The nurse intercepted me before I could make it in the room to see my next patient. "Mrs. X. brought her daughter Jennifer in because she has chest pain and trouble getting in a breath," she said anxiously. I put my chart down and hurried to the room where Jennifer, who is a bright and mature 14 year old, was sitting next to her mother. "Hello Jennifer. What seems to be the problem?" I asked.
She told me that she was fine this morning until around 10 A.M. when she started to have chest pain. She said it progressively got worse and it was difficult for her to take a deep breath. Nothing seemed to help and she was sent to the school nurse who took her temperature and found that she did not have a fever. Shortly thereafter, she said that her fingers started to tingle and she felt numb around the lips. The nurse called Mrs. X. and told her to pick Jennifer up from school and take her to the doctor immediately. She was afraid that this could be related to her heart...what with the chest pain and all.
Chest pain is not a common complaint in the pediatric patient, and in an otherwise healthy patient with no overt symptoms, it rarely signals a serious problem. When evaluating a child or an adolescent with chest pain the most important fact to establish is whether there is tenderness of the chest wall, or not. If the pain can be exaggerated or re-created by applying direct pressure on the chest then this most likely is related to a musculo-skeletal problem and NOT the heart or lungs. Since the heart and lungs are contained within, and protected by the rib cage, no amount of pressure should affect these organs.
Chest pain that is not accompanied by chest wall tenderness presents more of a challenge to the physician, especially if there are associated factors (relationship to eating) or symptoms (fever, cough etc.).
A pneumonia can certainly cause chest pain in a pediatric patient however this is usually associated with fever and upper respiratory tract symptoms such as a cough. A child with a pneumonia usually has been sick for a while prior to the onset of the chest pain, and is often times "ill-appearing" by the time they are seen in the office. A physician should be able to hear the pneumonia by listening to the lungs with a stethoscope and this can be readily confirmed by a chest x-ray.
An extremely rare lung condition called a spontaneous pneumothorax can occur with no prior warning. For some unknown reason, a portion of the lung suddenly collapses causing air to fill that part of the chest cavity. This may be the result of a spontaneous rupture of a tiny bleb, or blister, that has formed on the lung. This bleb may actually be a congenital malformation. This can cause the sudden onset of severe chest pain and difficulty breathing depending on how large of an area is involved. This can be confirmed by a chest x-ray. Mild cases can usually be observed and resolve with no treatment. Larger pneumothoraces often require the placement of a tube in the chest that is hooked up to a vacuum to get the air out of the chest cavity.
Certain gastro-intestinal disorders can cause chest pain in children or adolescents, however these are not too common. Gastro-esophageal reflux (GER) is a condition in which the acid contents of the stomach backflow, or reflux, up into the esophagus. The lining of the esophagus is not prepared to handle the acid load and this causes a burning pain in the area of the sternum, or breastbone. In GER there is no chest wall tenderness and the patient can usually give a good history of the pain occurring when the stomach is empty--before meals, or upon rising in the morning. They may even report getting relief after taking antacids. A detailed and thorough history is invaluable in diagnosing GER. There are certain studies that can be performed if the diagnosis is in question, and GER is quite responsive to medical treatment.
Another gastro-intestinal disorder that can cause similar symptoms as GER is a hiatal hernia. This is a condition in which a portion of the stomach "herniates" or protrudes above the diaphragm. This causes the acidic contents of that part of the stomach to mix with the esophagus. This causes a burning, or tearing type of pain, much like that seen in GER. The patient may report excessive burping, or loss of appetite. Once again, the history is critical in directing the physician to the diagnosis. Special studies like an upper G.I. study (barium swallow), or endoscopy (direct visualization of the stomach by a scope) may be required to establish the diagnosis. Hiatal hernias may respond to medical treatment, however surgery may be ultimately needed to correct this condition.
Children rarely suffer from angina like older people do. As a rule, heart problems almost never cause chest pain in children, especially in an otherwise healthy and thriving child.
Let's get back to Jennifer, the 14 year old with chest pain, trouble breathing and a tingling sensation in her hands. She does not have a fever, has normal vital signs, her pulse is strong and regular and she looks fine. Her heart exam is normal and her lungs are clear. The rest of her exam is unremarkable with the exception of tenderness of the sternum and the area just to the left of it. Pressing on this area causes her considerable discomfort and this is intensified by having her take a deep breath while I press. No other part of her rib cage is tender.
Jennifer has a condition known as costo-chondritis--an inflammation of the cartilage that connects the rib with the sternum. This cartilage is elastic and serves as a sort of "expansion joint" to allow the rib cage to expand with each breath. The cause of the inflammation is caused by a virus. Costo-chondritis is also known as Tietze's syndrome, named after the person who first described it.
This is a benign disorder that does not usually cause fever or a cough. Since it is caused by a virus, antibiotics are not necessary to treat it. It goes away with time, usually within a few days. Because of the pain, some patients breathe shallow and fast to minimize the chest wall excursion. This can happen subliminally without the patient even being aware that they are actually hyperventilating. Hyperventilation is a separate entity. In this particular case it is associated with the chest pain.This can lead to a vicious cycle: there is chest pain, rapid and shallow breaths, the feeling that they can't get air in, it frightens them and they breathe faster, they then experience the symptoms of hyperventilation (light headedness, tingling of the extremities, numbness around the mouth), this causes them to breathe faster...and so on. It is important to remember that not all cases of costochondritis are accompanied with hyperventilation.
For Jennifer, I made her breathe in a paper bag which made her feel better in a matter of seconds. When I explained the physiology of what was actually occurring, you could feel the tension and anxiety leave her body. I prescribed an anti-inflammatory drug for her and by the time she left the office she felt much better...so did mom. Mrs. X. called me two days later to tell me that Jennifer was playing softball and back to her normal self.