiform or spindle-shaped swelling at a sternochondral junction. Overlying skin is uninvolved in the disease process. The course of this syndrome is variable; pain and swelling are usually intermittent and may last from a few days to several weeks, but may persist for months to years. Recurrence of symptoms is common and episodes of pain have been reported after several years of absence.

Costochondritis (costosternal syndrome, costosternal chondrodynia) is a condition diagnosed by reproduction of pain by local pressure directly over an unenlarged costochondral or chondrostemal junction with no other physical abnormalities noted.8 It is characterized by mild to severe pain in the anterior chest wall, which can radiate to other areas of the chest, back, or abdomen and is exacerbated by a specific position, breathing or activity. The junctions most frequently involved are those of the fourth, fifth, and sixth ribs. Most of the time this disease is unilateral, but multiple, bilaterally affected areas have been reported. No racial or age preferences have been identified, but females seem to have a higher incidence of this disease than males. Symptoms can last from weeks to months, with varying intensity of the pain occurring during this time.

Chest wall syndrome predominantly affects adult patients, but has been reported in adolescents. The cause of this syndrome is unknown and no histológica! abnormalities have been described. Chest pain can be reproduced by local application of pressure or brought on by an activity. The intensity of pain varies from mild to severe. Symptoms most frequently occur during periods of inactivity but can occur during exercise. There are no other positive physical findings on examination other than point tenderness. The sternum is the most common location, but pains can originate from or radiate to any other area of the chest or upper abdomen. The condition may last for weeks to months but usually will resolve without any residual problems.9,10

Precordial catch is a condition that frequently begins in adolescence and is characterized by the sudden onset of brief, severe pain near or above the cardiac apex for 30 seconds to a number of minutes. Episodes of discomfort are intermittent and vary in frequency from a few times a day to single events months apart. Most instances of pain occur at rest or during mild activity. No cause has been identified, nor has any disease been positively associated with this illness.11

Slipping rib syndrome is a disorder involving the eighth, ninth, or tenth rib tips- These ribs do not attach directly to the sternum but have their costal cartilages united by fibrous tissue. Symptoms are caused by a tear of the fibrous tissue which allows the anterior end of the cartilage to curl upward and rub against the inside of the superior rib. Pain has been described as sharp, stabbing, or dull and is localized to the upper abdomen, epigastrium, or inferior costal regions. Symptoms can be reproduced by hooking fingers under the inferior rib and pulling anteriorly. This sign is diagnostic but direct tenderness over the cartilage is a more frequent finding. Symptoms can resolve spontaneously but surgical intervention may be necessary in the more severe cases.12

Strains, sprains, and fractures of the chest wall structures are a common cause of pain in adolescents. Pain may be associated with a specific activity but most frequently a precipitating event can not be recalled. Conservative management will usually be successful in treating this condition.13

Gynecomastia appears in 50% to 75% of boys in early phases of the growth spurt. Breast tissue can range in size from small, pea-size nodules beneath the nipples to large pendulous breasts. The condition can be unilateral or bilateral, and tissue is firm and rubbery and is usually tender to palpation. There is no discharge and no evidence of inflammation. Generally the smaller ones will resolve spontaneously within 1 to 2 years. Large amounts of tissue tend to persist, can lead to a great deal of anxiety, and are usually corrected by surgery.

Treatment. For the majority of these conditions the most important task is to convince the patient and parents that there is nothing wrong with the heart. After being relieved of this fear, most adolescents will respond and accept conservative management, which may include limiting activities if the symptoms recur, and prescribing analgesics. There is usually no need for more potent medication than aspirin, acetaminophen, or nonsteroidal anti- inflammatory agents. Occasion' ally some physicians inject a local anesthetic into a selected tender area. Unfortunately, relief is short and may create a dependency on this mode of therapy.

Cardiac Pain

Chronic chest pain due to a cardiac etiology is rare but of great concern. Brenner et al14 have reviewed the subject of chest pains caused by heart problems.

In general, a comprehensive history and physical examination along with a limited number of diag' nostic tests enables the primary practitioner to identify cardiac causes of chest pain. Pain described as occurring at rest or upon awakening and lasting for just a few moments is rarely associated with the heart. A history of exertional symptoms including pain that limit activity, syncope, palpitation, or dizziness should alert the physician to a possible cardiac problem. Most of these symptoms are either secondary to an inability to satisfy the increased oxygen demands of the body during exercise or from irritation of the pericardial or pleural serosa.

These are the major forms of cardiac problems:

* structural abnormalities

* acquired myopericardial or coronary disease

* dysrhythmias

Structural Abnormalities

Left ventricular outflow obstruction hypertrophie obstructive cardiomyopathy, aortic valve or subvalvular stenosis) is the most frequent cause of ischemie myocardial dysfunction in the pediatrie population. The presence of an obstruction and associated left ventricular hypertrophy create a condition in which exercise- induced hemodynamic changes are poorly tolerated.

Mitral valve prolapse exists in 5% to 22% of young women and possibly 6% to 10% of young men. Most patients are asymptomatic, but chest pain does occur as part of this syndrome. Pain is thought to result from papillary muscle necrosis and/or left ventricular endocardial ischemia. Other cardiac symptoms may be secondary to disturbances of rhythm. This diagnosis should be suspected when a midsystolic click and a late systolic murmur are heard during auscultation. These must be listened for with the patient in the supine, sitting, and standing positions because the findings can vary with the position of the patient and the examiner. Echocardiography is diagnostic for this syndrome.

Coronary artery anomalies are rare but will cause anginal chest pain in infants, children, and adolescents. A stress-test done under closely supervised conditions can best aid in the diagnosis of this problem.

