Pediatric Costochondritis Differential Diagnoses

Updated: Aug 20, 2018
  • Author: Joseph P Garry, MD, FACSM, FAAFP; Chief Editor: Lawrence K Jung, MD  more...
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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