- All children with new-onset back pain and especially children below the age of 10 years need a workup to rule out a serious medical condition
Infections, solid tumors, physical trauma, and congenital spinal malformations may cause back pain. An age under 10 years is a risk factor for back pain due to an underlying pathophysiology. The following red flags should be sought in children with newly diagnosed back pain: fever, pain in other locations, back pain that starts after physical trauma or after sports, radiculopathic pain, co-existent chronic conditions, or a history of glucocorticoid treatment. Neurological signs including muscular weakness, paresis, somatosensory abnormalities (dysesthesia, hypesthesia or allodynia) as well as anal sphincter dysfunction should be ruled out. Findings of local swelling, detectable lymph nodes, structural changes of the spine, hypermobility, local inflammation, or tenderness should be pursued, and blood pressure should be measured. It is crucial not to miss underlying conditions in children with back pain, especially in younger children. [1, 2]
- 1 in 5 school-age children experience back pain.
A large population study that followed children through adolescence in Canada found that across 12–19 years of age, 1 in 5 youth experienced low back pain that occurred weekly or more frequently with girls experiencing more frequent back pain over the course of adolescence than boys. Similarly, a large population study of school children in England aged 11-14 years of age found that 1 in 4 children experienced back pain in the prior month. The vast majority of youth with back pain in both of these studies reported experiencing pain-related functional limitations. [3, 4]
- Low back pain appears to increase with age in children and adolescents.
Research has shown that the prevalence of low back pain increases with age. Further, rates of low back pain have increased over time, with more recent studies showing highest prevalence rates, suggesting pediatric low back pain problems may be increasing. Taken together, this points to a potential important role of prevention and early detection efforts in childhood to reduce the lifetime burden of chronic low back pain. .
- 1 in 5 to 6 children and adolescents with low back pain seeks medical care.
Epidemiological studies from different countries (Finland, Iran, Nigeria, Portugal) show that between 12% to 20% of children and adolescents with low back pain have sought evaluation by a physician. Physician consultation greatly increases from the age of 13 to 15 years onwards. [6-10]
- Heavy school bags do not cause chronic low back pain
A causal correlation between wearing a heavy school bag and the development of low back pain is often discussed. However, empirically the association between schoolbag weight, design and carriage method and the risk of new-onset low back pain in school children and adolescents has not been confirmed. [2, 11]
- Moderate physical activity is a protective factor.
Moderate and regular endurance sports such as running, swimming or cycling, appear to be a protective factor for non-specific back pain in adolescence. In contrast, high levels of physical activity in athletes, technical sports, and especially competitive sports represent a risk factor for the occurrence of non-specific back pain in adolescence. [1, 12, 13]
- Psychosocial factors can predict chronic back pain trajectories.
High levels of anxiety and depression are predictive of recurrent back pain trajectories during adolescence. Specifically, youth with greater anxiety and depression are more likely to develop persistent pain with increasing pain intensity during adolescence. Studies are needed to examine psychological interventions for youth with chronic and recurrent back pain. [3, 14, 15]
- Up to a half of adolescents undergoing spinal fusion surgery experience chronic back pain after surgery
Spinal fusion surgeries, performed for spinal deformities like scoliosis, are amongst the most frequently performed major musculoskeletal surgeries in childhood and adolescence. Most children (about 80%) experience high intensity acute pain at home after spine surgery, which places them at risk for chronic postsurgical pain. Data shows about 20% develop chronic postsurgical pain, a condition defined by chronic pain which impacts health-related quality of life after surgery. Higher psychosocial distress in youth undergoing spinal fusion surgery, and their parents, is associated with higher acute and chronic pain. Psychosocial interventions targeting these risk factors may interrupt a negative trajectory of continued pain. [16, 17]
- Exercise interventions improve low back pain in children and adolescents.
A systematic review and meta-analysis evaluating effectiveness of non-invasive interventions to treat low back pain found that supervised exercise programs improved pain intensity experienced in the prior month by about 3 points on a 0-10 numeric rating scale, compared to no treatment. However, included studies had high risk of bias indicating that while these results are promising, further pediatric research is needed. [14, 18]
- Further research is needed to understand prognosis of back pain during childhood and adolescence.
A review of systematic reviews concluded that further pediatric research is needed to understand the prognosis of back pain in children and adolescents. In particular, research is needed to understand implications for pediatric chronic low back pain into adulthood. 
 Calvo-Munoz, I., et al., Risk Factors for Low Back Pain in Childhood and Adolescence: A Systematic Review. Clin J Pain, 2018. 34(5): p. 468-484.
