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com
312

REVIEW

Epidemiology of low back pain in children and adolescents

G T Jones, G J Macfarlane
...............................................................................................................................
Arch Dis Child 2005;90:312316. doi: 10.1136/adc.2004.056812

It has been estimated that over 80% of the population will

report low back pain (LBP) at some point in life,1 and each
year 7% of the adult population consult their GP with
symptoms.2 Prevalence increases with age, reaching a
peak during the sixth decade of life.3 Until recently little was
known about LBP at young ages. Clinically it was perceived
to be uncommonwith few children consulting because of
LBP in primary care. Large prospective epidemiological
studies have shown that, in those free of LBP at baseline,
the best predictor of future onset is a previous history of
LBP.4 Therefore, to understand the epidemiology of LBP,
and what predisposes someone to a trajectory of LBP in
adult life, it is important to examine the condition at young
ages, to determine factors responsible for onset of initial
episodes, and to examine whether LBP in childhood is
related to symptoms in adulthood.
...........................................................................

structured search of Medline (July 2004)

revealed that there have been relatively
few large epidemiological studies conducted investigating the occurrence and aetiology of low back pain (LBP) in children. This
article reviews evidence from the initial studies
in this area, summarises the emerging evidence,
and identifies areas for future study.

OCCURRENCE

See end of article for

authors affiliations
.......................
Correspondence to:
Dr G T Jones, ARC
Epidemiology Unit,
Division of Epidemiology
and Health Sciences, The
University of Manchester,
Stopford Building, Oxford
Road, Manchester M13
9PT, UK; gareth.jones@
manchester.ac.uk
Accepted 7 October 2004
.......................

www.archdischild.com

Estimates of LBP prevalence in children and

adolescents vary widely between studies depending on the age of study participants, and
on methodological differencesparticularly in
terms of LBP definition. Watson et al report a one
month period prevalence of 24% in schoolchildren aged 1114 years in northwest
England,5 whereas Balague et al show the one
year prevalence to be 26% in schoolchildren aged
1217 years in Switzerland.6 Salminen et al show
the one year prevalence of LBP with limitation
to activity to be 17.6% in 14 year old Finnish
children;7 also in Finland, Taimela et al report a
prevalence of 18%, using the same definition.8
Even studies that record pain over a very short
time interval (for example, point prevalence)
reveal that as many as 1 child in 20 may be
suffering from LBP at any one time.911 As in
adults, prevalence of LBP in childhood increases
with age and has been shown repeatedly to be
higher in girls than in boys.5 9 1214
Although it is difficult to measure LBP incidence,
studies have shown that new onset LBP is also
common. A recent study revealed that 19% of
children aged 1114 years, and known to be free of

symptoms at baseline, reported LBP 12 months

subsequently.15 Other authors have presented
similar results with 16%, 22%, and 22% of 8, 11,
and 13 year olds, respectively, reporting new onset
LBP two years after initial assessment.16
Some authors have reported that self-reported
LBP related disability in childhood is also
common. Watson et al reported that, in a large
community study, 94% of symptomatic children
aged 1114 years reported difficulty with one
or more of the activities listed in a modified
version of the Hannover Functional Ability
Questionnaire;5 these activities included reaching
up to a high shelf; sitting up in bed from a lying
position; and bending down to put on socks.
However, using a similar disability instrument,
Salminen et al reported limitations in only 18% of
individuals.7 Despite being reported as a common
and often limiting experience, few children
report LBP sufficient enough to prevent them
from attending school or playing sports.8 10 17
Consultations for LBP are also uncommon.5 9 17
Turner et al reported that of children referred
with back pain to the department of orthopaedic
surgery at a large childrens hospital in the UK,
spondylolysis was diagnosed in 13% of the
individuals. Infection, tumour, and disc prolapse
was reported in 8%, 6%, and 6% of cases,
respectively, and no specific cause was found in
approximately half of cases.18 Common imaging
techniques have proved to be poor at distinguishing between adolescents with and without LBP.
Harreby et al showed in the community that 13%
of 14 year old schoolchildren had radiological
abnormalities of the spinethe majority being
Scheuermanns changesbut was unable to
discriminate between LBP and non-LBP subjects
in this way.19 Similarly, using magnetic resonance imaging, other authors have shown that
while disc protrusion is more common in cases
(children with LBP) than in controls, there are
no significant differences between groups in
terms of Scheuermann-type changes, transitional vertebra, and disc space narrowing.20
In summary, LBP is a common condition in
childhood and, while it can be associated with
serious pathology, this is rare and, for the majority,
symptoms are mild, non-specific, and self-limiting.
Although self-reported limitation is common,
symptoms rarely result in consultation. Even
among those consulting to family physicians, most
will not have an organic cause identified.

