Nocturnal Leg Pain: Advice for Referrers

Nocturnal leg pain is usually caused by Benign Leg Pains of Childhood (or ‘growing pains’) which causes generalised leg aches in up to 30% of children between the ages of 2-12 years. It is thought that these pains are the result of muscle strain and fatigue, linked with muscle and bone changes that occur with growth. The pain is usually felt in the thighs, behind the knee and/or lower legs and almost always occurs in both legs. The pains can occur in the late afternoon or evening before bed and can wake the child from sleep. The pain can last a few minutes to hours if severe. The pain tends to be intermittent and often worse after an active day. Intermittent pain can continue for many months, or even years until growth stops. The child is well otherwise, has no pain when active and has no objective signs on examination.

Red Flags

Night pain that is increasing in severity
Unilateral or widespread pain (e.g. upper limbs or back)
Pain on waking in the morning
Pain that doesn’t improve with analgesia, massage or stretches
Impaired function or limitation of physical activity

Consider acute hospital referral if the following are present;

Increased swelling, redness, warmth or bruising of a localised area/joint
Pain associated with an injury
Limping or unable to weight bear
Leg pain associated with fever
Child generally unwell – including lethargy, night sweats or weight loss

Who NOT to refer

Patients with clinical history and examination findings in keeping with benign leg pains of childhood with no red flag features. Offer reassurance to parents/carers and follow simple management advice below
Patients with history of trauma or injury (should be referred to orthopaedics and acute referral considered – see above)

Who TO refer

Patients with any red flag features

Please include the following points from history in the referral letter

Nature and pattern of pain
Duration of symptoms
History of trauma, falls or injury
Systemic symptoms – fever, night sweats, unplanned weight loss, lethargy/fatigue, loss of appetite, rash

Please include the following points from the clinical examination in the referral letter

Overall appearance – does the child appear well?
Observations including temperature
Assessment of gait – walking/running
Joint examination - including above and below area of pain

Suggestions for management of benign leg pains of childhood

Offer reassurance to parents if no red flag features
Simple management advice – most pains eased by use of gentle massage and heat (warm bath before bed or heat pack/hot water bottle)
Muscle stretches before child goes to bed
Pain relief - paracetamol or ibuprofen
Supportive footwear
Vitamin D supplementation has been shown to reduce intensity and frequency of growing pains – 10 micrograms recommended for children (note – vitamin D supplementation should not be given to infants receiving formula milk until they are taking less than 500mls per day as infant formula contains added vitamin D)