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Definition of the Complaint

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Chest pain is a relatively common complaint in children with a frequency of 0.6% of pediatric emergency room visits. It occurs equally in boys and girls with a median age at presentation of 12 years. The most common causes of chest pain in children are generally benign but this complaint causes much anxiety among parents and patients due to concern for a cardiac etiology (Table 14-1).

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Table 14-1. Common Causes of Chest Pain in Children. 
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In understanding the multiple causes for chest pain, one must consider the various innervation patterns that occur throughout the chest. Musculoskeletal pain is transmitted via intercostal nerves while the vagus nerve innervates the large bronchi and trachea. Pain fibers from the parietal pleura travel via intercostal nerves while the visceral pleura lacks pain fibers. Peripheral diaphragmatic disease is transmitted through intercostal fibers, and therefore can cause referred pain in the chest wall. This is in contrast to the central diaphragm, innervated by the phrenic nerve, which results in pain referred to the shoulder. The pericardium has multiple innervations including the phrenic, vagal, and recurrent laryngeal nerves, as well as the esophageal plexus. Thus, pericardial disease can present with diverse sensations and can be difficult to diagnose. Finally, cardiac pain itself transmits via the thoracic sympathetic chain and other cardiac nerves. Chest pain, therefore, is a very general term that can describe a variety of symptoms and etiologies. Only by a very careful history and physical examination can one accurately determine the cause of the patient’s discomfort.

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Complaint by Cause and Frequency

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Causes of chest pain in children can be separated by age (Table 14-2) or etiology (Table 14-3). Chest pain is classified as idiopathic in 20%-61% of cases. In terms of organic etiology, 7%-69% of cases are determined to be musculoskeletal, 13%-24% of cases are respiratory (including asthma), less than 10% of cases are psychogenic and gastrointestinal in origin, and cardiac causes are found in 5% of cases or less. Children younger than 12 years of age are more likely to have a cardiac or respiratory etiology, whereas children older than 12 years of age will more often have psychogenic causes for their chest pain. In one study, most children presented with pain duration of less than 24 hours. However, children with a nonorganic cause are more likely to have pain lasting over 6 months.

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Table 14-2. Causes of Chest Pain in Childhood by Age. 

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