AETIOLOGY
Most of the work on the aetiology of LBP in
childhood and adolescence has been undertaken
during the past decade. Although many studies
purport to determine risk factors, the majority of
previous work has been cross sectional in nature

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Low back pain in children

and has been unable, therefore, to address the temporal nature

of any relation between exposure and outcome. As such, these
studies can only truly identify features associated with LBP,
rather than risk factors (or markers) for its development.
Studies of factors associated with the occurrence of LBP in
youth fall into four main categories: anthropometry, lifestyle
factors, mechanical load (principally schoolbag carriage), and
the role of psychological, social, and behavioural factors.
Anthropometry

Height
A number of authors have examined the association between
LBP and child height. Fairbank et al showed a significantly
increased sitting height (height minus leg length) in school
pupils aged 1317 years with a history of LBP, compared with
those free of pain, although the relation with standing height
proved inconclusive.21 Others have noted an association in
boys but not in girls.2224 Prospectively, however, a number of
studies have shown that child height at baseline does not
predict the future occurrence of LBP.25
Rather than height per se, it has been postulated that LBP
may result from differential growth rates between the vertebrae
and the surrounding muscle and ligamentous tissue,26 and this
muscle imbalance may increase the likelihood of pain in this
area. In support of this, some authors have pointed out that the
onset of LBP roughly corresponds with the adolescent growth
spurt, and that those with a high growth spurt (.5 cm in six
months) are three times more likely to report LBP than their
peers.27 Balague et al, however, showed no association between
LBP and trunk muscle weakness,27a and others have shown no
difference in growth between those reporting and those not
reporting LBP.25
Spinal mobility is often thought to be associated with LBP,
but overall there is relatively little evidence to support this.
Harreby et al report that hyper-mobility is associated cross
sectionally with severe LBP, but they report no association
with non-severe LBP.28 Prospectively, little work has been
conducted. In a longitudinal study of 98 children in Finland,
Kujala et al state that low maximal lumbar flexion in boys,
and extension in girls, is associated with the onset of LBP,25
but the evidence is weak.

Weight/body mass index

A number of authors have examined the association between
LBP and child weight and/or body mass index (BMI). Some
commentators have pointed out, however, that BMI is age
related and should be interpreted with care in childrenif it
ought to be used at all. Nonetheless, providing caution is
observed, BMI is probably the quickest and easiest measure
of obesity and, for these reasons, is very convenient in large
scale epidemiological studies. Cross sectionally, several
authors have reported no significant differences in weight
and/or BMI between children with and without LBP,13 24 29
whereas others have found that those reporting LBP are
heavier.21 Little work has been done of a prospective nature.
Salminen et al found that while weight at follow up was
greater in those with recurrent or continuous LBP, baseline
weight was not predictive of future pain.23 Similarly, Nissinen
et al showed that baseline weight was not significantly
associated with an incident episode of LBP over the
subsequent 12 months.22
Overall therefore, while there is some evidence that
children with LBP may be heavier, there is little evidence to
suggest that height, growth, weight, or BMI are associated
with the onset of LBP symptoms.
Lifestyle factors

