📊 Epidemiology
• Chest pain is common in children/adolescents
• Only 1-10% due to cardiac etiology
• Majority are idiopathic or musculoskeletal
• H&P alone often sufficient for diagnosis
⚠️ Red Flags for Cardiac Etiology
• Exercise-induced pain or syncope
• Palpitations with syncope
• Family history of sudden death, HCM, long QT
• History of Kawasaki disease or heart surgery
• Associated syncope (especially with exertion)
🩺 Common Benign Causes
• Costochondritis: reproducible tenderness, no swelling
• Precordial catch (Texidor twinge): brief, sharp, left-sided, worse with deep breath
• Musculoskeletal: heavy backpacks, coughing, sports
• GERD: substernal pain, after meals/recumbent
• Hyperventilation: anxiety, paresthesias, lightheadedness
🫁 Respiratory Causes
• Asthma: bronchoconstriction reported as chest pain
• Pneumonia/Pleuritis: pain with deep breath, fever
• Pneumothorax: sudden sharp pain, risk factors (Marfan, CF)
• Pulmonary embolus: oral contraceptives, surgery, central line
📌 Decision strategy: Exercise-induced chest pain + syncope or palpitations = urgent cardiac evaluation. Most pediatric chest pain is benign; H&P guides management. Never use "psychogenic" as diagnosis of exclusion.