Many people view the complaint of chest pain as a serious one and one which is linked inexorably to the heart. When it is present in an adult it conjures up the picture of a very seriously ill person with the prospect of death looming larger than ever. When a child complains of chest pain too, many parents panic and are ever so worried regarding many different and possible eventualities. Most of them believe that the child is developing some sort of heart problem.

Technically chest pain in anyone could arise from a variety of sources and virtually any structure in the chest can cause pain. This includes the lungs, the ribs, the chest wall muscles, the diaphragm and the joints between the ribs and breastbone. Injury, infection or irritation to any of these tissues can be responsible for chest pain. In other circumstances, though rarely, pain could be referred to the chest from another area such as the abdomen. Chest pain may also be a manifestation of stress or anxiety. It is only occasionally that chest pain in children is due to a cardiac cause. Although pain in the chest may be a symptom of a serious underlying disease in children this is quite rare and most fortunately, the majority of chest pains in children are caused by benign or self-limited illnesses.

One of the commonest causes of chest pain in children is due to some injury, a physical insult or trauma to the structures of the wall of the chest. Injury to the muscles and bones of the chest wall can have many causes. Some are obvious such as a direct blow during a sporting event, a fall or a deliberate assault. In other cases, the incriminating event may be less conspicuous. This group includes heavy lifting, frequent coughing or intense aerobic exercise which can all lead to some degree of strain being imposed on the chest muscles. Sometimes, unnoticed minor episodes of exertion may have been the trigger to produce some sort of muscle strain. Treatment is usually supportive with rest and over-the-counter pain relievers. However, it is necessary to seek medical advice when an injury causes chest pain that is severe, persistent, or associated with difficulty in breathing. Rarely intense pain in the chest may be from fractured ribs. These need to be seen by a doctor, mainly to exclude any damage to the deeper structures. Immobilisation of the chest, as one usually does for other areas like limbs with fractures, is not advisable, is of dubious value and could potentially cause some harm due to the process facilitating secondary infections of the lung.

A condition known as Costochondritis occurs secondary to inflammation of the joints between the breastbone and the ribs. It is particularly common in adolescent and pre-adolescent females but can occur in anyone at any age. This condition is frequently caused by a viral illness or by frequent coughing. Upper respiratory symptoms often accompany this illness. The symptoms may last for several weeks and there may be pain when inhaling or exhaling deeply. However, true difficulty in breathing is rare and should be a reason to look other diagnoses. The hallmark of costochondritis is tenderness to pressure over the costochondral joint, which corresponds to the depression on the sides of the breastbone. Treatment typically consists of a 1 to 2 week course of a simple pain-killer or an anti-inflammatory medicine. This too is a benign condition and it resolve satisfactorily in time.

Another condition known as the Precordial Catch Syndrome is a benign illness of unknown cause. It occurs most commonly in adolescents and is characterized by sudden onset of intense, sharp pain along the chest or back. The pain occurs exclusively with inspiration (inhaling). A typical episode lasts several minutes and resolves spontaneously. The pain can also be "broken" with a forced deep inspiration. Several episodes may occur per day. Although its cause remains uncertain, precordial catch syndrome does not cause any significant problems. There is no specific treatment, and the frequency of events usually declines through adolescence. It does not cause any long term problems.

Acid reflux can cause stomach or chest pains. This is a condition whereby the acidic contents of the stomach back flows or regurgitates back into the oesophagus or gullet. It sometimes manifests as a burning sensation below the sternum or breast bone, though children may not be capable of accurately describing this symptom. The pain may vary in relation to meals. If this condition is suspected, certain specialised investigation may need to be performed to confirm the diagnosis. There are now several ways of treating this condition.

Stress or anxiety are known causes of chest pain. Although few people are willing to believe that stress can elicit such an outwardly worrying symptom, stress-related chest pain is really no different than a stress-related headache. The pain is often dull or non-specific and worsens with further stress or anxiety. Common underlying stresses include loss of a relative, school examinations, scholarship examinations, changing of a school and "breaking up" with a boyfriend or girlfriend in adolescent life. However, it must also be pointed out that very often stress can make chest pain from another cause seem worse than it would otherwise seem. It is important to decipher whether chest pain is the cause of anxiety or the result of it.