Physical activity
An increased frequency of radiological abnormalities has
been observed in the spine of young athletes, with a greater

313

frequency associated with particular sports: weightlifting and

body building;30 gymnastics;31 rowing;26 30 and golf and racket
sports.30 32 Poor trunk muscle strength and decreased trunk
muscle endurance have been reported to be associated with
LBP by some, but not all, authors,24 26 33 although whether or
not this is related to physical activity is unclear: Sjolie showed
no correlation between regular physical activity and low back
strength.34
A number of other authors have referred to the J-shaped
curve relation of physical activity and LBPwhere moderate
levels of activity are associated with a general conditioning
effect, increased trunk muscle tone, the prevention of hyperflexion/extension and associated trauma, and a concomitant
decrease in the risk of LBP. In contrast, higher levels of
activity may be associated with over-training, insufficient
recovery between activities, greater exposure to injury, and
thus an increased occurrence of LBP.8 12 29 In addition, several
studies have shown an increase in the occurrence of LBP
associated with sporting activities at a competitive level.35 36
Much of the epidemiological evidence in this field is cross
sectional and cannot adequately address the issue of cause
and effect. Prospectively, however, Salminen et al reported
that physical activity at baseline was not predictive of back
pain at follow up,23 and others have also been unable to show
consistent increases in the risk of new onset LBP associated
with prior levels of physical activity.15

Sedentary activity
Few authors have studied the effects of regular or prolonged
sedentary activity on the occurrence of LBP. Some have found
that children who play video games for more than two hours
per day report more LBP than other children,37 but show
inconsistencies, in that the same is not true for watching
television for the same period of time. Balague et al showed
that children who watch a small amount of television per day
(,1 hour) were at no greater or lesser risk of back pain than
those who watched none,36 whereas watching 12 hours, and
watching .2 hours were associated with a 70% and a 210%
increase in the odds of LBP, respectively. Other studies have
shown similar results.14
However, all of the above papers report cross sectional
results and it is impossible, therefore, to examine whether
the sedentary activities are precursors, or consequences, of
back pain. Jones et al examined the relation between
sedentary activity and LBP prospectively, and showed no
association between sedentary activity at baseline and the
risk of new onset LBP 12 months subsequently.15
In summary, the evidence relating to lifestyle factors is
unclear. Although a number of authors have shown
consistent cross sectional associations between LBP and
physical activity, there is little consistent evidence from
prospective studies to suggest that physical activity is a risk
factor for future LBP. Similarly, although the cross sectional
associations between sedentary activity and LBP may appear
strongwith a convincing dose-risk relationmore recent
longitudinal results would suggest that the high levels of
sedentary activity in previous studies might have been
consequences of LBP, rather than risk factors for it, and
there is little evidence that prior sedentary activity is a risk
factor for future LBP onset.

Mechanical load
Despite much subjective and anecdotal evidence that carrying
heavy schoolbags causes LBP, there is actually very little
epidemiological evidence examining the relation. Gunzburg et
al showed that children who found their schoolbags to be
heavy experienced a 60% increase in the odds of LBP.37
Similarly, other authors have shown an increase in the
occurrence of LBP associated with the perception of schoolbag heaviness.35 38 Using a more objective assessment,

