Low back pain in children is less common than in adults, is seen more frequently in girls than in boys, and is more common than previously thought. The younger the child and the more acute the history, the more likely that there is serious underlying pathology responsible for the symptoms.

It is important that we understand about how to manage back pain in childhood, as evidence suggests that it can be a recurrent condition and may affect children and adolescents as they enter adulthood.

Neck pain can also be non-specific, but when associated with restricted movement, then consider inflammatory joint disease. However, isolated neck involvement in inflammatory joint disease is unusual, so be aware of red flags to suggest malignancy or infection.

Scoliosis is usually not painful – the presence of painful scoliosis warrants urgent referral.

Red flags include young age, persistent or worsening pain, night pain or systemic features (such as fever or weight loss) and neurological signs. Always consider malignancy. Benign bone tumours (osteoid osteomas) may occur in vertebrae and can cause night pain.

Contrary to popular belief, poor posture does not cause low back pain. Children should be encouraged to vary their posture regularly, rather than adopting static postures for prolonged periods.

It is important that children undertake regular and varied exercise (UK Chief Medical Officers Physical Activity Guidelines) and this can help to prevent and reduce back pain.

There is no convincing evidence that factors involving the use of school bags or backpacks increase the risk of back pain.

Simple analgesia may be useful for children, and advice should be given around this.

Factors such as stress, low mood and anxiety can be contributing factors in back pain, and avenues should be explored to address these if appropriate.

Consider spondylolysis, pars fracture and spondylolisthesis in physically active young people engaged in activity with hyperextension of the spine (e.g., cheerleaders, wrestlers, cricketers, gymnasts).

Consider ankylosing spondylitis in teenagers (especially boys) with inflammatory back pain and tenderness over the sacroiliitis joints.

Scheuermann’s disease’ can be a normal variant observed on a radiograph as a coincidence. Radiographs may show anterior wedging of the vertebrae, narrowing of disc spaces and Schmorl’s nodes. It can be associated with back pain in older children and adolescents but if there is severe pain then it is important to suspect another cause for the pain.