VERSAILLES, FRANCE — Physicians should stop dismissing nighttime lower limb pain in children as just growing pains, Raju P. Khubchandani, M.D., told attendees at the annual scientific meeting of the 12th European Pediatric Rheumatology Congress.
Such nighttime lower limb pain is a syndrome with multiple causes, the most common of which is likely hypermobility, according to Dr. Khubchandani of Jaslok Hospital and Research Centre in Mumbai, India.
Dr. Khubchandani, a pediatrician and consultant in pediatric rheumatology, urged that the label growing pains be changed to a more medical term with a catchy acronym, so that clinicians will take the children's complaints seriously.
“Even parents have stopped perceiving that 'growth' is responsible,” he said, characterizing growing pains as “a big but neglected issue” around the globe.
Presenting the findings from an investigation of 448 middle-income children in a Mumbai elementary school, Dr. Khubchandani reported that 28.1% suffered from lower limb pain at night. Prevalence rates in studies from other countries have ranged from 4.2% to 38%, he said, attributing the variation in part to different diagnostic criteria.
Dr. Khubchandani and his co-investigator Vijay Viswanathan, M.D., also of Jaslok Hospital, included intermittent pain and pain that lasted at least 3 months in the past in their criteria. Only bilateral, nonarticular, lower limb pain was considered. It had to occur in late evening or overnight with the child well by morning.
The criteria also required a normal physical exam with normal laboratory work and x-rays when available. Children with neuromusculoskeletal disorders were excluded.
Prevalence of growing pains ranged from 22% of children at age 6 years to 35% at age 9 in the Mumbai study, which assessed children aged 4–10 years. About a quarter of the boys (57/226) and nearly a third of the girls (69/222) presented with the condition.
The most common site was the calf (51%) followed by the anterior thigh (25%) and behind the knee (24%). In addition, 38% of children with growing pains complained of abdominal pain, 21% of headache, and 21% of sleep disturbances.
Hypermobility was so common among children presenting with growing pains that the investigators recommended in a poster that children presenting with growing pains be screened for that condition as well.
The school population included 98 children with hypermobility and growing pains. Another 139 had hypermobility without growing pains; only 28 had growing pains without hypermobility. The remaining 183 children had neither.
Other possible causes include restless legs, hyperactivity, emotional factors, fatigue, and anatomic defects, according to Dr. Khubchandani.
About a quarter of the children had a family member with a rheumatologic condition, leading him to speculate that some might have been using the adult as a behavioral model.
“This is not one entity. There are several things that can cause this syndrome,” he said in an interview after his talk.
“Any kid who comes with this syndrome, we automatically make a preconceived diagnosis,” he said. “We tell them it is growing pains. It will go away. We should evaluate further.”
Parents do take the condition seriously, according to Dr. Khubchandani. About 86% of the parents in the Mumbai investigation stayed up at night to massage their children's legs, while 10% gave a “warm fomentation” and the rest did both. “There was no parent who thought they should do nothing about it,” Dr. Khubchandani noted.
From the parents' points of view, the leading explanations were nutrition (34%), overexertion (29%), and calcium deficiency (26%).
Six percent thought their children had rheumatism. Only 3% attributed the pains to growth and even fewer, 2%, to attention seeking.
Dr. Khubchandani said that one of his concerns is that children are given unnecessary nutrients and calcium supplements in the absence of medical attention. “Mere reassurance does not prevent parents from acting,” he warned.
“Our 'no action' advice is considered as inaction.”