In the Musculoskeletal system probably the most important symptom to recognise is bone pain. Pain arising from a bone can be dull, deep seated and nags during rest phases too. These children are troubled by the pain during sleep, often awakening in the middle of the night with pain.

How Does One Differentiate This From Growing Pains Which Are Very Common in Children?

Many parents will remember their young children (usually school age) either just before sleep or just after going to sleep waking up, complaining of pain in both legs. The pain is usually not in the joint and mostly settles with a little massage or reassurance after which the child sleeps peacefully and wakes up bright and smiling in the morning!

A child with bone pains will have pain anywhere along the length of the bone but usually towards the growing ends, around and not within a joint. This child is progressively miserable and usually has pain the rest of the day too. Whichever limb is involved starts losing function also- if it’s the lower limb the child might limp which worsens and slowly might stop weight bearing altogether. Such progression or persistence of symptoms is NEVER a feature of growing pains.

What Causes Bone Pain?

Bone pain can be caused by anything related to infection, inflammation, or structural involvement of the bone. Osteomyelitis of the more common infective or less common inflammatory kind (not many professionals are aware of Chronic Recurrent Multifocal Osteomyelitis which is an inflammatory disease and unrelated to any infective cause), benign tumours like Osteoid Osteoma, or a wide range of malignancies, the most common of which is Childhood Acute Leukaemia.

About 30-40% of Acute leukaemia in children presents as bone pain and is often missed for various causes of joint pain. In India around 25,000 children are diagnosed with various cancers each year of which at least 9000 will be leukaemia and possibly about 4000 of these children might present with bone pain.

The price of missing this symptom can be severe as sadly several children receive steroids through mainstream or alternative medicine which immediately brackets them in a worse prognostic group.

Childhood Acute Lymphoblastic leukaemia which is the most common cancer in children can fool in its presentation. The counts can look “normal” unless one actively analyses them in context. Peripheral smear for blasts are often negative as it is a low peripheral blast disease.

The only consistent pickup is from recognising the symptoms, having a high index of suspicion and performing a bone marrow examination early.

Children with bone pain require extensive evaluation- often detailed imaging to pick up the cause. Even with bone infections, X-rays are a poor pickup in the early weeks and an early diagnosis requires an MRI to be performed with a biopsy.
 

Recognising and referring bone pain to appropriate centres where the diagnosis can actually be investigated, confirmed and managed is key.

The causes of bone pain can come in the treatment arena of Orthopaedics, Oncology and Rheumatology. Remember these red flag signs- deep dull boring usually persistent pain that disturbs sleep, associated with progressive functional impairment of the affected area.