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314

Jones, Macfarlane

Watson et al collected data on actual schoolbag weight over a

five day period and computed an average daily mechanical
load. These authors found that children with the heaviest
loads (6.418 kg per day) were no more likely to report LBP
than children with the lightest loads (,3.4 kg).29
Viry et al show a doubling in the odds of LBP associated
with a relative schoolbag weight (bag weight divided by body
weight) of .20%.10 In contrast, however, some have shown
no such relation,13 and others have shown a significant trend,
suggesting that the higher the relative bag weight, the lesser
the odds of LBP: Watson et al reported a 40% decrease in the
odds of LBP in children carrying .14% of their body weight,
compared to those carrying ,7%.29
The majority of studies published to date have been cross
sectional in design. However, Jones et al followed up 933
children who were known to have been free of LBP at
baseline. These authors showed that schoolbag weight at
baseline was not associated with the risk of LBP at follow up:
children carrying loads of 6.418 kg experienced no significant increase in risk compared to those carrying ,3.4 kg
(relative risk 1.2; 95% confidence interval 0.7 to 2.1).15
Similarly, no association was found for relative schoolbag
weight, although a small proportion of children with the
heaviest mechanical exposures (in terms of load and duration
carried) did show a small increase in risk.
In summary, the evidence to date does not suggest that
mechanical load is an important cause of back pain in
children across the range of schoolbag weights commonly
carried to school. Future prospective studies, however, can
usefully determine the risk associated with specific weights,
and duration and method of carriage.

Psychological factors and the social environment

In children, the majority of aetiological studies on LBP have
focused on mechanical and/or lifestyle factors. In the last
decade, however, following a similar shift in studies of LBP in
adults,39 40 a number of authors have examined the role of
psychological and psychosocial factors in the epidemiology of
LBP in childhood.
Balague et al show, cross sectionally, that children with a
high negative affect score were more likely to report a history
of LBP than other children; whereas, a low positive
affect score was associated with a decreased reporting of
Table 1

symptoms.6 Brattberg also reports an association between LBP

and a number of psychosocial factors.16 The author reports that
the odds of reporting LBP are two or three times greater in those
with several negative psychosocial experiences. In addition,
others have shown that children reporting conduct and
emotional problems were twice as likely to report LBP than
other children.29 Vikat et al showed a doubling in the odds of
LBP in children who reported that they suffered from one
psychosomatic symptom per week, compared to children who
reported none,41 and this relation increased with increasing
number of symptoms. Further, others have reported that
children with other musculoskeletal pain symptoms not only
had more emotional and behavioural problems than other
children, but also reported an increased occurrence of depressive symptoms and sleep problems.42
Croft et al showed that in adults free of LBP at baseline,
individuals with higher levels of anxiety and depression were
more likely to report an episode of LBP in the subsequent
12 months than other individuals,40 and Papageorgiou et al
showed that workplace dissatisfaction was also associated
with an increase in new episodes of LBP.39 In children,
however, little prospective work has been carried out. Jones
et al followed up the cohort of Watson et al,29 and reported
that conduct and emotional problems, in addition to the
occurrence of other somatic symptoms (headache, abdominal
pain), were significantly predictive of new onset LBP 12
months subsequently.15 Further, on multivariable analysis,
these authors showed that behavioural characteristics and
prior somatic symptoms were independently predictive of
LBP at follow up (see table 1). In addition, these authors have
subsequently shown that these factors are not only associated
with an increased risk of LBP, but are also predictive of the
onset of other musculoskeletal pain symptoms.43
In summary, there is good evidence that children with LBP
are more likely to report negative psychosocial experiences, and
there is some evidence to support the hypothesis that such
negative experiences predict those at high risk of future onset.

DOES LBP IN CHILDHOOD PREDISPOSE TO LBP IN

ADULTHOOD?
Adolescent LBP is not restricted to single and rare episodes.
Several authors have shown that at least one third of children

Multivariable modelpredictors of the onset of LBP in children (Jones et al15)

New onset LBP

Age (years)
11
12
13
14
Sex
Male
Female
Conduct problems
Low
Medium
High
Sporting activity (past week)
0100 min
120160 min
180220 min
240340 min
>360 min
Abdominal pain (days in past month)
None
17 days
.7 days

www.archdischild.com

Yes

No

Relative risk (95% CI)

19
61
67
21

(12.5%)
(1630%)
(23.8%)
(24.1%)

133
321
214
66

1.0
1.6 (0.9 to 2.8)
2.1 (1.1 to 3.8)
2.7 (1.4 to 5.5)

72 (16.9%)
96 (20.1%)

353
382

1.0
1.4 (0.97 to 2.0)