Known structural abnormalities may be a cause of chest symptoms. Previously diagnosed atrial and small ventricular septal defects or pulmonary valve or aortic valve stenosis should not result in myocardial ischemia. Complaints of chest pain in patients with these conditions should be told they have no association.

In children with previously operated or unoperated congenital heart disease, ischemie conditions may be present, depending on the abnormality and/or previous treatment. This group is at high risk for ischemia or sudden death during exercise or at rest.

Acquired Myopericardial and Coronary Arterial Diseases

Chest pain is rarely the sole complaint in this condition. Symptoms include fever, malaise, and shortness of breath. Buns result from either the initial inflammation or from injured zones of the left ventricle, producing ischemie, exercise-induced anginal

symptoms or rhythm abnormalities. Diseases causing the condition include myopericarditis, autoimmune pericarditis, coronary arteritis and aneurysms, contiguous inflammation, and tumors.

Dysrhythmia

Chest pains result from rhythm disturbances based on physiologic alterations of cardiac output. These changes result in increased subendocardial wall stress and diminished diastolic coronary perfusión. This can be the result of any tachyarrhythmia. In healthy children and adolescents, sustained supraventhcular tachycardia is generally well tolerated for several hours before symptoms or signs of ventricular dysfunction appear. In individuals with impaired cardiac tissue, symptoms may be noted more quickly. Chest pain as the only manifestation of ventricular dysrhythmia is unusual.

PULMONARY PAIN

Few patients with chronic chest pain have pulmonary disorders. Most instances of pain are associated with other signs and symptoms, a history of chronic illness, or smoking.

The most common diseases are associated with dyspnea, cough, tachypnea, and inflammation. Asthma, cystic fibrosis, and bronchitis often lead to complaints of pain. Conditions affecting the pleura will produce the classic "inspiratory pain" that varies from mild to severe.

With more and more people participating in athletic activities, a common complaint is a "stitch. " This is believed to be caused by stress on the peritoneal ligaments, which are attached to both the rapidly moving diaphragm and to the heavy abdominal viscera. Discomfort is usually felt in the right upper quadrant under the costal margin and is described as a sharp, cramping sensation produced while running or walking. It usually disappears with rest.

Gastrointestinal Pain

Association of chest pain with eating or defecation suggests a gastrointestinal etiology. More than 50% of these involve the esophagus. Less frequent disorders involve the stomach, duodenum, and biliary tree, and rarely colonie, pancreatic, hepatic, or peritoneal disease. Problems leading to complaints are due to faulty functional motility or structural abnormality. Pains are usually deep, difficult to localize or reproduce, and usually radiate away from the point of origin. 15

There are three major types of chest pain of esophageal origin: heartburn, pain on swallowing, and spontaneous esophageal spasm. Gastroesophageal reflux and hiatal hernia with secondary esophagitis are the most common gastrointestinal causes of heartburn. Less frequently seen are esophageal problems causing pain on swallowing, disorders of esophageal motility (achalasia), or obstructive lesions of the esophagus (strictures). Primary esophageal spasm is rare in children and adolescents. When present it is usually associated with esophagitis.

Structural or functional diseases of the other parts of the gastrointestinal system are usually associated with features that allow for an appropriate diagnosis.

Psychogenic Pain

Chronic pain of psychogenic origin is well documented in the medical literature. It should not be a diagnosis of exclusion nor used to explain "idiopathic" conditions. This symptom has been associated with a number of disorders: hyperventilation, depression, and somatization.

Chest pain is a common occurrence in the hyperventilation syndrome. 16' 17 Shortness of breath, lightheadedness, palpitations, tachycardia and syncope are other symptoms frequently seen in this condition. A possible mechanism for the discomfort is a decrease in myocardial oxygen supply, secondary to decreased coronary blood flow and increased oxygen affinity of the blood in the coronary capillaries.

Kashani et al18 reported on the importance of suspecting the diagnosis of depression in a patient who complains of chest pain. Studying 100 children in an outpatient pediatrie cardiology clinic they were able to identify 13 who met the criteria for a major depressive disorder based on Diagnostic and Statistical Manual (DSM-III). Four of these 13 children were referred solely for evaluation of chest pain and had no identifiable organic etiology for this complaint.

Asnes19 and associates studied 36 children referred when no organic etiology could be found to explain the complaint of chest pain. They diagnosed a psychogenic cause in almost a third of these patients. More than half of these had a history of other recurrent somatic complaints and 30% had a history of sleep disturbances. They also found that 47% had a family member with a history of similar symptoms or other vague somatic complications.

Treatment of these conditions is dependent on the recognition of a psychological problem. Involvement of family members will probably be necessary for successful management.

SUMMARY

Chest pain is a common symptom of older children and adolescents. The majority of the conditions causing it are benign and self-limiting. Almost all diagnoses can be made with a thorough history and physical examination. Most important, the patient and parents need to be assured that there is no heart defect and that there is no imminent danger of dying.

REFERENCES

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17. Saltzman HA, Heyman A, Sicker HO: Correlation of clinical and physiologic manifestations of sustained hyRetventilation. N EnglJMed 1963; 268;143l-1436.

18. Kashani JH. Santulli R, Bemporad JR: Depression in children and adolescents with cardiovascular symptomatology: The significance of chest pain. } Am Acod Child Psjrchimry 1982; 21:187-189.

19. Anes RS, Santulli R. Bemporad JR: Psychogenic chest pain in children. Clin Pediatr 1981; 20:788-791.

10.3928/0090-4481-19861001-07

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