A 6-year-old boy is brought to the pediatrician with leg pain. Over the last few months, he has had pain in both legs that occurs only at night. The pain is worst in his thighs although he occasionally has pain in his calves as well. The episodes last a few hours each and improve with massage and over-the-counter medications. The pain has remained unchanged over the past few months. When he has the pain, the patient does not feel an urge to move the legs. He has no leg pain during the day. He is able to walk, run, and play at school without any complaints, and his mother has noticed no change in his activity level. He has no fever, chills, or weight loss and there is no history of recent trauma. On examination, the boy has full range of motion of the hips and knees bilaterally. No swelling or tenderness to palpation is noted and he has a normal gait. His mother is very worried because his 9-year-old cousin died of leukemia 6 months earlier. Which of the following is the most appropriate next step in management of this patient?

Question

A 6-year-old boy is brought to the pediatrician with leg pain.  Over the last few months, he has had pain in both legs that occurs only at night.  The pain is worst in his thighs although he occasionally has pain in his calves as well.  The episodes last a few hours each and improve with massage and over-the-counter medications.  The pain has remained unchanged over the past few months.  When he has the pain, the patient does not feel an urge to move the legs.  He has no leg pain during the day.  He is able to walk, run, and play at school without any complaints, and his mother has noticed no change in his activity level.  He has no fever, chills, or weight loss and there is no history of recent trauma.  On examination, the boy has full range of motion of the hips and knees bilaterally.  No swelling or tenderness to palpation is noted and he has a normal gait.  His mother is very worried because his 9-year-old cousin died of leukemia 6 months earlier.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d73a_6d59_bc81_9539e63f8154_MD0003_00 Growing pains are a common musculoskeletal complaint in children, occurring in approximately 10%-30% of children age 2-12 years. The etiology of growing pains is unknown, but they are unrelated to growth, despite their name. The diagnosis of growing pains can be made clinically (Table) in the absence of systemic symptoms and abnormal examination findings. Laboratory studies and radiographs are not necessary. Management of growing pains consists of parental education and reassurance along with massage, muscle-stretching exercises, and administration of over-the-counter analgesics. Children with growing pains should be followed closely to monitor for pain that increases in frequency or intensity, which may warrant further evaluation. (Choice A) Blood cultures are indicated in children with osteomyelitis or septic arthritis, which are bone and joint infections that present with fever, localized pain, and decreased range of motion. None of these are present in this patient. (Choice B) Bone scans are used in the diagnosis of metastatic bone disease or osteomyelitis, both of which typically present with unilateral pain and systemic symptoms such as fever or weight loss. Bone scans are not indicated in children suspected of having growing pains. (Choice C) A complete blood count can be used to diagnose leukemia, which can be a cause of limb pain in children. Leukemia classically presents with fever, weight loss, pallor, and other systemic symptoms that are not present in this patient. Bone pain due to leukemia tends to persist and progressively worsen, unlike what is seen in this patient. Restless leg syndrome is associated with iron-deficiency anemia and causes night-time symptoms but is unlikely in this patient who has no urge to move the legs. (Choice E) X-rays can be used to diagnose both benign (eg, osteoid osteoma) and malignant (eg, osteosarcoma) bone tumors. Although osteoid osteomas frequently present with limb pain that is worse at night and responds to treatment with nonsteroidal anti-inflammatory drugs, they are most common in the second decade of life, are often associated with unilateral pain, and may cause a limp and point tenderness on examination. X-rays are indicated in children with systemic symptoms, unilateral limb pain, limp, limitation of activities, or abnormal physical examination findings. This patient has none of these. osteoid osteoma osteosarcoma (Choice F) The etiology of growing pains is unknown; although psychogenic illness has been mentioned as a potential cause, it has never been formally studied. Children with growing pains often have a lower pain threshold and more depressive symptoms when compared to other children, but psychiatric evaluation is not required for these patients. Educational objective: Growing pains are bilateral, lower-extremity pains that occur at night in children age 2-12 years. Children with growing pains have no systemic symptoms, normal activity levels, and normal physical examinations. Treatment consists of observation, parental reassurance, massage, and over-the-counter pain medications. References: Growing pains: a study of 30 cases and a review of the literature. (http://www.ncbi.nlm.nih.gov/pubmed/21654473) Decreased pain threshold in children with growing pains. (http://www.ncbi.nlm.nih.gov/pubmed/14994414) Are growing pains a myth? (http://www.ncbi.nlm.nih.gov/pubmed/10048249)

A 6-Year-Old Boy Is Brought to the Pediatrician with Leg