ACR Patient Education Fact Sheet: Arthritis in Children

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ARTHRITIS IN CHILDREN

http://www.rheumatology.org/public/factsheets/arth_in_children.asp?aud=pat

Growing up with arthritis can be challenging, but with coordinated care

from a team of rheumatology professionals, most children with arthritis

live a full and active life. There are various types of childhood

arthritis, which can last from several months to many years. Early

diagnosis and treatment is essential for any child with arthritis,

because it can help avoid joint damage and disability.

Fast Facts

* Arthritis in children is treatable

* It is important to seek treatment from health care professionals

knowledgeable about childhood arthritis.

* Ask your child's rheumatologist about summer camps and other

activities to meet other children with arthritis.

What JRA is

There are several different types of juvenile arthritis. The most common

form is juvenile rheumatoid arthritis (JRA), also known as juvenile

idiopathic arthritis. There are several different types of JRA. All

cause joint inflammation and begin before the age of 16, but otherwise

are often associated with distinct symptoms and complications and may

require different approaches to treatment.

Systemic onset JRA affects about 10 percent of children with arthritis.

It begins with a recurrent fever that can be 103 ° F or higher, often

accompanied by a pink rash that comes and goes. Systemic onset JRA may

cause inflammation of the internal organs as well as the joints.

Swelling of the joints may not be present at onset and may appear months

or even years after the onset of fevers. Anemia (a low red blood cell

count) and elevated white blood cell counts are also typical. Arthritis

may persist despite the fevers and other systemic symptoms going away.

Pauciarticular JRA, which involves fewer than five joints, affects about

half of all children with arthritis. Often only one knee is affected.

Girls are more at risk than boys. Children who develop this form of JRA

when they are younger than 7 years old have the best chance of having

their joint disease subside with time, but are at increased risk of

developing an inflammatory eye problem (iritis or uveitis) that may

persist independently of the arthritis. Because iritis and uveitis

usually do not cause symptoms, regular exams by an ophthalmologist (eye

doctor) are essential both to detect these conditions and prevent vision

loss. Older children with pauciarticular JRA may develop “extended”

arthritis that involves multiple joints and lasts into adulthood.

Polyarticular JRA affects five or more joints and can begin at any age.

Some affected children actually have the adult form of rheumatoid

arthritis that begins at an earlier-than-usual age.

What causes JRA

JRA targets the lining of the joint, known as the synovial membrane,

causing inflammation or synovitis. When synovitis persists, joint damage

may occur. It is not known what causes JRA. These conditions are not

regarded as hereditary and rarely affect more than one family member.

Research suggests that some children have a genetic predisposition to

JRA, but develop the condition only after exposure to an infectious

trigger—as yet unknown. Dietary and emotional factors do not appear to

play a role in the development of JRA.

Who gets JRA

About 1 child in every 1,000 develops some type of juvenile arthritis.

These disorders can affect children at any age, although they are

uncommon in the first six months of life.

How JRA is diagnosed

JRA may be difficult to diagnose because some children may not complain

of pain at first, and joint swelling may not be immediately obvious.

There is no blood test that can be used to diagnose the condition.

Diagnosis of JRA therefore depends on physical findings, medical history

and the ruling out of other disorders. Typical symptoms include:

* limping

* stiffness when awakening

* reluctance to use an arm or leg

* reduced activity level

* persistent fever

* joint swelling

A number of other conditions can look like JRA, including infections,

childhood malignancies, bone disorders, Lyme disease and lupus. These

disorders must be ruled out before a diagnosis of JRA can be confirmed.

How JRA is treated

Optimal care is tailored for each child with JRA and provided by an

experienced team of healthcare providers that should include a pediatric

rheumatologist, physical and occupational therapist , social worker and

nurse specialist. This core team can coordinate efforts with the child's

pediatrician, adult rheumatologists, other physicians (such as an

ophthalmologist or orthopedic surgeon), other health professionals

(dentist, nutritionist or psychologist), schools and additional

community resources as necessary to ensure that the child receives the

best care possible.

