When you should worry about your child's back pain

Children are not immune to back pain.  According to a review of the epidemiology of low back pain in children in the British Medical Journal, children on average have a 15% to 26% chance of having back pain.  Similar in adults, childhood back pain varies widely  depending on their age, sex, and socioeconomic status. 
Almost all back pain in children is related to muscle/joint pain and is self-limiting and resolves without complications. There are times though when you should pay close attention to your child's complaints. 

1. Pain For More Than a Month
Prolonged pain is not normal.  Children have an amazing ability to heal fast. If your child hasn't had a re-injury and still has symptoms that are not healing, you should seek care. Conditions, such as a stress fracture, can be the underlying cause. The most common type of spinal stress fracture is called a spondylolysis, an injury to the bone in the back of the spinal column. This injury occurs most often in adolescents who do sports involving repetitive hyperextension (bending backwards) of the spine, such as gymnasts and divers. If the stress fracture occurs on both sides of the spinal column, this can cause instability of the spinal column, or a condition called spondylolisthesis. This condition, also called a spinal "slip," can lead to the vertebral column alignment to shift.
Prolonged pain can also be a sign that there is a more serious injury to the joints or muscles involving damage to these structures.

2. Back Pain with Generalized Illness
Prolonged back pain with flue like symptoms, including fever, loss of appetite, fatigue, and weakness, can be a red flag for infection.   Infection of the spine is a very rare, but is a very serious condition. Infection of the urinary tract can be another reason for back pain and generalized illness as it can mimic back pain and can often be ignored.  Children will also complain of stiffness in the back accompanied with a flu or various viral infections. This pain is self-limiting with the flu symptoms.  If the pain and fever persist you should visit your doctor.

3. Night Pain 
You should be concerned if your child is woken up in the night due to their pain. This can be a concern if your child hasn't had a significant injury to their back but is waking up with dull achy pain. The concern is a spinal tumor in this case. Tumors of the spine are very rare but need to be taken seriously. Night pain associated with weight loss, pain that isn't aggravated by movement, and loss of appetite, all lead to a concern of a spinal tumor. 
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4. Back Pain and a Change in Posture
Back pain with a change in the posture, can indicate an underlying structural problem.  The two most common conditions to cause this is Scheuermann's Disease and scoliosis.
Scheuermann's Disease is characterized by a decrease height in the front of the vertebral bodies in the mid back spine, causing an increased forward curve or hump back.  It is unknown why it occurs, starts in adolescence and has less than an 8% prevalence in both girls and boys.  The condition can cause tension in the entire spine due to the forward positioned change of posture. Some studies show that it can be triggered by a flexion injury, (excessive forward bending),  to the mid back. 
Scoliosis is again found in adolescence, more common in girls, and you will observe a change in your child's posture.  A low shoulder, a curved spine, a high rib cage on one side when bent forward, can all be an indication of scoliosis. Scoliosis is rarely painful but can cause spinal fatigue and chronic back tightness. 

5. Numbness and Other Symptoms in the Arms or Legs
Arm or leg symptoms in a child are a good reason to bring your child to a health care provider.  The nerves of the cervical, (neck) spine travel out of the neck to the arms and the nerves from the lumbar spine travel into the legs.  Sometimes these nerves can be aggravated and even impinged by the structures around the spine including the joints, muscles and more commonly the discs.
​ It is rare for a child to have a disc protrusion but it can happen in older adolescents who participate in sports.  Sciatica is the name of a condition where the low back nerve roots are irritated and symptoms such as numbness, pain, weakness, pins/needles, and burning pain radiate down the leg.  In more emergent cases, the nerve roots can be irritated causing changes in bowel and bladder control.  This is a definite reason to get your child checked ASAP. 
A numb arm(s) can also be due to a disc irritating the nerve roots but in the neck.  Contact sport athletes can also get a nerve stretch, or stinger, when a hit causes excess lateral flexion of the neck, pulling on the nerve root.  

Summary:

To summarize, be concerned when your child is complaining of constant pain that is not relieved by rest and can't be reproduced with movement. Get to the doctor if there is back pain associated with fever or other flu like symptoms that has your child not eating or being their usual active self. Watch a change in your child's posture or if they complain of any arm or leg numbness. 

Activity fact: The number one cause of back pain in children is due to a weak core musculature due to inactivity.  Get out and get active with your kids!