Growing Pains

by Dr. Moshe Ipp

Growing pains which typically occur at night in children 4-8 years of age, are more common in girls than boys and affect either leg at one time or another. The pain is often intense, crampy in quality and in the deep musculature of the calf or thigh or behind the knee, and rarely lasts more than 10- 20 minutes. The pain will usually wake the child from sleep, once per night for several nights a week for a few weeks then disappear only to return in a similar pattern at some future time. The cause of growing pains is not well understood but most experts would agree that growth itself, which occurs at such a slow rate is unlikely to cause pain of such intensity. Other factors that have been implicated include overexertion, fatigue and chemical imbalance. Physical examination is always normal and investigations such as blood tests and x-rays are not helpful in confirming the diagnosis. It is not necessary or useful to give pain relievers such as acetaminophen (Tempra, Tylenol) or Ibuprofen (Advil, Motrin) since the pain usually subsides before these medications have had time to take effect. Gentle massage to the affected area, a heating pad and reassurance may help ease the discomfort as the pain subsides spontaneously on it's own accord. The characteristic symptoms described above and the absence of any visible abnormality of the affected part help to distinguish growing pains from other sometimes more serious conditions.

Consider growing pains	Consider a more serious cause of leg pain
Healthy child typically 4-8 years of age	Ill looking, fever, pale, rash, weight loss, any age
Affects either leg at one time or another	Affects one leg regularly
Pain is located between joints	Pain is located in the joint, or at one specific point
Occurs at night	Day or night
Subsides within 10-20 minutes, intermittent	Persistent, prolonged or chronic
Walks normally	Child limps or refuses to walk
Physical examination is normal, no point tenderness	May have redness, swelling, reduced joint movement.

If a child presents with typical symptoms consistent with growing pains (Table 1), namely chronic, intermittent, bilateral, deep muscular pain without associated systemic symptoms and the history and physical examination are otherwise unremarkable, that is, there is no fever, limp, joint redness, warmth or swelling, then the likelihood of a serious underlying condition is remote and most experts would agree that no laboratory tests or x-rays are needed. However, despite the benign and self-limited nature of growing pains, some reviews on the topic still recommend screening tests such as a CBC, ESR and lower limb x-rays. The usual explanation given for these screening tests is to reassure the parents and patient and probably the physician that no organic disease is present. This was confirmed in recent Canadian survey of primary care physicians and specialists where it was found that most physicians perceived that normal results were reassuring to parents and children with growing pains 5. In fact there is no published evidence that normal results, which would be predicted in children with typical growing pains, do indeed reassure parents any more than simply explaining the benign nature of the condition to them, without actually performing the diagnostic tests. Physicians also need to consider the discomfort to the child and the direct and indirect costs related to these investigations. Instead of ordering unnecessary screening tests it would be more prudent for physicians to take the time to reassure parents and explain the benign nature of growing pains to them by indicating that there is nothing seriously wrong with their child. Parents must be encouraged to return if any of the more worrisome symptoms indicated in Table 1 occur, or if they remain concerned about their child's condition. Pain relievers are usually unnecessary since the symptoms usually subside before the medication takes effect, but massage or a heating pad may help the child endure the 10-20 minutes of discomfort.

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