43 (12.5%)
72 (19.6%)
52 (28.7%)

302
295
129

1.0
1.6 (1.1 to 2.4)
1.9 (1.2 to 3.1)

40
36
18
32
42

(16.1%)
(22.8%)
(11.0%)
(20.9%)
(23.3%)

209
122
145
121
138

1.0
1.9
1.0
1.8
2.3

69 (15.2%)
75 (21.0%)
20 (27.0%)

385
283
54

1.0
1.3 (0.9 to 1.9)
1.9 (1.1 to 3.4)

(1.1
(0.6
(1.1
(1.3

to
to
to
to

3.3)
1.9)
3.2)
3.9)

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Low back pain in children

with LBP have recurrent episodes.7 8 10 Further, although very

few longitudinal studies exist, Harreby et al showed that
schoolchildren reporting LBP had an increased risk of having
back pain 25 years subsequently.19 In contrast, in a 13 year
follow up study of 335 children aged 817 years, reporting of
back pain at recruitment did not predict back pain at follow
up, but did predict the reporting of pain (generally) in
adulthood.44 Studies of other pain syndromes in childhood,
such as abdominal pain or headache, on which there is more
data, show consistently that there is a future risk of either the
specific pain syndrome, medically unexplained syndromes, or
adverse psychological outcomes.4547

CONCLUSIONS
In summary, LBP in children and adolescents, as in adults, is
a common condition: some have shown a lifetime prevalence
as high as 7080% by 20 years of age. In addition, several
studies have calculated new onset rates of around 20% over a
12 year period. Pain prevalence increases with age and is
higher in girls than boys. Although many children report
certain limitations to daily activities as a result of their pain,
health service consultation is low, and serious disability and
hospitalisation is rare. For the majority of children, LBP is
non-specific and self-limiting, and studies have shown that
common imaging techniques are poorly able to discriminate
between children with, and those without, LBP. Thus, in the
minority of cases that do present to primary care, an organic
cause is seldom found.
A number of studies have shown an association between
physical lifestyle and LBP, although most studies have been
cross sectional in design and are, therefore, unable to
examine the temporal nature of any such relations.
Prospective studies, however, have been unable to show
any consistent evidence suggesting an increase in the risk of
LBP associated with prior levels of physical or sedentary
activity.15 23 Similarly, although several studies, but not all,
have shown a cross sectional association between high
mechanical load and LBP, more recent longitudinal studies
have shown that heavy schoolbag weight is not associated
with an increase in the risk of future LBP. In contrast, there is
strong evidence highlighting the role of psychosocial and
behavioural factors. A number of authors have shown strong
cross sectional associations between adverse psychological or
psychosocial factors and the occurrence of LBP, and others
have shown that these factors, in the absence of LBP,
significantly predict the future onset of symptoms.
In summary, there are currently few large scale prospective
studies of the epidemiology of LBP in childhood. However,
those that exist are providing increasing evidence that
psychological and psychosocial factors play an important
role in the aetiology of LBP, at least in the short term.
Juvenile LBP appears to be, on the whole, mild and nonspecific, and there is a paucity of research focusing on the
persistence of symptoms. Further studies are needed to
examine the role of potential risk factors in the longer term
particularly psychological and social factors.
.....................

Authors affiliations

G T Jones, G J Macfarlane, ARC Epidemiology Unit and The Unit of

Chronic Disease Epidemiology, Division of Epidemiology and Health
Sciences, University of Manchester, UK
Gareth T Jones is funded by the Arthritis Research Campaign (ARC),
Chesterfield, UK
Competing interests: none declared

REFERENCES
1 Walker BF. The prevalence of low back pain: a systematic review of the
literature from 1966 to 1998. J Spinal Disord 2000;13:20517.

