Chest pain in children: common causes by age

Chest pain in children and adolescents is common and almost always triggers fears of heart disease in families. However, in pediatric practice, this symptom is rarely associated with a cardiac cause. According to current data, chest pain accounts for approximately 1% of visits to pediatric emergency departments, while the proportion of true cardiac causes typically remains below 1-2%. [1]

The most common sources of pain in children are not in the heart, but in the chest wall, respiratory system, upper gastrointestinal tract, and psychoemotional system. In major reviews and clinical guidelines, the leading categories remain musculoskeletal causes, idiopathic pain, anxiety and panic episodes, asthma, respiratory tract infection, gastroesophageal reflux, and esophagitis. Cardiac causes account for only a small percentage of cases, although they are precisely what physicians are required to detect. [2]

The primary goal of the initial assessment is not to immediately order as many tests as possible, but to identify children at real risk of severe pathology. Therefore, the modern approach is built around a detailed interview, assessment of vital signs, and a thorough examination. In the absence of warning signs, many children respond to an explanation of the cause, simple pain relief, and observation. [3]

It's also important to understand another practical point: a significant number of children don't receive a definitive diagnosis on the day of their visit. This isn't always a mistake. Pediatric guidelines clearly state that many patients leave the department without a definitive diagnosis, but after a thorough examination and medical history, critical and life-threatening causes have already been ruled out. Moreover, in approximately one-third of children, symptoms may persist after six months without evidence of serious organic disease. [4]

When a previously healthy child experiences a new episode of pain, a severe cardiac or respiratory cause is unlikely, but not impossible. Therefore, extremes are equally undesirable: one cannot automatically assume such pain is "cardiac," but one also cannot blindly attribute it to growth, nerves, or an awkward position without checking for warning signs. A balance between calm and vigilance is considered the correct modern approach. [5]

Group of reasons	Approximate role in the structure of appeals	Practical conclusion
Non-cardiac reasons	98-99%	These are the ones that are found in most children.
Cardiac causes	0.6-2%	Rare, but require mandatory exclusion in case of “red flags”
Musculoskeletal and idiopathic causes	50-68%	The most common group
Respiratory causes	3-12%	More often with cough, fever, shortness of breath, pain when inhaling
Gastroesophageal causes	2-8%	You need to think about heartburn, vomiting, pain after eating
Psychogenic causes	10-30%	Important for anxiety, hyperventilation, and recurrent episodes

The table reflects the general modern profile of the causes of chest pain in children. [6]

Main causes and age-related characteristics

The most common cause of chest pain in children is chest wall pain. This group includes muscle strain, pain after exertion, localized soreness after coughing, injury, or prolonged awkward positioning, as well as costochondritis. Typically, this type of pain involves the child being able to point to the painful area with a finger, and the discomfort intensifies with movement, deep inhalation, or pressure on a specific area. [7]

Precordial sting syndrome is a distinctly different and common benign cause of pain in older children and adolescents. It manifests as a sudden, sharp, stabbing pain, usually on the left side of the sternum or in the projection of the cardiac apex. The pain is short-lived, typically lasting 30 seconds to 3 minutes. It may intensify with inhalation, often occurring at rest, and no abnormalities are found on examination. Special tests are usually not required for this typical presentation. [8]

Respiratory causes are the second most common. In asthma, bronchitis, pneumonia, pleurisy, and spontaneous pneumothorax, pain is often associated with coughing, shortness of breath, or inspiration. Pleuritic pain typically worsens with deep inspiration, while pneumothorax typically has a sudden onset, unilateral pain, and difficulty breathing. In young children, the possibility of foreign body aspiration should also be considered, especially if the episode has an acute onset and is accompanied by coughing, wheezing, or asymmetrical breath sounds. [9]

