Chest Pain, Benign: Costochondritis and Precordial Catch Syndrome

What is it?

Chest pain is well-known to be a sign of danger in adults, and so when children and teens get chest pain, they often worry too. In fact, serious causes of chest pain in children are extremely rare. Your doctor has decided that your child, like most, has one of the very common and not dangerous causes of chest pain. This Aftercare Instruction is about the two most common causes of chest pain in children and teens. Costochondritis (koss-toe-kon-dry-tiss) is the word we use for soreness of the joints between the ribs and the breastbone, or sternum. Most people don’t realize it, but each rib is connected to the sternum by a small joint, which lets the ribs and the sternum move against each other when we breathe.

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Just like other joints, these joints are lined with cartilage and have a tiny bit of lubricating fluid inside them. Also, just like other joints, these joints can become sore or inflamed. When that happens, a person feels pain. People with costochondritis often complain of "chest pain," or pain with breathing, coughing, or laughing. The pain gets worse if we apply gentle pressure to the front of the chest. The soreness often comes on a few days after a person has had a viral infection like a cold or the flu. Other people develop costochondritis after minor trauma. Most of the time, however, there is no obvious cause. Even without treatment, costochondritis goes away on its own.

The "pre-cordial catch syndrome," or PCS, is the other common cause of benign chest pain in children and teens. PCS pain is usually very brief and sudden, and is located just around the place where you feel the heart beat most strongly on the front of the chest. It does not get worse with exertion or exercise, but it does get markedly worse when the person breathes in. Medical scientists do not know the cause of PCS, but it is clear that it is not dangerous.

Many young people with chest pain worry that they might be having a heart attack. Fortunately, heart attacks are extremely rare in children and teenagers, whereas costochondritis and PCS are extremely common. A doctor can easily tell the difference just by talking with the child or teenager, and doing a physical examination.

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Most children and teens (and their parents) are worried about the pain, and often about whether it indicates something serious, like a heart attack, pneumonia, or other illness. Doctors, while they can usually diagnose costochondritis or PCS without any tests, sometimes have concerns about more serious illness in the chest. When that is the case, doctors often order simple tests like X-rays or EKGs.

We treat costochondritis the way we treat any joint inflammation or mild arthritis. That means we recommend rest, pain relievers, and anti-inflammatory medicines. Since a person cannot completely rest the joints in this case (they would have to stop breathing!), we recommend taking it easy in general, avoiding any exercise that would make a person breathe fast or deeply, or any lifting at all. Usually resting is not necessary for more than 3-5 days. Children and teens can usually get good pain relief with the proper dose of ibuprofen (Advil® or Motrin® and others). Some kids get relief from a heating pad at a mild or medium setting. If rest and ibuprofen do not provide relief, it is likely there is something else going on.

Children and teens with PCS need no particular treatment at all. Usually, just the reassurance that they aren’t having something dangerous happening is all that they need to hear. PCS should not interfere with normal activity, and there's no reason to use medication.

There is really no part of costochondritis or PCS that should cause concern. The only real worry is that sometimes what seemed like costochondritis or PCS turns out to be something more serious. The following are signs of more concerning illness:

• Chest pain that extends into the left side of the jaw or arm
• Chest pain that a person describes as a "heavy" feeling
• Pain that does not improve at least a little after 24 hours of regular doses of ibuprofen
• Fever
• Cough, especially a cough that produces phlegm ("flem," or "flame")
• Extreme anxiety with the pain or a feeling of "impending doom"
• Blueness or paleness of the lips or fingernails
• An irregular, rapid, or pounding heart rate
• Marked difficulty breathing or catching one’s breath (different from mild pain with breathing)

Children and teens with costochondritis or PCS can go to school, camp, or work. Children and teens with costochondritis should not participate in gym classes or other strenuous activities until they are completely better.

Many things cause chest pain, and a few of them can be serious. Among the milder causes are heartburn, also called "GE Reflux Disease," "GERD," or "acid stomach." It is usually worse after a meal and when lying down. It goes away almost completely with an antacid.

Children and teens almost never have a true "heart attack" like adults do, but they can have other heart conditions that may cause pain or discomfort. Some of these are irregular or rapid heart beats called "arrhythmias," and infection or inflammation of the heart muscle (myocarditis) or of the covering of the heart (pericarditis). People who have any of these conditions generally are quite ill-appearing.

Lung conditions sometimes cause chest pain as well. Pneumonia and asthma are the most common. People with pneumonia usually have cough and fever, while people with asthma usually have cough and wheezing or noisy breathing. People with these conditions also do not look well in general. More rarely, older children and teens (especially boys who smoke) can have a collapsed lung, known as pneumothorax. If the collapse is small, the person can look fairly well. An x-ray will show the collapse.

A "pulmonary embolism," or PE, is a blood clot that blocks one of the big arteries leading from the heart to the lungs. It is rare in children and teens, though girls who use oral contraceptives and smoke have a higher risk. People with a PE are usually very sick-appearing. They may appear anxious or terrified, and may look blue or pale. A PE can happen especially after a long period of not moving much, like after a long plane trip or an operation.

Having a child with a complaint such as chest pain can be tiring and frustrating, especially if you think you are being told "there’s nothing wrong." As badly as you feel for your child, you yourself may feel out of control, inadequate, or even angry – these are normal feelings. Parents often feel stressed to the breaking point, especially when there are other children or adults to take care of. One of the best things you can do for your child is to be sure you take care of yourself. If possible, try to have other adults take care of your child for an hour or two each day so you can get some rest or just some quiet time. If you get so stressed that you are worried about your baby’s safety, call your local Parents’ Anonymous Hotline or visit the Parents Anonymous website to find a group near you.