Question: My 13-year old son complains of chest pain. Since his grand-father passed away from a heart attack, recently, how concerned should I be that my son’s pain could be due to something serious?
Because of the well-known association of chest pain with significant cardiovascular disease and sudden death in adult patients, many parents have heightened concerns that a child complaining of chest pain may be suffering from an undiagnosed heart condition.
Study after study has shown that chest pain is predominantly a benign complaint and that cardiac causes only account for 4-6% of all cases. Yet, it remains an alarming complaint for many parents, it frightens and concerns the majority of patients, and chest pains, in children, still remain the second most common reason for referral to pediatric cardiologists.
Pediatricians are trained to manage chest pains, in children, by being thorough, taking the parent’s concerns seriously, developing a relationship of trust with the family, and by working with the family over a long period of time.
Recently, I consulted with a respected colleague of mine, Dr Joyce Harder, an experienced and well-known cardiologist at the local children’s hospital. I was astonished to be reminded that chest pains in children are due to idiopathic causes in 12-85% of the cases! (Idiopathic is the medical terminology for “we-do-not-quite-know-why-and-nobody-else-knows-either”)
The range of 12-85% struck me as rather wide. However, the list of other causes includes: Musculoskeletal (15-31%); Pulmonary (12-21%); Psychiatric (5-17%); and Gastrointestinal (4-7%)
At this time of the year, when viruses run rampant in families, causing many sleepless nights for parents and fuelling fears of all kinds of rare complications, the problem of chest pain is especially common. One virus in particular (Coxsackie) bedevils families’ sleep; because it may cause a situation called “Pleurodynia” (the child experiences excruciating spasms of sharp chest pain). The pain that assaults the child’s chest is referred to by some clinicians as “The Devil’s Grip”.
Chest pains in general are commonly chronic in nature. Up to 19% of patients have their symptoms for more than 3 years. Yet, in 81% of patients with persistent symptoms, the chest pain resolves with time. It is found equally in male and female patients. The average age of presentation is 13 years-old. Under 12-years, the most likely cause is respiratory reasons after the idiopathic category; over 12-years psychogenic causes are more common.
My advice to a parent of any child with pain, whether it be due to headaches, abdominal pains, joint pains or chest pain, is to keep a detailed diary. This makes it easier to identify certain patterns over time. (Good clinicians are good mainly because their experiences over many years have enabled them to recognize patterns of signs and symptoms). The pain should be described in terms of time of onset, duration, frequency, nature, intensity, location, points of radiation, precipitants and relieving factors. Gastrointestinal causes are more likely when the pain is related to meals or body position (heartburn and reflux can get worse in certain body positions).
Some symptoms and signs should alert both the parent and physician of a potentially serious reason for chest pains: irregular heart rates, exercise induced chest pain, persistent fast heart rate, high blood pressure, low blood pressure, syncope (fainting or collapsing), shortness of breath, coughing up blood, fever, fast breathing, turning blue, passing blood in the stool, vomiting blood, and symptoms which occur regularly at night.
As a tired parent myself (winters in Canada have a tendency to test any parent’s ability to handle sleep-deprivation), I have found that when kids are truly sick, they are sick day and night. No serious symptom goes to sleep when the child goes to sleep, only to wake up when the child wakes up!
Will chest pains in children become a less common reason for getting a pediatric cardiologist consultation? I doubt it. Even though tough heart conditions make up only 6% of the causes, most parents remain concerned, especially when the pain persists over months and sometimes years. When it starts to affect the family’s lifestyle in an adverse way, it becomes hard to re-assure anyone; buying time is not an option. Voltaire said that a doctor’s primary role is to entertain the patient, while the illness runs it course. This may be one of the most difficult tasks to perform when it comes to managing chest pain in children.
If you would like to learn more I will be doing a one hour seminar next month on this topic via a PowerPoint presentation (see and use the word “Herald” as the coupon code for access).
Dr. Peter Nieman is the host of healthykids.ca, the father of four children and a member of the American Academy of Pediatrics and the Canadian Pediatric Society. He is a part-time teacher at the Alberta Children’s Hospital.
Access www.healthykids.ca for a terrific new resource in helping families raise healthy children - HealthyKids with Dr. Nieman will optimize your child's complete health.
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