Gastroesophageal causes are also common. Gastroesophageal reflux and esophagitis can cause burning or vague chest pain, epigastric discomfort, postprandial pain, repeated vomiting, painful swallowing, and food refusal. In adolescents and children with atopic diseases, eosinophilic esophagitis and episodes of food impaction should also be considered if pain is accompanied by difficulty swallowing. [10]

Psycho-emotional factors cannot be dismissed as "imaginary." Anxiety, hyperventilation, and panic attacks can indeed cause severe pain or exacerbate existing discomfort. In such situations, a child may complain not only of pain but also of shortness of breath, palpitations, tremors, tingling in the fingers, fear, and recurring attacks without objective signs of heart disease. This possibility is especially important in adolescents, but a diagnosis of psychogenic pain is only permissible after excluding dangerous causes. [11]

Age	What do people usually think about first?	What is especially important not to miss
Up to 4 years	Trauma, respiratory tract infection, foreign body aspiration	Foreign body in the respiratory tract, severe infection
5-11 years	Chest wall pain, costochondritis, asthma, reflux	Pneumonia, pleurisy, myocarditis after infection
12-18 years old	Costochondritis, precordial sting syndrome, anxiety episodes, exertional muscle pain	Myocarditis, pericarditis, arrhythmia, spontaneous pneumothorax
Any age with "red flags"	Extended assessment required	Cardiac, respiratory, vascular and esophageal pathology

This is a guideline for age, not a hard and fast rule: history and examination remain decisive. [12]

The nature of pain	The most probable direction of search	Typical tips
Local, reproducible upon pressure	Chest wall pain, costochondritis	It gets worse with movement and deep breathing.
Very short stabbing pain on the left side at rest	Precordial stab syndrome	Normal examination, duration seconds or minutes
Pain with cough, fever, shortness of breath	Respiratory cause	Bronchitis, pneumonia, pleurisy, asthma
Burning after eating or lying down	Gastroesophageal cause	Heartburn, vomiting, painful swallowing
Pain during exertion	A cardiac cause needs to be ruled out.	Of particular importance are fainting, palpitations, and family history.
Sudden one-sided pain with shortness of breath	Pneumothorax until proven otherwise	Urgent assessment required

The table helps to link the complaint to the most probable group of causes. [13]

When urgent medical care is needed

A key rule in modern pediatrics is that "red flags" are more important than the pain intensity itself. Even moderate pain can be dangerous if it occurs during physical activity, is accompanied by fainting, severe shortness of breath, cyanosis, pallor, cold sweat, or palpitations. This is why history and physical examination remain the primary triage tools. [14]

Particularly concerning are pain during maximum exertion, syncope during exertion, prior cardiac arrest, congenital or acquired heart disease, previous cardiac surgery, pronounced palpitations, a family history of sudden unexplained death, cardiomyopathy, or severe arrhythmias. These signs significantly increase the likelihood of a cardiac cause and require consultation with a pediatric cardiologist. [15]

Equally important are the examination findings. A new abnormal murmur, signs of heart failure, a pericardial friction rub, muffled heart sounds, unexplained high fever, hemodynamic instability, and electrocardiogram abnormalities are incompatible with the "simply age-related" formula. With such findings, the child requires a more in-depth evaluation and sometimes hospitalization. [16]

Among respiratory and vascular causes, particular attention should be paid to sudden unilateral pain with difficulty breathing, hemoptysis, severe pleural pain, hypoxia, unexplained tachycardia, recent surgery, prolonged immobility, the presence of a central venous catheter, thrombophilia, and other risk factors for pulmonary embolism. In adolescents, such scenarios are rare, but they are considered urgent. [17]

In the presence of "red flags," one should not be complacent simply because a chest X-ray or electrocardiogram is normal. Current guidelines emphasize that normal results from these tests do not replace a full cardiac evaluation in a child with a concerning history or physical examination. In such a situation, exercise is typically restricted until the examination is complete. [18]

