Back pain in children is becoming increasing common, more so in girls than boys; but is rarely a serious problem. In younger children back pain may be growth related or may indicate more serious pathology such as infection or tumours.  In older children back pain is commonly musculo-skeletal; overuse, carrying heavy backpacks, and sprains and fractures may cause pain. Less common conditions include slipped discs and inflammatory diseases. Congenital disorders such as scoliosis may present at any age.

Paediatric red flags

This list is not exhaustive nor a diagnostic tool, but areas to consider to help evaluate if there is mor serious pathology

Children presenting with red flags, indicating the possibility of more serious underlying pathology, warrant urgent assessment, with some cases requiring referral directly to the Emergency Department or CAU.

• Unremitting pain
• Night pain (Pain that awakens the child from sleep)
• Systemic symptoms; fever, malaise, unexplained weight loss, sickness
• Changes in bladder and bowel habit
• Hot, swollen and inflamed joint(s)
• Early morning stiffness (may indicate JIA) with persistent swelling
• Painful guarded movement/ muscle spasm/ significant loss of range of motion, in absence of trauma
• Acute torticollis persisting over 7 days with an inability to achieve midline head and neck position
• Regression of development / loss or deterioration of function
• Antalgic gait / inability to weight bear / gait disturbance / lower limb asymmetry
• Sensation changes (pins and needles/ numbness), absent or exaggerated reflexes, unexplained muscle weakness  

Action: Key assessment points

Subjective:

• Red flags, particularly night pain
• Age of menarche in girls, spine ceases growth 2 years after onset
• Activity levels/sports/school attendance/school bags
• Screen time/posture

Objective:

• Undress, to see the spine check  posture / symmetry - kyphosis/scoliosis
• Observe spinal range of movement, gait and function
• Palpate for areas of vertebral tenderness or muscle spasm
• Neurological examination if indicated
• pGALS

Action: Initial GP management

• Exclude serious pathology
• Exclude inflammatory cause (bloods – if inflammatory processes suspected)
• Provide advice on healthy active lifestyle/diet/fitness and posture
• Give info leaflet:- “Your Healthy Back”

Refer to Paediatric Physiotherapy

• Mechanical or postural back pain
• Tight/Weak muscles / poor core stability/chronic pain
• Reduced function/activity levels due to pain e.g.  running, jumping, PE
• Rehab following a period of inactivity/post-surgery
• Back pain associated with obesity
• Postural scoliosis with pain

Action: Refer to Acute Paediatricians via the Children’s Assessment Unit

• Under 5 years old
• A fever and/or red flags suggesting serious pathology
• In severe pain, agitated or has significant muscle weakness
• Acute onset painful or restricted spinal movements, without trauma

Action: Refer to Paediatric  Orthopaedics/Spinal Team at SGH

• Spondylolysis/spondylolisthesis
• Structural scoliosis/ kyphosis
• Scheurmanns disease
• Disc pathology
• Trauma

Action: Refer to Paediatric Rheumatology

• AM stiffness
• Guarded movement / muscle spasm
• FH of AS/RA
• Increased ESR/ CRP/ Rheum factor