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Chest Pains

Dear Dr. Lanny: My 11-year-old son has told me on a few occasions that his chest hurts. He's pretty active–plays soccer and basketball–and not overweight. Sometimes he complains of pain after he's eaten a big cheeseburger. Other times I can't figure out why he's hurting. He's too young to have heart disease, right? This is a little worrisome because heart problems run in my husband's family.

A: I don't believe I've mentioned my age in this column, but let me just say that the word "Medicare" is not that many years in the future. Today I was out bike riding with another "young" man who actually uses that word. The main topic of conversation for the first 10 miles was the heart attacks both of us have had in the last two months. Obviously if we are out bicycling, we're doing OK. I only bring up my experience to point out the differences in the likely causes of chest pain in your son compared with us more mature types.

When you reach your 40s, particularly if there is family history of heart disease, or unexplained sudden death, any chest pain needs to be taken very seriously, and acted upon with haste. Although most minor chest pain in adults does not turn out to be heart-related, the potential consequences are so great that a call to your doctor to discuss the situation should always be your first course of action.

Happily, the likelihood of a life-threatening situation causing chest pain in your son or in any child is exceedingly low. Chest pain in children and adolescents is not an uncommon complaint, and it can come from a variety of causes. Because parents almost immediately worry that chest pain in their son or daughter is heart-related, I will address cardiac disease first.

As in all medical problems, the doctor's two main tools are the history of the situation and the physical exam. Is there a family history of heart disease? Unexplained sudden death in family members? Did you have dizziness with the chest pain? Did you faint? What were you doing at the time? How long did it last? What helped? What made it worse? Has this happened before? And many more. Usually this will lead your doctor toward or–more likely–away from a cardiac concern.

Many children have, or have had, a heart murmur at some time in their life. These murmurs are usually of no concern and may be called innocent, or functional, or benign. In the context of an otherwise healthy child, growing well and without chest pain, evaluation of the murmur by your pediatrician is sufficient. A child with a new murmur associated with chest pain would be much more concerning. Again, your doctor must combine the physical exam and the history in deciding if any further tests or referrals are necessary. In most cases they are not.

Much more likely than heart disease is some sort of muscular or skeletal injury. A direct hit to the chest, possibly sports-related or just horsing around, can cause pain, as can overuse of a muscle group. Often a child won't feel the injury in the heat of competition, and by the time the chest hurts the patient doesn't recall the injury.

Respiratory causes, both infectious, such as pneumonia, and non-infectious, such as asthma, are common reasons for chest pain and can be easily diagnosed. Gastrointestinal causes may be more subtle and can include ulcers, reflux disease and the occasional bout of heartburn, which may really be either of the previous two problems. Here again, history and a physical will lead to the cause.

As those of you who have read this column over the years are aware, one of the doctor's best friends--particularly in the winter--is the viral illness. When all else fails, that's the likely cause. We have one other close friend with no relationship to the seasons, and that is idiopathic. Loosely translated, it means, "I don't know."

In chest pain, this is a frequently invoked cause. "It's idiopathic chest pain" means that the doctor doesn't know the cause, is pretty confident it doesn't fit in the previous categories and it doesn't suggest anything dangerous. He's not worried, and you probably shouldn't be either.

Remember that no immediate diagnosis is a reasonable outcome, and it does not mean that more needs to be done. Your doctor will be there if circumstances change and more information becomes available.

 In summary, although chest pain is quite frequent in children, it is not usually dangerous, and it usually will resolve with time and possibly some temporary pain medication. Anxiety concerning chest pain is understandable and a call to your doctor should be able to determine if watchful waiting or more rapid evaluation is needed.

 Dr. Alan Freshman, father of two grown boys, practices at Syracuse Pediatrics. Consult your own physician before making decisions about your family's health care. Send e-mail to him at editorial@familytimes.biz.

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