"Red flag"	Why is this important?
Pain during physical activity	Increases the likelihood of a cardiac cause
Fainting or near-fainting, especially with exertion	Arrhythmia, cardiomyopathy, and ischemia are possible.
Family history of sudden death, cardiomyopathy, arrhythmia	Alertness is needed regarding hereditary pathology
New pathological noise	Requires exclusion of structural heart disease
Pericardial friction rub, muffled tones	Pericarditis and effusion are possible.
High temperature without a clear cause accompanied by chest pain	Myocarditis, pericarditis, and pneumonia cannot be missed
Shortness of breath, hypoxia, sudden unilateral pain	Pneumothorax and severe respiratory causes must be excluded.
Hemoptysis, immobilization, thrombophilia	Need an evaluation for pulmonary embolism

Such signs require in-person and often urgent evaluation, even if the pain subsequently subsides.[19]

Diagnostics

Diagnosis begins with a very detailed interview. The doctor will ask when the pain began, how long it lasts, where it is located, whether the pain can be pinpointed with a finger, whether it intensifies with inhalation, movement, or exertion, whether it radiates to the arm, back, neck, or jaw, and whether it is accompanied by shortness of breath, palpitations, dizziness, cough, fever, vomiting, or difficulty swallowing. They will also ask about recent infections, vaccinations, injuries, medications, chronic illnesses, and family history of heart disease. [20]

The examination and vital signs are no less important than the story itself. The child's respiratory rate, pulse, temperature, blood pressure, oxygen saturation, appearance, pallor, edema, cyanosis, signs of respiratory distress, heart murmur, chest pain, and respiratory asymmetry are assessed. Childhood guidelines specifically emphasize that abnormal vital signs are much more likely to indicate a true pathology than an isolated complaint without objective abnormalities. [21]

Electrocardiography remains the most valuable available test when a cardiac cause is suspected, but it is not prescribed for everyone, but rather for those with a worrisome history, palpitations, syncope, abnormal examination, and other risk factors. Chest radiography is indicated if there is shortness of breath, pain on inspiration, cough, hemoptysis, trauma, focal respiratory symptoms, or significant changes in vital signs. This approach helps to avoid missing a serious cause while simultaneously avoiding unnecessary testing. [22]

The cardiac troponin test is not suitable for routine screening of all children with chest pain. Its role is limited to situations where the physician suspects myocarditis, pericarditis, or ischemic myocardial injury. The same applies to echocardiography: it is indeed useful, but mainly in children with a pathological examination, abnormal electrocardiogram, a significant family history, or pain on exertion, and most often after discussion with a cardiologist. [23]

Holter monitoring and exercise testing are of limited value in most cases of chest pain and should not be ordered automatically. Evaluation for pulmonary embolism is also not performed routinely, but only in the presence of risk factors and a corresponding clinical picture. Current guidelines specifically emphasize that most children can be safely classified into benign cases and those requiring further investigation after a thorough history and examination. [24]

Method	When needed	What helps to detect
Electrocardiography	Pain on exertion, syncope, palpitations, pathological examination, family history	Arrhythmia, myocarditis, pericarditis, cardiomyopathy
Chest X-ray	Dyspnea, cough, pain on inspiration, trauma, focal respiratory signs, abnormal vital signs	Pneumonia, pneumothorax, foreign body, cardiomegaly
Cardiac troponin test	Suspicion of myocarditis, pericarditis, ischemia	Myocardial damage
Echocardiography	Pathological examination, abnormal electrocardiogram, family history, pain with exertion	Structural heart disease, effusion, cardiomyopathy
Holter monitoring	Only on the recommendation of a cardiologist	Episodic arrhythmias
Computed tomography of the pulmonary arteries or ventilation-perfusion study	Only if pulmonary embolism is suspected	Vascular cause of pain

The table shows that the survey should be targeted rather than formulaic. [25]

