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Night Pains

Daniel is a 4 year old boy who attends the GP with a 6 month history of waking up at night in pain. His mother says that he screams and cries, and says the pain is in both his legs, from his thighs to his shins. He asks his mother to rub his legs and this sometimes helps to calm him down. He eventually goes back to sleep after up to an hour. Sometimes his mother can predict that Daniel will wake up (e.g., if he has had a particularly active busy day). His mother is exhausted as she also has a 3 month old baby and she is not sure if Daniel is ‘playing up’ because of the attention she is giving his sister.

Daniel is reported to wake up in the morning seemingly well. There has been no observation of limp.  Daniel is very active and likes running. He never has pain throughout the day, and his mother has not noticed any joint swelling. There is no morning stiffness. He reached all his milestones at the appropriate age, and there have been no concerns about regression of milestones.  

He has a past medical history of otitis media and asthma. He lives with his mother, stepdad and baby sister. He is due to start school in September.

Examination – the GP performs a pGALS musculoskeletal examination, which shows hypermobility and flat feet, but normal arches on tip toe. There are no other abnormalities.

The photograph below shows Daniel's legs with flat feet on standing but normal arches on tip toe - these changes are normal for a child of his age.

Pain waking the child at night is usually a concern, but can be due to growing pains if there are no other red flags and criteria for growing pains are met (see rules of growing pains).  

Pain waking the child at night is usually a concern, but can be due to growing pains if there are no other red flags and criteria for growing pains are met (see rules of growing pains).  

The GP reassures Daniel and his mother, explains that no further investigations are needed.

The diagnosis of growing pains can be confidently made as Daniel has a typical history of symmetrical pains in the lower legs, no daytime symptoms, no limp, no red flags and a normal examination.

However, caution is needed and the 'rules of growing pains' must be met.  Any atypical features should warrant investigation and prompt referral to the appropriate specialist.

The family should be advised if Daniel becomes unwell, develops a limp, day time symptoms or the pains are asymmetrical. 

A parent information leaflet is available: Growing Pains Information Sheet. 

The rules of growing pains can be found here.

You would be concerned about inflammatory symptoms, and should consider Juvenile Idiopathic Arthritis (JIA) as a likely differential.

Limitation and pain on hip rotation is always a concern. In this age group, consider Perthes disease and arrange an urgent hip X-ray. Infection, inflammation and malignancy must also be considered (See red flags). 

Arrange urgent review by appropriate specialist, with urgent x-ray and blood tests to exclude infection, malignancy and inflammatory arthritis.

Gross motor – walking, climbing and managing stairs.

Fine motor and vision – holding pen with appropriate grip. Starting to manage zips and buttons independently. No visual concerns.

Flat feet and hypermobility are common in this age group. The majority will resolve and not require any intervention. If significant pain, consider referral to a paediatric musculoskeletal specialist and physiotherapy.

Simple analgesia such as paracetamol (acetaminophen) or Ibuprofen. 

Leg massaging can also be helpful.

Growing pains are often predictable after times of being physically active. Sometimes a warm bath in the evening and analgesia before bedtime, after especially physically active days, can help to prevent night waking.  

Advice for parents to manage growing pains is available.

 

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