 Jones, G.T., et al., Predictors of low back pain in British schoolchildren: a population-based prospective cohort study. Pediatrics, 2003. 111(4 Pt 1): p. 822-8.
 Stanford, E.A., et al., The frequency, trajectories and predictors of adolescent recurrent pain: a population-based approach. Pain, 2008. 138(1): p. 11-21.
 Watson, K.D., et al., Low back pain in schoolchildren: occurrence and characteristics. Pain, 2002. 97(1-2): p. 87-92.
 Calvo-Munoz, I., A. Gomez-Conesa, and J. Sanchez-Meca, Prevalence of low back pain in children and adolescents: a meta-analysis. BMC Pediatr, 2013. 13: p. 14.
 Ayanniyi, O., C.E. Mbada, and C.A. Muolokwu, Prevalence and profile of back pain in Nigerian adolescents. Med Princ Pract, 2011. 20(4): p. 368-73.
 Dianat, I., A. Alipour, and M. Asghari Jafarabadi, Prevalence and risk factors of low back pain among school age children in Iran. Health Promot Perspect, 2017. 7(4): p. 223-229.
 Minghelli, B., R. Oliveira, and C. Nunes, Non-specific low back pain in adolescents from the south of Portugal: prevalence and associated factors. J Orthop Sci, 2014. 19(6): p. 883-92.
 Tiira, A.H., et al., Determinants of adolescent health care use for low back pain. Eur J Pain, 2012. 16(10): p. 1467-76.
 Kjaer, P., et al., Prevalence and tracking of back pain from childhood to adolescence. BMC Musculoskelet Disord, 2011. 12: p. 98.
 Yamato, T.P., et al., Do schoolbags cause back pain in children and adolescents? A systematic review. Br J Sports Med, 2018. 52(19): p. 1241-1245.
 Guddal, M.H., et al., Physical Activity Level and Sport Participation in Relation to Musculoskeletal Pain in a Population-Based Study of Adolescents: The Young-HUNT Study. Orthop J Sports Med, 2017. 5(1): p. 2325967116685543.
 Kamper, S.J., T.P. Yamato, and C.M. Williams, The prevalence, risk factors, prognosis and treatment for back pain in children and adolescents: An overview of systematic reviews. Best Pract Res Clin Rheumatol, 2016. 30(6): p. 1021-1036.
 Fisher, E., et al., Psychological therapies for the management of chronic and recurrent pain in children and adolescents. Cochrane Database Syst Rev, 2018. 9: p. CD003968.
 Dunn, K.M., et al., Trajectories of pain in adolescents: a prospective cohort study. Pain, 2011. 152(1): p. 66-73.
 Rabbitts, J.A., et al., Prevalence and Predictors of Chronic Postsurgical Pain in Children: A Systematic Review and Meta-Analysis. J Pain, 2017. 18(6): p. 605-614.
 Rabbitts, J.A., T.M. Palermo, and E.A. Lang, A conceptual model of biopsychosocial mechanisms of transition from acute to chronic postsurgical pain in children and adolescents. Journal of Pain Research, 2020. doi: 10.2147/JPR.S239320.
 Michaleff, Z.A., et al., Low back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions. Eur Spine J, 2014. 23(10): p. 2046-58.
Jennifer A. Rabbitts, MBChB, Department of Anesthesiology & Pain Medicine, University of Washington, and Seattle Children’s Hospital, 4800 Sand Point Way NE MB.11.500.3, Seattle WA 98105, USA; phone: 206-987-2704, email: firstname.lastname@example.org, website: https://www.seattlechildrens.org/rabbitts-lab/. Funding source: National Institute of Arthritis, Musculoskeletal, and Skin Diseases (R01AR073780, PI: Rabbitts; the content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH).
Julia Wager, PhD, and Michael Frosch, MD, PhD, German Paediatric Pain Centre, Children’s and Adolescents’ Hospital, Datteln, Germany, and Department of Children’s Pain Therapy and Paediatric Palliative Care, Faculty of Health, School of Medicine, Witten/Herdecke University, Witten, Germany, Dr.-Friedrich-Steiner Str. 5, Datteln, 45711, Germany, Phone: +49 (0) 2363-975-184, e-mail: email@example.com; firstname.lastname@example.org
Amy Holley, PhD
Associate Professor of Pediatrics, School of Medicine
Oregon Health & Science University
William Zempsky, MD
Division Head, Pain & Palliative Medicine
Francine L. and Robert B. Goldfarb-William T. Zempsky, MD Endowed Chair for Pain and Palliative Medicine
Connecticut Children’s Hospital