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Pediatric Costochondritis Differential Diagnoses

  • Author: Joseph P Garry, MD, FACSM, FAAFP; Chief Editor: Lawrence K Jung, MD  more...
 
Updated: Mar 09, 2015
 
 

Diagnostic Considerations

Several studies have demonstrated repeatedly that the most common causes of pediatric chest pain presenting to an emergency department or for an outpatient office visit include musculoskeletal causes as the most common etiology, followed by respiratory and then gastrointestinal causes.[1, 13, 6, 14] Among pediatric and adolescent patients who have no history of cardiac abnormality or cardiac disease, it is uncommon to elicit an actual cardiac cause to their chest pain. Drossner et al. studied pediatric patients presenting with chest pain to two tertiary care pediatric emergency departments over a 3 1/2 year time frame.[13] They found, among a study population of 4288 patients, a prevalence of 0.6% of patients who demonstrated a cardiac etiology as the cause of their chest pain.[13] Among a population of 380 children referred to a pediatric outpatient clinic for chest pain, only one patient (0.3%) was found to have a cardiac cause.[6] Saleeb et al. evaluated 3700 pediatric and adolescent patients seen at Children's Hospital Boston for an evaluation of chest pain over a period of ten years.[14] Their study found a prevalence of 37/3700 (1%) for cardiac causes for chest pain. Furthermore, they found that no patient who was diagnosed with non-cardiac chest pain (99%) subsequently died from a cardiac cause over the 17,886 patient years of follow up.[14]

Another important finding associated with pediatric and adolescent chest pain is that of underlying psychological conditions. In this population, it has been demonstrated that those with non-cardiac chest pain have a higher prevalence of both anxiety and depression.[15, 16] In comparison to a population of pediatric and adolescent patients with innocent heart murmurs, Lipsitz et al. found a prevalence of anxiety disorders of 70% in those with non-cardiac chest pain, as compared to a prevalence of 41% in those with innocent heart murmurs.[15] Furthermore, it was noted that the onset of the psychological condition predated the onset of non-cardiac chest pain. Lee et al., in a similar population of patients, also found significantly higher levels of anxiety, depression, and anxiety sensitivity among those with non-cardiac chest pain.[16] Anxiety sensitivity is defined as a "fear of fear", and represents a psychological vulnerability to the development of anxiety through heightened interoceptive awareness.[16] Loiselle et al. also found that among children with non-cardiac chest pain, these children demonstrated higher levels of internalizing and somatic complaints, as well as their parents who also demonstrated higher anxiety levels.[17] Their study also showed significantly higher health care utilization in the year prior to a cardiology evaluation for their non-cardiac chest pain.[17]

Overall, it is important to note that in pediatric and adolescent patients presenting with chest pain, absent an obvious etiology, the most common causes are musculoskeletal, pulmonary/respiratory, and gastrointestinal etiologies. A cardiac etiology for the chest pain has a very low prevalence of 1% or less. And psychological factors, comprising principally anxiety and depression, can be found in a higher prevalence among this cohort of patients.

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Joseph P Garry, MD, FACSM, FAAFP Associate Professor, Department of Family Medicine and Community Health, University of Minnesota Medical School

Joseph P Garry, MD, FACSM, FAAFP is a member of the following medical societies: American Academy of Family Physicians, American Medical Society for Sports Medicine, Minnesota Medical Association, American College of Sports Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Barry L Myones, MD Co-Chair, Task Force on Pediatric Antiphospholipid Syndrome

Barry L Myones, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American College of Rheumatology, American Heart Association, American Society for Microbiology, Clinical Immunology Society, Texas Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

David D Sherry, MD Chief, Rheumatology Section, Director, Amplified Musculoskeletal Pain Program, The Children's Hospital of Philadelphia; Professor of Pediatrics, University of Pennsylvania School of Medicine

David D Sherry, MD is a member of the following medical societies: American College of Rheumatology, American Pain Society

Disclosure: Nothing to disclose.

Chief Editor

Lawrence K Jung, MD Chief, Division of Pediatric Rheumatology, Children's National Medical Center

Lawrence K Jung, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Rheumatology, Clinical Immunology Society, New York Academy of Sciences

Disclosure: Nothing to disclose.

Additional Contributors

James M Oleske, MD, MPH François-Xavier Bagnoud Professor of Pediatrics, Director, Division of Pulmonary, Allergy, Immunology and Infectious Diseases, Department of Pediatrics, Rutgers New Jersey Medical School; Professor, Department of Quantitative Methods, Rutgers New Jersey Medical School

James M Oleske, MD, MPH is a member of the following medical societies: Academy of Medicine of New Jersey, American Academy of Allergy Asthma and Immunology, American Academy of Hospice and Palliative Medicine, American Association of Public Health Physicians, American College of Preventive Medicine, American Pain Society, Infectious Diseases Society of America, Infectious Diseases Society of New Jersey, Medical Society of New Jersey, Pediatric Infectious Diseases Society, Arab Board of Family Medicine, American Academy of Pain Management, National Association of Pediatric Nurse Practitioners, Association of Clinical Researchers and Educators, American Academy of HIV Medicine, American Thoracic Society, American Academy of Pediatrics, American Public Health Association, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

References
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