Growing pains

Growing pains are described as acute muscular pain in the legs which can cause nocturnal waking.

This condition occurs in about 15% of children. The child does not limp. Symptoms are relieved by massage and simple analgesics (1)

• prevalence of 37% in children aged 4-6 years (2)
• GP mainly affects children between the ages of 3-12 years (2)

Typical features of growing pains (GP) (2)

• it is usually nonarticular, in 2/3 of children is located in the shins, calves, thighs or popliteal fossa and is almost always bilateral
  
  
• pain usually appears late in the day or is nocturnal, often awaking the child
  
  
• duration ranges from minutes to hours
  
  
• intensity can be mild or very severe
  
  
• by morning the child is almost always pain free
  
  
• there are no objective signs of inflammation on physical examination
  
  
• GP is episodic, with pain-free intervals from days to months
  
  
• in severe cases the pain can occur daily
  
  
• study evidence showed that in children suffering this condition, GP had frequency of at least once a week in about 40% of sufferers
  
  
• often parents can predict when the child will have pain on days of increased activity or when the child is more moody.

Indications for concern (3)

• systemic upset red flags to suggest sepsis or malignancy
  • fever, malaise, anorexia, weight loss, raised inflammatory markers, bone pain, persistent or worsening night pain
  • abnormal growth (height and weight)
• abnormal developmental milestones
  • Delay (especially major motor skills)
  • Regression of achieved motor milestones Impaired functional ability (ask about play, sport, schoolwork, 'clumsiness')
• limping (intermittent or persistent)
• morning symptoms (other than tiredness after disturbed sleep)
• widespread pain (such as upper limbs and back)
• school absenteeism
  
  

When patients have typical clinical characteristics there is generally no need to do any laboratory or imaging tests (1)

• consider very rare causes with a similar presentation but there are likely to be other features as well (1):
  • benign osteoid osteoma - causes similar pain which occurs mostly at night; however symptoms are unilateral
  • leukaemia - may present with bilateral leg pain
• if there is clinical concern then referral should not be delayed while arranging investigations in primary care and referral to general paediatrics, paediatric orthopaedics or rheumatology is appropriate, depending on local referral pathways (3)
  • investigations that may be indicated in primary care
    • Full blood count (and film)
    • Acute phase reactants (erythrocyte sedimentation rate, C-reactive protein)
    • Biochemistry (bone biochemistry and vitamin D)
    • Thyroid function
    • Muscle enzymes
    • Growth chart (height and weight)
    • X-ray of legs (hips with frog views)
• important negatives (1):
  • normal FBC, ESR
  • joints themselves are normal
  • there are no cardiovascular features

Management:

• if there are no features suggestive of a sinister cause for the symptoms then reassurance is all that is required
  • most important intervention is to explain the natural benign course of the GP, thus decreasing anxiety and fear. Despite the benign prognosis, GP may have an impact on the child and family, especially among children with frequent nocturnal attacks
  • comforting, local massage therapy during pain episodes or analgesics is used. Some children need to chronically use medications, especially paracetamol and non-steroidal anti-inflammatory drugs (NSAID) (2)

Reference:

1. GP (April 15th 2005), 68.
2. Uziel Y, Hashkes PJ. Growing pains in children. Pediatr Rheumatol Online J. 2007 Apr 19;5:5.
3. Arthritis Reasearch Campaign (2008). Hands On - Growing pains: a practical guide for primary care.