315

2 McCormick A. Morbidity statistics from general practice: fourth national study

199192/a study carried out by the Royal College of General Practitioners,
the Office of Population Censuses and Surveys, and the Department of Health.
London: HMSO, 1995.
3 Papageorgiou AC, Croft PR, Ferry S, et al. Estimating the prevalence of low
back pain in the general population. Evidence from the South Manchester
Back Pain Survey. Spine 1995;20:188994.
4 Papageorgiou AC, Croft PR, Thomas E, et al. Influence of previous pain
experience on the episode incidence of low back pain: results from the South
Manchester Back Pain Study. Pain 1996;66:1815.
5 Watson KD, Papageorgiou AC, Jones GT, et al. Low back pain in
schoolchildren: occurrence and characteristics. Pain 2002;97:8792.
6 Balague F, Skovron ML, Nordin M, et al. Low back pain in school children: a
study of familial and psychological factors. Spine 1995;20:126570.
7 Salminen JJ, Pentti J, Terho P. Low back pain and disability in 14-year-old
schoolchildren. Acta Paediatr 1992;81:10359.
8 Taimela S, Kujala UM, Salminen JJ, et al. The prevalence of low back pain
among children and adolescents: a nationwide, cohort-based questionnaire
survey in Finland. Spine 1997;22:11326.
9 Burton AK, Clarke RD, McClune TD, et al. The natural history of low back pain
in adolescents. Spine 1996;21:23238.
10 Viry P, Creveuil C, Marcelli C. Nonspecific back pain in children. A search for
associated factors in 14-year-old schoolchildren. Rev Rhum Engl Ed
1999;66:3818.
11 Troussier B, Marchou-Lopez S, Pironneau S, et al. Back pain and spinal
alignment abnormalities in schoolchildren. Rev Rhum Engl Ed
1999;66:37080.
12 Brattberg G, Wickman V. Prevalence of back pain and headache in Swedish
school children: a questionnaire survey. The Pain Clinic 1992;5:21120.
13 Grimmer K, Williams M. Gender-age environmental associates of adolescent
low back pain. Appl Ergon 2000;31:34360.
14 Troussier B, Davoine P, de Gaudemaris R, et al. Back pain in school children.
A study among 1178 pupils. Scand J Rehabil Med 1994;26:1436.
15 Jones GT, Watson KD, Silman AJ, et al. Predictors of low back pain in British
schoolchildren: a population-based prospective cohort study. Pediatrics
2003;111:8228.
16 Brattberg G. The incidence of back pain and headaches among Swedish
school children. Qual Life Res 1994;3:S2731.
17 Olsen TL, Anderson RL, Dearwater SR, et al. The epidemiology of low back
pain in an adolescent population. Am J Public Health 1992;82:6068.
18 Turner PG, Green JH, Galasko CS. Back pain in childhood. Spine
1989;14:81214.
19 Harreby M, Neergaard K, Hesselsoe G, et al. Are radiologic changes in the
thoracic and lumbar spine of adolescents risk factors for low back pain in
adults? A 25-year prospective cohort study of 640 school children. Spine
1995;20:2298302.
20 Tertti MO, Salminen JJ, Paajanen HE, et al. Low-back pain and disk
degeneration in children: a case-control MR imaging study. Radiology
1991;180:5037.
21 Fairbank JCT, Pynsent PB, van Poortvliet JA, et al. Influence of anthropometric
factors and joint laxity in the incidence of adolescent back pain. Spine
1984;9:4613.
22 Nissinen M, Helio
vaara M, Seitsamo J, et al. Anthropometric measurements
and the incidence of low back pain in a cohort of pubertal children. Spine
1994;19:136770.
23 Salminen JJ, Erkintalo M, Laine M, et al. Low back pain in the young. A
prospective three-year follow-up study of subjects with and without low back
pain. Spine 1995;20:21017.
24 Salminen JJ, Maki P, Oksanen A, et al. Spinal mobility and trunk muscle
strength in 15-year-old schoolchildren with and without low-back pain. Spine
1992;17:40511.
25 Kujala UM, Taimela S, Oksanen A, et al. Lumbar mobility and low back pain
during adolescence. A longitudinal three-year follow-up study in athletes and
controls. Am J Sports Med 1997;25:3638.
26 Harvey J, Tanner S. Low back pain in young athletes. A practical approach.
Sports Med 1991;12:394406.
27 Feldman DE, Shrier I, Rossignol M, et al. Risk factors for the development of
low back pain in adolescence. Am J Epidemiol 2001;154:306.
27a Balague F, Damidot P, Nordin M, et al. Cross-sectional study of the
isokinetic muscle trunk strength among school children. Spine
1993;18:1199205.
28 Harreby M, Nygaard B, Jessen T, et al. Risk factors for low back pain in a
cohort of 1389 Danish school children: an epidemiologic study. Eur Spine J
1999;8:44450.
29 Watson KD, Papageorgiou AC, Jones GT, et al. Low back pain in
schoolchildren: the role of mechanical and psychosocial factors. Arch Dis
Child 2003;88:1217.
30 Duggleby T, Kumar S. Epidemiology of juvenile low back pain: a review.
Disabil Rehabil 1997;19:50512.
31 McMeeken J, Tully E, Stillman B, et al. The experience of back pain in young
Australians. Man Ther 2001;6:21320.
32 Sward L, Eriksson B, Peterson L. Anthropometric characteristics, passive hip
flexion, and spinal mobility in relation to back pain in athletes. Spine
1990;15:37682.
33 Salminen JJ. The adolescent back. A field survey of 370 Finnish
schoolchildren. Acta Paediatr Scand Suppl 1984;315:1122.
34 Sjolie AN. Access to pedestrian roads, daily activities, and physical
performance of adolescents. Spine 2000;25:196572.
35 Szpalski M, Gunzburg R, Balague F, et al. A 2-year prospective longitudinal
study on low back pain in primary school children. Eur Spine J
2002;11:45964.