An important and significant set of causes of chest pains include problems with the lungs and their coverings known as pleura. Many infective diseases of the lungs and pleura lead to pains in the chest. Pain arising from the pleura could be quite severe. These pains are made worse by inspiration or breathing in and coughing. These symptoms of pains in the chest due to infective causes are usually associated with high fever and other respiratory tract symptoms such as cough and difficulty in breathing. In these situations the chest pains may be the presenting feature of lobar pneumonia or bronchopneumonia. Inflammation of the outer covering of the lung, the pleura, causes quite severe chest pains. In fact, in many cases of pneumonia, the pains in the chest are due to the infection spreading to the pleura. Infections of the upper airways tend to cause central chest pain, especially on coughing. In addition, rupture of the lung with escaping of air into the pleural cavity causes severe chest pain. Similarly, an accumulation of fluid, pus or blood in the pleural cavity causes pains in the chest. All these conditions are quite important as they could be readily treated with appropriate forms of treatment.

Unlike in adults, chest pain due to a cardiac cause is quite uncommon in children. The human heart has three layers. The outer covering is the pericardium, the middle muscle is the myocardium and the inner layer is the endocardium. Pericarditis is an inflammation of the outer lining of the heart. It is often caused by viruses and is usually a self-limited infection. It is a cause of chest pain and the typical pericarditis pain is sharp, is in the middle of the chest and may radiate to the shoulders. Assuming a sitting position or leaning forward frequently alleviates the pain. Cough, troubled breathing and fever are common.

Extreme thickening of the heart muscle and prolonged episodes of fast heart rate can also limit the heart’s blood supply. The thickened muscle outstrips the blood supply and a fast heart rate limits the time available for the blood to be supplied to the heart muscle. This is due to a reduction in the blood supply to the heart muscle itself and is similar in causation to the coronary or ischaemic heart problems in adults. However, the coronary arteries that supply blood to the heart muscle are normal in these cases. Children with such problems may experience a "typical" crushing mid-sternal chest pain that radiates to the neck and chin or to the left shoulder and arm. Troubled breathing and sweating may also occur. Any child with these symptoms should be seen by a qualified doctor.

Mitral valve prolapse is a minor abnormality of the valve which is the structure that controls the flow of blood from the left upper chamber known as the left atrium to the left lower chamber which is the left ventricle. It occurs in up to six percent of females and is less frequent in males. It is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole the contraction of the ventricles. Although mitral valve prolapse is reportedly associated with an increased incidence of chest pain, the exact cause remains unclear. In the absence of other signs and symptoms of concern, chest pain in patients with mitral valve prolapse tends to run an uncomplicated course.

In certain cases chest pains may be due to irritation of the nerves supplying the chest wall by some problem occurring in the spine. This was often a problem due to spinal tuberculosis in the past. This is extremely rare now. Shingles or herpes zoster does produce severe chest pain in the skin area in which the rash appears. The pain may come on and be quite troublesome even before the characteristic rash appears.

When a parent is confronted by a child complaining of chest pains it is essential not to panic. It is always good to remember that chest pain in children is usually due to a benign or self-limited illness. Heart disease or other serious illness is an unlikely cause. However, if a child has severe chest pain or chest pain associated with troubled breathing, fever, sweating, or a heart rate greater than 200, the child should be seen by a qualified doctor without any further delay. In the absence of these symptoms, most chest pain can wait for a convenient time to be evaluated. It is usually better to start with the family doctor or a general paediatrician rather than a specialist cardiologist. Most children with chest pain do not require the services of a specialized physician. Additionally, different causes of chest pain fall under the expertise of different types of specialists. If the child needs to see a specialist, a general practitioner or a general paediatrician can decide which type of doctor is most appropriate.

Evaluation of the more serious causes of chest pain would include obtaining a careful history of the complaint and a thorough physical examination. This would be followed by the relevant investigations which depend on a good index of suspicion as to what the most likely cause of the pain. Such investigations may include x-rays, electrocardiograms (ECGs) echocardiograms and even specialised imaging such as CT scans or MRI scans.