The overall goal of treatment of JRA is to control symptoms, prevent

joint damage and maintain function. Children with polyarticular JRA

whose symptoms persist or who test positive for rheumatoid factor (an

antibody found in approximately 80% of patients with adult onset

rheumatoid arthritis) are more likely to develop joint damage, and may

require more aggressive treatments.

The first line of treatment involves a non-steroidal anti-inflammatory

drug (NSAID), such as ibuprofen (such as Motrin or Advil) or naproxen

(Naprosyn), administered in a dose appropriate for the child. Younger

children may be prescribed liquid preparations or medications that

require less frequent administration. Because NSAIDs sometimes cause

gastrointestinal distress, such as stomachaches, they should be taken

with food.

Disease modifying drugs (DMARDs) are added as a second-line treatment

when arthritis remains active despite NSAID therapy. DMARDs include

hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), methotrexate

(Rheumatrex), and more recently developed “anti-TNF agents” such as

etanercept (Enbrel), infliximab (Remicade), and adalimumab (Humira).

Each of these medications may cause side effects that need to be

monitored and discussed with your rheumatologist. Some of these

medications have been FDA-approved only for adults, but clinical trials

are under way to test their effectiveness and safety in children. In

addition, new therapies are being developed and will likely be available

in the future.

Where only a single joint is involved, a steroid preparation may be

injected into the joint before any additional medications are given.

Oral steroids such as prednisone (Deltasone, Orasone) may be used in

certain situations, but only for as short a time and at the lowest dose

possible, in order to avoid long-term side effects such as weight gain,

poor growth, and risk of infection.

Prevention

Because it is not known what causes JRA, it is not known how to prevent

these conditions.

Children living with arthritis

Children with JRA should attend school, participate in extra-curricular

and family activities, and otherwise live life as normally as possible.

To foster a healthy transition to adulthood, adolescents with JRA should

be allowed to enjoy independent activities, such as taking a part-time

job and learning to drive.

Opportunities for your child to interact with other children who also

have arthritis may be available in or near your community. Ask your

rheumatologist about summer camps and other available group activities.

A positive outlook and continued physical activity will help prevent

loss of function. Physical and occupational therapy can increase joint

motion, reduce pain, improve function, and increase strength and

endurance. Therapists may construct splints to prevent joint

contractures or deformity, and work with school-based therapists to

address issues at school.

Parents should be familiar with Federal Act 504, which may provide

children with JRA special accommodations at school. Families with

children with rheumatic disease may be eligible for assistance through

state agencies or services such as vocational rehabilitation. They may

also benefit from information and activities available through the

American Juvenile Arthritis Organization, listed below under resources.

Points to Remember

Arthritis in children consists of several diseases that may show up in

different ways. In spite of their diagnosis, most children with

arthritis can expect to live normal lives.

The rheumatologist's role in the treatment of arthritis in children

Optimal care for children with arthritis is provided by a pediatric

rheumatology team that has extensive experience and can most effectively

diagnose and manage the complex needs of the child and family. The core

team consists of a pediatric rheumatologist, physical and occupational

therapist, social worker, and nurse specialist. These professionals can

coordinate care with the child's pediatrician, adult rheumatologists,

other physicians and health professionals, as well as schools and

community resources necessary to ensure the child's best long-term

physical and psychological health.

To find a rheumatologist

For more information about rheumatologists, visit

http://www.rheumatology.org/public/rheumatologist.asp?aud=pat

For a listing of rheumatologists in your area, visit

http://www.rheumatology.org/directory/geo.asp?aud=pat

For more information

The American College of Rheumatology has compiled this list to give you

a starting point for your own additional research. The ACR does not

endorse or maintain these Web sites, and is not responsible for any

information or claims provided on them. It is always best to talk with

your rheumatologist for more information and before making any decisions

about your care.

The Arthritis Foundation

http://www.arthritis.org

The American Juvenile Arthritis Organization (a council of The Arthritis

Foundation)

http://www.arthritis.org/communities/juvenile_arthritis/about_ajao.asp

National Institute of Arthritis and Musculoskeletal and Skin Diseases

Information Clearinghouse

http:// www.niams.nih.gov

Updated May 2004

Written by S. Abramson, MD, and reviewed by the American College

of Rheumatology Communications and Marketing Committee.

©2004 American College of Rheumatology