Dear Editor,
We read with great interest the article titled “Risk factor analysis for growing pains in children: results of parental survey”. 1 The authors should be commended for investigating an important, yet poorly understood, pediatric pain syndrome. Given the prevalence and impact of this condition on patients and their families, identifying potential risk and protective factors is an important step toward improving diagnosis and counseling. While we appreciate the authors’ contributions, several study limitations warrant discussion and substantially affect the interpretation of the reported associations.
One notable limitation pertains to the cross-sectional study design. While the authors do acknowledge this limitation, we believe that the authors, at times, overemphasize several variables as independent risk and protective factors of growing pains and propose causal relationships. Specifically, the authors conclude that children with maternal smoke exposure during pregnancy, prolonged sleep latency, and extreme fatigue after exercise should be counseled about their increased risk of developing growing pains. Due to the cross-sectional study design and limitations surrounding temporality, causal relationships cannot be established and can only provide measures of association. 2 Also, despite including a case-control comparison, this does not overcome the main limitation of the cross-sectional design. Furthermore, the authors do not acknowledge that measured variables may represent consequences of recurrent pain, rather than potential antecedent risk factors. For example, decreased physical activity and altered sleep patterns could develop after symptom onset, rather than contribute to pain development. These limitations merit further emphasis by the authors to avoid overinterpretation of the findings.
The study is also susceptible to confounding bias. Several variables previously associated with growing pains (generalized joint hypermobility, vitamin D deficiency, psychosocial stress, and family history of chronic pain) appear to be inadequately characterized or were not incorporated into the analytical model.3,4 Failure to account for these factors may have resulted in confounded estimates of association.
Another notable limitation, not addressed by the authors, is exclusion of participants that did not have access to a personal electronic device and could not fill out the electronic questionnaire. Exclusion of these participants may disproportionately exclude patients of lower socioeconomic status (SES). Social determinants of health have been shown to influence pediatric musculoskeletal conditions through differences in nutrition, healthcare access, sleep environment, and psychosocial stress. 5 SES remains largely unexplored in growing pains literature and inclusion of validated SES measures (parental education, household income, or neighborhood deprivation indices) could substantially strengthen future investigations and may clarify variability not explained by traditional clinical variables.
Despite these limitations, the authors contribute important epidemiologic data and address an important clinical question. However, considering limitations of study design, outcome assessment, and generalizability, we believe that the present findings should be interpreted as hypothesis-generating rather than definitive evidence of causative risk and protective factors. Growing pains is most likely a multifactorial syndrome involving biomechanics, altered pain perception, sleep disturbances, psychosocial factors, and possible genetic susceptibility. As such, in order to meaningfully inform clinical practice, future studies should move beyond survey-based association analyses and employ prospective longitudinal study designs incorporating objective clinical evaluation, standardized diagnostic criteria and comprehensive assessment of biological, psychosocial, and SES factors.
Footnotes
Author contributions: Conceptualization, Literature Review, Manuscript Drafting, and Final Revisions: SF & DSM
Funding: The authors received no financial support for the research, authorship, and/or publication of this article.
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
ORCID iDs
Sahand Fallahi https://orcid.org/0009-0009-6244-601X
Diego Silva-Mendoza https://orcid.org/0009-0007-4915-3744
Ethical considerations
Not applicable as the research is a letter to editor concerning published literature.
Data Availability Statement
Data sharing is not applicable to this article as no datasets were generated or analyzed in preparation of the manuscript.*
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data sharing is not applicable to this article as no datasets were generated or analyzed in preparation of the manuscript.*