Question 2: Is vitamin D useful in the treatment of growing pains?
Clinical scenario
A 6-year-old girl attends your general paediatric outpatient clinic. She describes intermittent pain in both legs over a period of 4 months. The pain is worse at night. She is otherwise well and clinical examination is normal. Blood tests sent by her general practitioner are normal except for a vitamin D level of 35 nmol/L. You make a diagnosis of growing pains and wonder whether there is any evidence to support giving vitamin D in the management of growing pains.
Structured question
Is treatment with vitamin D an effective management option in a 6-year-old girl with growing pains?
Search strategy and outcome
We searched PubMed and Medline (1946–present) using the key words: ‘Vitamin D’ AND ‘child* OR adoles*’ AND ‘growing pains’. The search was performed in June 2017. The results were filtered to include only English articles. The PubMed search yielded 14 results. Following review of the titles and abstracts five articles were identified for full-text review. The Medline search yielded five results. These were the same five articles identified for full-text review in our PubMed search. After a detailed appraisal of these five articles, we selected four papers which we felt adequately addressed the clinical question. No further studies were identified for inclusion after hand searching the references of these articles. Table 1 summarises the articles included. The level of evidence was graded according to the Oxford levels of evidence.1
Table 1
Summary of articles considering vitamin D in children with growing pains
Commentary
Growing pains is a poorly understood condition and the pathogenesis remains uncertain.2 3 Estimates of the prevalence of growing pains in the UK range from 2% to 37%.3 4 There are no diagnostic tests or definitive diagnostic criteria. Diagnosis is made clinically on the presence of typical features and exclusion of symptoms and signs which may point to an underlying pathology requiring further investigation. Some typical features of growing pains are outlined in box.
Box
Typical features of growing pains.6
- Pain in both legs
- Pain starts between the ages of 3 and 12 years
- Pain typically occurs at the end of the day or during the night
- There is no notable limitation of activity and no limping
- The typical distribution of the pain is anterior thigh, calf and posterior knee
- The pain is intermittent with some pain free days and nights
- Physical examination reveals no abnormalities with no evidence of orthopaedic disorder, swelling, erythema, tenderness, local trauma, infection or reduced range of motion
- The laboratory tests are within reference range with no objective findings, eg, erythrocyte sedimentation rate, radiograph and bone scan
- Pain persists at least 3 months
- There is no associated lack of well being
It has been suggested that hypovitaminosis D may contribute to the development of growing pains.4–7 It is estimated that as many as 25% of children in the UK may be vitamin D deficient.8 Our literature search identified four studies examining the relationship between vitamin D and growing pains.
The studies by Park et al, Qamar et al and Vehapoglu et al examined the incidence of hypovitaminosis D in children with growing pains. The studies excluded patients with clinical evidence of rickets and other potential causes of bone pain such as rheumatological or neuromuscular conditions. The study by Park et al identified hypovitaminosis D in 57% of cases. This is compared with an estimated population prevalence of 29.8% in Korea.9 The study by Qamar et al identified hypovitaminosis D in 94% of cases. No data are provided to suggest how this compares to the population prevalence. The study by Vehapoglu et alidentified hypovitaminosis D in 86% of patients. This compared with an estimated population prevalence in Turkey of 40%–60%.10These studies suggest a high prevalence of hypovitaminosis D in patients with growing pains in comparison with estimated population prevalence. Vitamin D status is influenced by sun exposure, latitude, skin pigmentation and other factors and therefore the generalisability of the study findings to the UK population is questionable.
Vehapoglu et al also assessed the effect of a single dose of vitamin D supplementation on pain intensity and vitamin D levels. They used a validated visual analogue scale and measured pain intensity of the latest attack at baseline and 3 months. They found a statistically significant improvement in the visual pain scores and a rise in vitamin D levels at review. There was no control or placebo group included. The study by Morandi et al also considered the effects of vitamin D supplementation on pain scores and vitamin D levels. They used the validated Wong-Baker Faces Pain Rating scale and measured pain at baseline, 3 months and 24 months. Vitamin D supplementation was associated with a rise in vitamin D levels and corresponding statistically significant improvement in pain scores. Neither study examined whether the reported improvement in pain had any meaningful clinical significance, for example, less frequent wakening at night. Public Health England now recommend that all children up to 5 years of age should receive vitamin D supplementation.11 Thus, recommending vitamin D supplementation in those presenting with growing pains, who are not currently taking supplements, should be a routine practice.
Clinical bottom line
- There is a high prevalence of hypovitaminosis D in children presenting with growing pains in Korea and Turkey when compared with the estimated population prevalence. (Grade C)
- No clear association or causal relationship has been demonstrated in the literature between low vitamin D levels and growing pains. However, it is possible that some children presenting with unexplained lower limb pain may have these symptoms secondary to low vitamin D levels. (Grade C)
- Vitamin D supplementation in those found to have low vitamin D levels may be associated with pain reduction in those suffering from growing pains. (Grade C)
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