Risk stratification of pediatric chest pain: red flags, diagnostic yield, and an evidence-informed clinical framework

Chest pain in children and adolescents is usually noncardiac, but uncommon cardiac and other serious conditions require timely recognition. Existing reviews describe etiologies and diagnostic investigations; translating this evidence into decisions across clinical settings remains challenging. This narrative review integrates pediatric chest-pain cohorts, diagnostic studies, pathway evaluations, and professional guidance to clarify how clinical context should influence testing and disposition. A reproducible, focused literature update was performed on 27 September 2026 using PubMed records accessed through Europe PMC, with additional verification of references and institutional guidance. Evidence was interpreted according to study design, population selection, and applicability rather than pooled into a new effect estimate. Observational studies support history- and examination-directed evaluation, but heterogeneous outcome definitions, selective testing, and limited follow-up constrain conclusions about safety. We propose an assessment framework separating physiological instability, stable presentations with cardiac warning features, stable presentations suggesting a noncardiac disorder, and provisionally low-risk presentations. Low risk is a conditional clinical assessment requiring an adequate history, reassuring vital signs and examination, and no concerning disease-specific features; it is not a quantified probability or a discharge rule. Conservative outpatient management additionally requires a workable reassessment plan. Troponin testing should address a plausible concern for myocardial injury, and its interpretation depends on pretest probability, assay characteristics, and symptom timing. Point-of-care ultrasound is an optional, expertise-dependent adjunct with limited direct evidence in unselected pediatric chest pain. Clinical setting, access to investigations and specialists, and follow-up reliability affect the appropriate next step. The framework organizes existing evidence and identifies implementation gaps; it has not been derived or validated as a clinical decision rule and requires prospective evaluation before protocol-level adoption.