Growing Pains

Our six-year-old wakes us up almost every night with leg pains. Her grandmother says it’s “growing pains” and I say there’s no such thing. Can you settle this for us? And tell us what to do?

Well, her grandmother might be right. There is such a thing as growing pains, and it’s pretty common. It’s a diagnosis of exclusion, meaning that there are no specific physical findings or diagnostic tests and you have to exclude other, more serious causes for those pains. Fortunately, the process of exclusion can be straightforward.

First we need to define this problem as best we can, understanding there is no established consensus. What most experts (pediatricians, pediatric orthopedists, and pediatric rheumatologists) agree on are the following points:

• Growing pains awaken children from sleep at night or from naps.
• There are no findings of any musculoskeletal problems, and the physical exam is normal.
• They occur most commonly in preschool and school-aged children (ages 2-12 years).
• Up to 20% of children can be affected, and this is more common in girls than boys.
• Growing pains are benign and usually resolve within a year or two of onset.
• Pain occurs primarily in the legs and is bilateral.
• The pain is described as being deep, and localized to the thigh or calf.
• The pain can be severe enough to cause the child to cry.
• Symptom-free periods are common, and can last for days, weeks, or even months.
• Pain is usually relieved by massage, heat, or ibuprofen/acetaminophen.
• Up to one third of children with growing pains will also have recurrent headaches and/or abdominal pain.
• There is frequently a family history of growing pains.

With these factors in mind, making the diagnosis of growing pains is almost always a “clinical diagnosis,” meaning it’s based on a good history and physical exam. Here’s what we should see:

• Pain usually occurs late in the day or awakens the child from sleep.
• The pain is not related to any joint.
• It is frequently worsened by increased physical activity during the day.
• Most experts would expect the pain to occur at least once a month for at least three months.
• The physical exam is completely normal.

That’s the key point here—the physical exam must be normal. Any of the following findings will prompt further studies:

• Unexplained fever, weight loss, or lack of energy/activity.
• Decreased range of motion of any joint, joint swelling, or tenderness directly over a bone.
• Abnormal and unusual skin changes.
• A limp or signs of gait instability.
• Swollen lymph nodes.
• Pain during the day.
• Unilateral limb pain.
• Arm pain only, with no leg pain.

If any of these are present, the diagnosis of “growing pains” is not appropriate. The list of other, more serious possibilities is long, and beyond the scope of what we’re considering here. Once again, the physical exam should be completely normal, and that should be reassuring. Interestingly, about 50% of those experts we mentioned earlier would consider diagnostic studies in the child with probable growing pains, even in the face of a normal exam. These will typically include plain x-rays of the involved extremity, a blood study that looks for evidence of inflammation, and a CBC, checking for any evidence of a bone marrow problem. All of these will be normal in a child with growing pains.

So, once we are comfortable with this diagnosis, what are we to do? How do we help our six-year-old in the middle of the night? As previously mentioned, heat and gentle massage should help. And a measure of patience. None of us want to be awakened at three in the morning. But neither does our child. Patience and reassurance will go a long way.

Regarding the use of medications, appropriate doses of ibuprofen or acetaminophen will usually control this pain. If your child has two or three episodes a week, consider giving the medicine before bed. If more frequent, a longer acting analgesic (naproxen) given in the evening may help prevent or at least lessen the intensity of the pain. None of these medications is to be used long-term, and about a week is all that we would recommend. If the pain is worsening or is uncontrollable, it might be time for another evaluation.

Along with patience and reassurance, another key to effective management of this problem is to encourage your child’s normal activities. Don’t let this dominate you or your child’s home-life and emotions.

So yes, “growing pains” are real, but they can be managed and they’ll go away.

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This is an excerpt from the new book I’m writing with pediatrician Dr. Robert Alexander. The book will address 100 questions from parents regarding their children’s health. Feel free to email us with questions:askthedox@yahoo.com