Treatment

Treatment depends not on the pain itself, but on its cause. In modern pediatric algorithms, the basic principle is simple: first, pain relief and stabilization of the patient's condition, then treatment of the underlying pathology. For typical benign pain, an explanation, a simple analgesic, and brief observation are often sufficient, whereas suspected myocarditis, pericarditis, pneumothorax, or pulmonary embolism require a completely different approach. [26]

For chest wall pain and costochondritis, the mainstay of treatment is usually rest, as needed, reducing the triggering stress, and simple pain relief. In practice, paracetamol or ibuprofen are most often used, unless there are contraindications and if the medication is recommended by a doctor for the child. It is especially helpful to explain to the family that pain produced by pressure in a child is much more often associated with muscles and cartilage than with the heart. [27]

In most cases, precordial sting syndrome does not require specific treatment. The key here is a clear explanation of the benign nature of the attack. Such episodes are usually brief, resolve spontaneously, and are not associated with heart or lung disease. When a child understands that the pain is frightening but not dangerous, the frequency of repeated emergency visits significantly decreases. [28]

If a respiratory, gastrointestinal, or psychoemotional cause is identified, it is treated specifically. For asthma and other broncho-obstructive conditions, basic and symptomatic therapy is adjusted; for bacterial pneumonia, antibacterial treatment is considered; for reflux and esophagitis, diet is reviewed and specialized therapy is prescribed; and for anxiety disorders and panic episodes, explanations, breathing techniques, and, if necessary, psychological or psychotherapeutic support are used. Reviews emphasize that in anxiety, not only a pharmacological approach but also cognitive-behavioral support plays a key role. [29]

If a cardiac cause is suspected or if any "red flags" are present, a child should not be left under home observation alone. Myocarditis and pericarditis require a comprehensive evaluation with symptom analysis, physical examination, electrocardiography, imaging, and laboratory tests. In these scenarios, as well as in cases of pain on exertion, unexplained syncope, and a family history of sudden death, exercise should be temporarily restricted until the evaluation is complete. [30]

Cause	What usually helps	When hospitalization or urgent referral is needed
Chest wall pain	Simple pain relief, rest as you feel, explanation of the cause	Usually not needed
Costochondritis	Paracetamol or ibuprofen, reduction of the provoking load	Only needed in case of atypical picture
Precordial stab syndrome	Clarification, observation, sometimes calm breathing	Usually not needed
Asthma, bronchitis, pneumonia, pleurisy	Treatment of respiratory causes according to diagnosis	In case of shortness of breath, hypoxia, severe condition
Reflux, esophagitis	Nutritional correction and specialized therapy	For pain with difficulty swallowing, dehydration, severe inflammation
Myocarditis, pericarditis, arrhythmia, cardiomyopathy	Urgent cardiac evaluation	Often needed
Pneumothorax, pulmonary embolism	Emergency care and inpatient assessment	Necessarily

The table shows how different the tactics can be for the same symptom. [31]

Prognosis, monitoring and prevention

The prognosis for most children is favorable, as the majority of causes are not associated with severe organic pathology. It is important for families to hear not only "nothing to worry about," but also a clear explanation of why a cardiac cause is unlikely in a particular case. Modern pediatric guidelines consider such an explanation part of treatment, not simply an adjunct. [32]

Recurrent episodes of pain are possible, and they do not always indicate a worsening condition. Some children continue to complain of pain for months, even though examinations reveal no serious pathology. Therefore, the goal of observation is not to endlessly repeat the same tests, but to assess whether the nature of the pain has changed or whether new warning signs have appeared. [33]

A follow-up visit plan should be very specific. A repeat in-person assessment is necessary if pain begins to occur with physical activity, shortness of breath, syncope, persistent palpitations, high fever, hemoptysis, severe weakness, or sudden unilateral pain on inspiration develops. Such changes are more important than the simple frequency of episodes. [34]

