It’s time to get this niggling pain off our chest… An approach to chest pain in Paediatric ED


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Author: Imogen Paul / Editor: Liz Herrieven, Charlotte Davies / Codes: / Published: 22/09/2020

Chest pain in children and young people is thankfully, in the most part, not too concerning, probably similarly to chest pain in adults, covered here. But explaining exactly what the cause of it is, can be tricky. And when do we need to worry?

So what are some common causes?

  1. Costochondritis: If there’s been a recent history of coughing/straining and this seems to make the pain worse this is quite likely. It might also be tender to touch. A short course of ibuprofen and plenty of reassurance is all that’s needed.
  2. Acid reflux: Typically a burning feeling which can come right up to the throat, sometimes brought on by food. This can sometimes come on for no reason, or a viral illness can trigger it off. A trial of Gaviscon (or Peptac) or PPI (proton pump inhibitor, not insurance) is a good place to start, and some sensible advice around smaller and less spicy/acidic foods (and don’t forget to ask about the diet coke… that’s not good for reflux).
  3. Stress/anxiety: This can be more difficult to diagnose without sounding dismissive of the very real pain. Other causes should be considered, but a careful discussion with the family can sometimes lead the child to realise the link themselves! If other causes are much less likely and the ECG is normal, some relaxation exercises/apps and GP follow up is probably best.
  4. Precordial catch syndrome: This pain is sharp and comes on quite suddenly, causing alarm for the child and family. It is caused by irritation of the nerves between the ribs, but is not concerning. After a few slow deep breaths it normally disappears within a few seconds.
  5. Lung causes: If there are symptoms of a chest infection or asthma exacerbation which came on with the pain, this may be the cause. The pain can sound pleuritic, and it can be hard to separate from costochondritis. This doesn’t matter too much if it sounds lung related and not otherwise concerning reassurance can be given. Us adult types always wonder about pulmonary embolism in pleuritic pain… but that’s really rare in children.

Other things to consider:

  • Do we need an ECG? This is a relatively quick, cheap and non-invasive investigation. It should always be done before discharging anxiety related pain, and is also helpful if the pain sounds like it could be cardiac. If the pain doesn’t fit with an exact clinical picture, an ECG can help to reassure us it is not cardiac. Do we need a troponin to reasure us? I’d say no, and the editor’s local paediatric cardiology team say no child should ever have a troponin done without discussing with them first.
  • Has there been a recent trauma? There may be bruising, bony tenderness and pain on movement. A chest x-ray might be needed to rule out a pneumothorax.
  • Is this a repeat presentation? If a child re-attends with the same presentation either the concerns haven’t been addressed, or the symptoms are worsening. Either way, the family are worried. Make sure not to jump back to the original diagnosis without considering other causes. Perhaps the child warrants some investigation to rule out thyroid/electrolyte problems? Or maybe they need to be signposted for help managing anxiety?
  • Is there a possibility of drug use? Although they may not readily disclose, it is important to ask about. Cocaine/amphetamines can have nasty cardiac side effects.

What are concerning features that would warrant further investigation?

Mostly, a thorough history and clinical examination is all that’s needed to reach a likely diagnosis. Occasionally, there are features that are more worrying and the patient should probably be admitted to be looked into further.

Exertional chest pain. Syncope or pre-syncope. Palpitations. If any of these feature in the history this could be one of the rare cases of cardiac related chest pain. Sometimes undiagnosed valvular problems or other structural heart issues can present in ED like this. An ECG and referral to paediatrics for further workup should be considered, or at least senior discussion.

A family history of early onset heart problems, or a personal history of previous heart problems, may mean referral to paediatrics could be helpful. Especially if the child has been under cardiology for previous heart issues – even if the pain doesn’t sound too concerning, be very careful. These families may have had lots of experience with chest pains, and if they are worried we should be too! We all ask about sudden death because we’re worried about arrythmias – but also ask about deaths whilst swimming.

There are also certain medical conditions to be aware of. Connective tissue or inflammatory disorders like lupus, inflammatory bowel disease or juvenile arthritis can be associated with heart inflammation. Myocarditis and pericarditis are not common, but worth considering if a child has a history of these types of conditions.


In summary, chest pain is a relatively common presentation to the Paediatric ED. But concerning causes are very rare. Most of these children can be discharged home, but it is worth having an awareness of other causes that it is best not to miss.

For more information have a look at this journal article.

If paediatric ECGs cause you anxiety, have a look at our RCEMLearning blog, or DFTB blog.

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