Pectus Excavatum in Children: Signs, Diagnosis and Treatment

Pectus excavatum is a common chest wall difference in which a child’s breastbone is pushed inward, creating a visible dip or sunken area in the center of the chest. In many children it causes few or no physical problems, but in others it can affect heart and lung function and lead to self-consciousness about appearance.

What Is Pectus Excavatum?

Pectus excavatum is a congenital chest wall deformity, meaning it is usually present at birth or develops early in life. The ribs and the cartilage that connect the ribs to the breastbone (sternum) grow in a way that pulls the breastbone inward instead of leaving it flat or slightly raised.

This inward growth creates:

• A central indent or hollow in the chest
• A shape sometimes called “funnel chest” or “sunken chest”
• A dip that may be shallow, moderate, or quite deep

Pectus excavatum is the most common chest wall deformity in children, affecting roughly 1 in 300–500 people. It occurs more often in boys than in girls and can appear in more than one member of the same family.

Why Does the Chest Become Sunken?

Experts do not fully understand why pectus excavatum develops in some children and not others. However, several factors are believed to play a role:

• Abnormal cartilage growth: The connective tissue that links the ribs to the sternum grows too much or unevenly, pulling the breastbone toward the spine.
• Genetic tendency: Many children with pectus excavatum have a family history of the same or other chest wall differences, suggesting a hereditary component.
• Association with other conditions: Some children also have skeletal or connective tissue disorders such as Marfan syndrome, scoliosis, or other inherited musculoskeletal conditions.

In most children, pectus excavatum is not caused by anything a parent did or did not do during pregnancy or early childhood.

How Pectus Excavatum Changes as Children Grow

Pectus excavatum can look and behave differently over time.

• Infancy and childhood: The chest dip may be mild and easy to overlook.
• Early adolescence: During growth spurts, the hollow often becomes more noticeable and can deepen quickly.
• After growth is complete: Once a child is fully grown, the deformity usually stabilizes and does not change much.

Because the deformity tends to worsen around puberty, doctors often follow children more closely during these years and consider treatment timing carefully.

Common Signs and Symptoms

Not every child with pectus excavatum will have health problems. Some children notice only the change in appearance, while others experience symptoms related to the heart and lungs.

Visible Features

• A noticeable dent in the chest, often in the middle but sometimes off to one side
• Chest that looks deeper when the child inhales
• Ribs that may stick out more beside the sunken area
• Postural changes, such as rounded shoulders or slouched upper back

Possible Physical Symptoms

When the chest is deeply sunken, the heart and lungs may not have as much room as they should. This can lead to:

• Shortness of breath, especially during exercise
• Fatigue or low stamina compared with peers
• Chest pain or pressure
• Rapid or pounding heartbeat, or awareness of the heartbeat (palpitations)
• Frequent respiratory infections or wheezing in some children

Emotional and Social Effects

The way the chest looks can also affect how children feel about themselves. Many children and teens with pectus excavatum report:

• Feeling embarrassed to swim or change clothes in front of others
• Avoiding sports or activities that reveal the chest
• Worry, sadness, or low self-esteem because of body image

Even when physical symptoms are mild, the emotional impact can be significant and is an important reason some families seek treatment.

When Should Parents Seek Medical Advice?

Parents should talk with a healthcare professional if they notice:

• A visible inward curve or dent in the child’s chest at rest
• Any worsening of the deformity during growth spurts
• New or increasing shortness of breath, fatigue, or chest pain during exercise
• Emotional distress related to the chest’s appearance

Specialists who often evaluate pectus excavatum include pediatricians, pediatric surgeons, thoracic (chest) surgeons, and pediatric cardiologists or pulmonologists when needed.

How Doctors Diagnose Pectus Excavatum

Diagnosis usually begins with a detailed conversation and a thorough physical examination.

Physical Examination

• Visual inspection of the chest shape and depth of the hollow
• Listening to the heart and lungs
• Checking posture, spinal alignment, and rib position
• Looking for signs of associated conditions like scoliosis or connective tissue disorders

Imaging and Functional Tests

To understand how the deformity affects internal organs, doctors may recommend tests such as:

• Chest CT scan or MRI: Shows the shape of the breastbone and how closely it lies to the spine; helps measure severity and whether the heart and lungs are compressed.
• Echocardiogram (heart ultrasound): Evaluates heart structure and function, and how blood flows through the heart.
• Lung function (pulmonary function) tests: Measures how much air the lungs can hold and how well air moves in and out.
• Exercise (stress) testing: Assesses breathing capacity and heart response during physical activity.
• Chest X-ray: May show the position of the sternum and any spinal curvature.

Severity Measurement: The Haller Index

Some centers use a CT-based number called the Haller index to estimate how severe the chest deformity is.