Prevention depends on the cause. For chest wall pain, moderate physical activity, attention to muscle strain, proper posture at the table, and prompt treatment of persistent cough are helpful. For children with asthma, it's important to control the underlying condition. If signs of reflux are present, nutrition and medical monitoring are important. For more severe forms of pain, prevention focuses on reducing stress, normalizing sleep, and teaching self-regulation strategies. [35]

It's especially important to emphasize that children should not be subject to long-term restrictions on school or physical activity without medical advice. Current guidelines explicitly state that repeated exclusion from activities and sports is not recommended unless specifically ordered by a physician. The exception is children with "red flags," for whom activity is effectively restricted until the examination is completed. [36]

Situation after inspection	What is usually recommended
Typical benign pain without red flags	Explanation of the cause, simple pain relief, observation
Recurring pain without new symptoms	Routine check-up with a pediatrician
Change in the nature of pain	Re-evaluation in person
Pain on exertion or fainting	Urgent cardiac evaluation
Sudden pain with shortness of breath	Urgent Care
Normal examination and typical chest wall pain	Long-term activity restriction is usually not necessary.

This table helps to distinguish between safe observation and a situation where delay is urgent. [37]

FAQ

Can chest pain in a child be related to the heart?
Yes, but this is rare. According to current data, a cardiac cause is found in only a small percentage of children with this complaint. More common causes include the chest wall muscles, airways, esophagus, or anxiety. [38]

Do all children with chest pain require an electrocardiogram?
No. An electrocardiogram is useful when there are alarming findings from the history, examination, palpitations, syncope, chest pain on exertion, or a family history of cardiac pathology. Current guidelines do not require routine electrocardiography for all children with typical benign chest pain. [39]

What is precordial sting syndrome?
It is a benign form of pain, typical in older children and adolescents. The pain is typically sharp, stabbing, on the left side, short-lived, intensifies with inspiration, and resolves on its own. Physical examination is normal, and there is no association with heart disease. [40]

How can you differentiate costochondritis from "heart" pain?
With costochondritis, the pain is often localized, triggered by pressure on the costochondral joints, and intensifies with movement and deep inhalation. Other warning signs of heart pain in a child include: provocation by exertion, fainting, palpitations, a family history of sudden death, abnormal murmurs, or abnormalities on the electrocardiogram. [41]

Should all children with chest pain be tested for cardiac troponin?
No. This test is used selectively, primarily when myocarditis, pericarditis, or ischemic myocardial injury is suspected. As a screening test for all children with chest pain, it is considered ineffective. [42]

Can sports be continued if pain recurs?
If the child has no red flags and the doctor has determined a benign cause for the pain, long-term activity restriction is usually not necessary. However, if pain occurs with exertion, syncope, palpitations, a family history of sudden cardiac death, or another warning sign, sports activities should be limited until a cardiac evaluation is completed. [43]

Can anxiety cause real pain?
Yes. Psycho-emotional reactions can cause real, not "imaginary," pain and exacerbate existing discomfort. However, such a conclusion is only permissible after a doctor has ruled out dangerous cardiac, respiratory, and esophageal causes. [44]

When should you seek immediate emergency care?
Urgent care is needed for pain accompanied by fainting, severe shortness of breath, cyanosis, sudden one-sided pain, hemoptysis, high fever with severe symptoms, rapid heartbeat, cold sweat, or a sudden deterioration in health. These combinations may indicate a cardiac or respiratory emergency. [45]

Can a child complain of chest pain due to reflux?
Yes. Gastroesophageal reflux and esophagitis can cause a burning sensation behind the breastbone, discomfort after eating, pain when lying down, repeated vomiting, and painful swallowing. In such cases, the doctor evaluates the relationship of symptoms with food and body position and rules out other causes. [46]

Is echocardiography necessary if the examination is routine?
Not always. Echocardiography is typically used in children with an abnormal examination, electrocardiogram abnormalities, a significant family history, or pain with exertion. For typical benign pain and a normal initial examination, this method is often not necessary. [47]