Growing pains in children – symptoms, diagnosis and management

What exactly is growing pains in children?

Five-year old Nicky woke up at 1 am screaming with pain in the legs. His parents soothed him and massaged his legs, and within half an hour the pain resolved and Nicky fell asleep. Next morning, Nicky went about his activities as though nothing happened in the night. Parents were relieved. The pain was back, however, after a week or so. Next morning, the anxious parents took him to a doctor. Fortunately, for Nicky, the pain was diagnosed as growing pains . Many parents believe that growing pains occur when the child is growing rapidly, that is, during the rapid growth period between birth and two years of age, and then during adolescence. However, growing pains have actually nothing to do with growing up! Medically, it is termed benign idiopathic nocturnal limb pains of childhood, which, generally, affects children aged 3 to 12 years.[1]

Symptoms

There are no definite symptoms except for muscular pains in front of the thighs, in the calves, or behind the knees. Pains occur commonly during nights.The pains may be intense for some children, while milder for others. Growing pains do not occur every day. The pain does not limit or affect the child s activities. Researchers found that frequency of pain episodes gradually declines over 1 to 2 years and, in most cases, pain goes away completely as the child reaches adolescence. [2] Take your child to the doctor if s/he experiences

• Pain in just one leg
• Pain every night
• Pain in arms or back
• Pain associated with an injury
• Swelling in the joints
• Fever
• Weight loss
• Loss of appetite
• Fatigue, tiredness

You may also need to take the child to see the doctor if s/he is reluctant to walk or limps, especially in the morning. If the physical examination is normal , your child most probably is experiencing growing pains. However, if there are other symptoms apart from the pain, it may be due to other medical conditions.

Differential diagnosis Medical conditions that can have intense pain as one of the symptoms include:

1. Injury related leg pain: This is easily diagnosed. Pain is usually localized. However, it may not be that obvious in cases of non-accidental trauma, or battered child syndrome. Try to be more specific when explaining this to the doctor.

2. Osgood-Schlatter disease and Runner s knee: Osgood-Schlatter disease is an inflammatory disease characterised by a painful bump just below the knee where the tendon from the kneecap attaches to the tibia (shin bone). This condition is more commonly found in adolescent boy athletes. Similarly, Runner s knee commonly affects girl athletes (runners).

3. Juvenile Idiopathic Arthritis (JIA): This type of arthritis is difficult to diagnose, but it is different from growing pains because of the symptoms such as persistent swelling and joint pain, fever, and rash. The main difference between JIA and growing pains is the persistent nature of pain and morning symptoms. [3]

4. Infections: Infections are usually accompanied by fever and toxicity. Swelling, redness, and tenderness at the site of pain are other symptoms of infections.

5. Benign and malignant tumours: Some tumours may produce pain in the legs, but these pains are usually associated with swelling. Although these pains, too, can cause night time awakening, but unlike growing pains they are persistent and grow in severity. Malignant tumours are, additionally, associated with fever and weight loss.

6. Restless Leg Syndrome(RLS): Although no confirmed link between RLS and growing pains has been found, a study published in the journal Sleep revealed that some children diagnosed with growing pains later go on to develop RLS, and a family history of RLS is common in these children. In some cases, symptoms are severe enough to warrant treatment. [4] Here are Everything you wanted to know about Restless Legs Syndrome

Causes Scientists are not yet very clear about the mechanisms by which these pains occur. They have put forth theories as to the causes of growing pains. Some of these are as follows:

• Postural or orthopaedic defect: Studies have shown that growing pains are associated with postural or orthopaedic defects such as flat foot, knock-knee, scoliosis (curved spine, usually S or C shaped), and bad posture. Intervention with in-shoe devices such as triplane wedges or orthoses in many cases reduced the episodes of aching legs. [5] However, researchers are still debating on this issue.

Similarly, Hypermobile joints, orknee joints that move beyond the normal range of motion expected from the joint, could also cause growing pains. This theory, too, is yet unproved.

• Decreased bone strength: Some researchers think growing pains may be linked to decreased bone strength. [6] They found that bone strength density, especially in the shinbone region, in children with growing pains was much less than that of healthy children. However, other researchers think that this theory cannot explain the sudden pain episodes in the night or pain in the arms of some children.

• Psychological origin: Negative psychosocial environment could also be the cause of growing pains in children. John Apley in his study on growing pains in children with non-arthritic pain found that emotional disturbance and family stress are significantly associated with growing pains. [7]

• Lower pain threshold: Children with growing pains have a relatively lower pain threshold compared with their healthy counterparts. They may also have headaches and stomach aches.

• Family history: Family history, too, can have a role to play in causing growing pains in children.

• Vitamin D deficiency: Many children with growing pains can also be caused by vitamin D deficiency, especially in areas that do not get much sun. For example, a Korean study found a high prevalence of vitamin D deficiency in Korean children with nonspecific lower-extremity pains. We believe that vitamin D deficiency is an important contributor to growing pains in children, said the researchers. [8]On the other hand, many studies have not found any link between vitamin D deficiency and growing pains. Read more about 6 signs you have vitamin D deficiency

Management of growing pains Growing pains in children is not a serious condition and, in most cases, it does not require treatment. But as a parent/ guardian, you could do the following: [3]

• Give a firm massage and rub the legs.
• Use hot packs on the pain area.
• Give an analgesic to the child when the pains happen. Importantly, do not use analgesics on a long-term basis as it could be harmful.
• Help the child with muscle stretching exercises. The exercises are to be done twice a day for 10 minutes in the morning and in the night. This will also fulfil their psychological need as they will be getting extra attention from you.
• Keep a diary to note what activities or incidents trigger these pains.
• If the child has postural defect, supportive footwear can help.

Reference:

1. Uziel Y, Hashkes PJ. Growing pains in children. Pediatric Rheumatology Online Journal. 2007;5:5. doi:10.1186/1546-0096-5-5.

2. El-Metwally A, Salminen JJ, Auvinen A, Kautiainen H, Mikkelsson M. Lower limb pain in a preadolescentpopulation: prognosis and risk factors for chronicity - a prospective 1- and 4 year follow-up study. Pediatrics. 2005;116:673-81.

3. Mohanta, M P. Growing Pains: Practitioners Dilemma. Indian Pediatrics 51.5 (2014): 379-383.

4. Rajaram, S S, et al. Some Children With Growing Pains May Actually Have Restless Legs Syndrome. Sleep. Jun 2004 15;27(4):767-73.

5. Evans, A M. Relationship Between Growing Pains And Foot Posture In Children. Journal of the American Podiatric Medical Association 93.2 (2003): 111-117.

6. Friedland O, Hashkes PJ, Jaber L, Cohen A, Eliakim A, Wolach B, Uziel Y: Decreased bone strength in children with growing pains as measured by quantitative ultrasound. J Rheumatol. 2005, 32: 1354-1357.

7. Naish JM, Apley J. Growing Pains : A Clinical Study of Non-Arthritic Limb Pains in Children. Archives of Disease in Childhood. 1951;26(126):134-140.
8. Park, Min Jung et al. Prevalence Of Vitamin D Deficiency In Korean Children Presenting With Nonspecific Lower-Extremity Pain. Yonsei Medical Journal 56.5 (2015): 1384.

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