This measurement is only one part of the decision-making process. Doctors also weigh symptoms, test results, and the child’s feelings about their chest.

Treatment Options for Pectus Excavatum

Treatment is tailored to the child and depends on severity, symptoms, age, and emotional impact.

Observation and Non-Surgical Management

For many children with mild deformities and no symptoms, careful monitoring may be all that is needed.

• Regular checkups to track chest appearance and growth
• Periodic heart and lung evaluations if recommended

Doctors may also suggest:

• Targeted exercise and posture training to strengthen chest and back muscles, which can improve overall posture and sometimes lessen the visual depth of the indent.
• Breathing exercises to support lung expansion and endurance.
• Psychological support or counseling if body image concerns are affecting confidence or social activities.

Some centers offer external devices that create gentle suction on the chest to gradually pull the sternum outward over time (vacuum bell therapy). Evidence is evolving, and this option is not suitable for all children, so it is usually discussed case by case.

Surgical Correction

Children with more severe deformities, significant symptoms, or major emotional distress may benefit from surgery.

Goals of surgery include:

• Allowing the heart and lungs more room to function
• Improving exercise tolerance and breathing
• Flattening or normalizing the chest shape
• Supporting better posture and self-esteem

There are two main types of surgical approaches commonly used in children and adolescents:

• Minimally invasive repair (e.g., Nuss-type repair): A curved metal bar is placed behind the sternum through small side incisions in the chest, then rotated to push the breastbone forward. The bar usually remains in place for several years before being removed. This approach avoids a large front chest incision.
• Open repair (e.g., Ravitch-type repair): The surgeon makes a larger incision on the front of the chest, reshapes or removes abnormal cartilage, and may support the sternum with a bar or other device while it heals.

Both operations are major surgeries and are usually performed at specialized centers with experience in pediatric chest wall deformities.

Risks and Recovery

As with any surgery, there are risks such as bleeding, infection, pain, and reactions to anesthesia. After surgery, children typically:

• Stay in the hospital for several days for pain control and monitoring
• Limit certain physical activities for weeks to months (especially contact sports)
• Attend follow-up visits and imaging as directed

Many studies report improved exercise capacity and quality of life after surgical correction in appropriately selected patients.

Living With Pectus Excavatum

Whether or not a child needs surgery, there are practical ways families can support daily health and well-being.

Helpful Daily Habits

• Encourage good posture: Sitting and standing tall helps the chest appear more open and may ease mild discomfort.
• Promote regular, age-appropriate exercise: Activities that strengthen core, back, and chest muscles—such as swimming or gentle resistance training—can be beneficial when approved by a doctor.
• Monitor symptoms: Note any changes in stamina, breathing, or chest pain and share them with the child’s care team.
• Support emotional health: Honest conversations, reassurance, and access to mental health professionals can help children cope with self-consciousness or social worries.

Questions to Ask Your Child’s Care Team

• How severe is my child’s pectus excavatum?
• Is there any sign that the heart or lungs are affected?
• How often should we schedule follow-up visits or tests?
• What non-surgical steps can we take now?
• At what age would surgery, if needed, be most appropriate?
• What are the expected benefits and risks of surgery in my child’s specific case?

Frequently Asked Questions (FAQs)

Is pectus excavatum dangerous?

In many children, pectus excavatum is mild and does not cause serious health problems. However, when the chest is deeply sunken, it can limit how well the heart and lungs work, especially during exercise. This is why a full medical evaluation is important.

Will my child outgrow a sunken chest?

Children do not typically “outgrow” pectus excavatum. The deformity often becomes more noticeable during growth spurts and then stabilizes when growth is complete. The appearance may not improve on its own, but many children remain healthy without surgery.

Does every child with pectus excavatum need surgery?

No. Surgery is usually reserved for children who have significant symptoms, documented effects on heart or lung function, or major emotional distress because of the chest shape. Mild cases are often observed and managed conservatively.

What is the best age for surgery?

Doctors often recommend surgical repair during later childhood or early teenage years, when the chest wall is still flexible but close to a major growth phase. The ideal timing depends on the child’s size, severity of the deformity, and overall health.

Can exercise alone fix pectus excavatum?

Exercise and posture training can strengthen muscles and may slightly improve how the chest looks and feels, but they do not change the underlying bone and cartilage deformity. For moderate to severe cases, exercise is usually combined with medical monitoring and, when appropriate, surgical or device-based treatment.

Is pectus excavatum linked to other medical problems?

Some children with pectus excavatum also have conditions such as scoliosis or connective tissue disorders like Marfan syndrome. For this reason, doctors may recommend additional evaluations if there are other physical signs or a strong family history.