www.archdischild.com

Downloaded from http://adc.bmj.com/ on July 22, 2015 - Published by group.bmj.com

316

Jones, Macfarlane

36 Balague F, Dutoit G, Waldburger M. Low back pain in schoolchildren: an

epidemiological study. Scandinavian Journal of Rehabilative Medicine
1988;20:1759.
37 Gunzburg R, Balague F, Nordin M, et al. Low back pain in a population of
school children. Eur Spine J 1999;8:43943.
38 Negrini S, Carabalona R, Pinochi G, et al. Backpack and back pain in
schoolchildren: is there a direct relationship? J Bone Joint Surg Am
1998;80B:247.
39 Papageorgiou AC, Macfarlane GJ, Thomas E, et al. Psychosocial factors in the
workplacedo they predict new episodes of low back pain? Evidence from
the South Manchester Back Pain Study. Spine 1997;22:113742.
40 Croft PR, Papageorgiou AC, Ferry S, et al. Psychologic distress and low back
pain. Evidence from a prospective study in the general population. Spine
1995;20:27317.
41 Vikat A, Rimpela M, Salminen JJ, et al. Neck or shoulder pain and
low back pain in Finnish adolescents. Scand J Public Health
2000;28:16473.

42 Mikkelsson M, Sourander A, Piha J, et al. Psychiatric symptoms in

preadolescents with musculoskeletal pain and fibromyalgia. Pediatrics
1997;100:2207.
43 Jones GT, Silman AJ, Macfarlane GJ. Predicting the onset of widespread body
pain among children. Arthritis Rheum 2003;48:261521.
44 Brattberg G. Do pain problems in young school children persist into early
adulthood? A 13-year follow-up. European Journal of Pain: Ejp
2004;8:18799.
45 Fearon P, Hotopf M. Relation between headache in childhood and physical
and psychiatric symptoms in adulthood: national birth cohort study. BMJ
2001;322:1145.
46 Hotopf M, Carr S, Mayou R, et al. Why do children have chronic abdominal
pain, and what happens to them when they grow up? Population based cohort
study. BMJ 1998;316:1196200.
47 Hotopf M, Wilson-Jones C, Mayou R, et al. Childhood predictors of adult
medically unexplained hospitalisations. Results from a national birth cohort
study. Br J Psychiatry 2000;176:27380.

IMAGES IN PAEDIATRICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
doi: 10.1136/adc.2004.060632

Acute haemorrhagic oedema of infancy

previously healthy 12 month old

girl presented with a one week
history of coryzal symptoms and a
24 hour history of an unusual rash.
Initially, her right ear had appeared
bruised, but over 12 hours both ears
became progressively more swollen,
protruding, and discoloured (figs 1 and
2). The rash on her limbs and face was
initially papular, then the lesions
increased in number and size, becoming
annular and purpuric (fig 3). There was
some swelling of her top lip and a right
subconjunctival haemorrhage. There
was no respiratory difficulty, abdominal
discomfort, or joint pain. She was
normotensive and urinalysis was negative. Full blood count and clotting
screen were normal. There was no
further progression of the rash, but 72
hours later she developed tense oedema
of both hands and feet. The rash and
oedema resolved completely within two
weeks.
This presentation is typical of acute
haemorrhagic oedema of infancy, which
was first described in 1913,1 but has
been rarely reported in the English
language literature.2 It is characterised
by the sudden appearance of sharply
demarcated, annular, purpuric lesions,
limited almost entirely to the face and
limbs and often accompanied by
oedema and low grade fever. It is
frequently preceded by respiratory tract
infection, drug intake, or vaccination,
and typically affects children between
4 and 24 months of age.3 Systemic
symptoms such as abdominal pain,
gastrointestinal
bleeding,
arthritis,
and nephritis are rarely reported.
Spontaneous and complete resolution
occurs within one to three weeks
although recurrences are not uncommon. There is no specific therapy.
Systemic corticosteroids do not alter
the disease course. The histological
findings in skin biopsy specimens are
those of a leucocytoclastic vasculitis. IgA

www.archdischild.com

Figure 1 Haemorrhagic swelling of right ear.

Figure 3 Typical annular purpuric lesions and

smaller papular lesions on the right leg.

to be made for this generally benign

disease of infants.2 3
C M McDougall
Department of Child Health, University of
Aberdeen, Royal Aberdeen Childrens Hospital,
Westburn Road, Aberdeen AB25 2ZG, UK
S K Ismail
Royal Aberdeen Childrens Hospital, UK
A Ormerod
Aberdeen Royal Infirmary, UK
Correspondence to: Dr C M McDougall,
Department of Child Health, University of
Aberdeen, Royal Aberdeen Childrens Hospital,
Westburn Road, Aberdeen AB25 2ZG, UK;
[email protected]
Figure 2 Prominent swelling and discoloration
of both ears, swollen upper lip, a right
subconjunctival haemorrhage, and a purpuric
lesion on the left cheek.

deposition is observed in about one

third of specimens.
Acute haemorrhagic oedema of
infancy may be considered a mild
variant of Henoch-Scho
nlein purpura,
but recognising it as a distinct clinical
entity allows an appropriate prognosis

Parental consent has been obtained for

figures 13

References
1 Snow IM. Purpura, urticaria and angioneurotic
edema of the hands and feet in a nursing baby.
JAMA 1913;61:1819.
2 Saraclar Y, Tinaztepe K, Adaliog
lu G, et al. Acute
hemorrhagic edema of infancy (AHEI)a variant
of Henoch-Scho
nlein purpura or a distinct
clinical entity? J Allergy Clin Immunol
1990;86:47383.
3 Legrain V, Lejean S, Taieb A, et al. Infantile acute
hemorrhagic edema of the skin: study of ten
cases. J Am Acad Dermatol 1991;24:1722.

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Epidemiology of low back pain in children and

adolescents
G T Jones and G J Macfarlane
Arch Dis Child 2005 90: 312-316

doi: 10.1136/adc.2004.056812
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