August 28, 2008
Juvenile Arthritis: Not Just an Old Person’s Disease
By Taghdiri, Celia
Many people are shocked to learn that arthritis isn't just "an old person's disease." The reality is about 300,000 U.S. children, or one in 250, have joint inflammation that causes pain, redness, heat and swelling. Juvenile arthritis occurs before age 16. The most common is juvenile idiopathic arthritis (JIA). Idiopathic means arising from an unknown cause. Targeting the body's joints, JIA is more frequent in girls and occurs generally from one to three years of age, and later from eight to twelve years. According to the Arthritis Foundation, there are three different kinds of JIA: oligoarticular, poliarticular and systemic onset.
Scientists are unsure of what causes JIA but some studies suggest there may be a genetic predisposition to the disease. With JIA, the immune system, which normally helps to fight off harmful, foreign substances such as a virus or bacteria, identifies some of its own cells and tissues as foreign and begins to attack healthy cells and tissues. The result is inflammation.
According to the National Institute of Arthritis, Musculoskeletal and Skin Diseases, one of the earliest signs of JIA may be limping in the morning because of an affected knee. There are periods when the symptoms are better and times when children experience flareups. Some children with arthritis may have growth problems, depending on the severity of the disease and the joints affected. Juvenile arthritis may cause joints to grow unevenly.
Three Types of JIA
Oligoarticular is the most common form of JIA in young children, and affects four or fewer joints. This type of JIA usually damages larger joints such as the knees, ankles and/or elbows.
Polyarticular JIA is a more severe form of the disease and affects five or more joints, usually the small joints of the fingers and hands but also the knees, hips, ankles and feet. It can cause bumps on the body on areas subjected to pressure from sitting or leaning, and low-grade fever. Joints from the neck and jaw may also be affected.
The least-common form of JIA is systemic onset, which affects 20% of all children with JIA. In addition to joint swelling and inflammation, systemic JIA causes high fevers that may last for weeks, and a light skin rash appears on the child's chest, thighs and other body parts. It may also affect the heart, liver, spleen and lymph nodes. In most cases, this form of JIA is chronic and these children require regular evaluations and X-Rays.
Eye inflammation can also occur with JIA. Uveitis, or the inflammation of the iris (the colored area of the eye), may occur with or without active joint symptoms. The inflammation can lead to scarring of the pupil; if the scarring deteriorates and is not treated, it can lead to blindness.
Fortunately, arthritis-related eye problems are highly treatable. Typically, they are treated with a steroid eyedrop to reduce the inflammation. A pediatric ophthalmologist can detect uveitis early and would need to examine the eyes every three to four months after diagnosis, then follow up for years afterwards.
There is not one single test doctors use for diagnosis. Rather, they conduct a physical exam, study the patient's medical history, X- Rays and laboratory test results. A physical exam looks for joint inflammation, rash, nodules and eye problems that may suggest the presence of juvenile arthritis. A complete medical history helps determine the length of time symptoms have been present. Joint swelling or pain must last at least six weeks for the physician to consider a diagnosis of juvenile arthritis. The physician also needs to be aware if other family members have had arthritis conditions. X- Rays may be needed if the doctor suspects injury to the bone or unusual bone development.
Lab tests may include erythrocyte sedimentation rate (sed rate or ESR), antinuclear antibody test (ANA) and a rheumatoid factor test (RF). Lab results, however, are not used solely as diagnostic factors. A child can manifest JIA symptoms but have normal or near- normal lab test results.
ESR measures how quickly red blood cells fall to the bottom of the test tube. It is a non-specific inflammatory indicator. If the test reveals elevated inflammation, JIA is just one possibility. ANA detects autoimmunity and it is also useful in predicting which children are likely to have eye disease with JIA. The RF test helps the doctor to differentiate among the three types of JIA, particularly with adolescents.
Medical Treatments for JIA
Robert Sheets, MD, pediatric rheumatologist at Rady Children's Hospital in San Diego, CA, says treatment is key. "Early diagnosis and appropriate aggressive therapy can frequently lead to a good prognosis."
Treatment options include oral and injected medication along with physical therapy to strengthen the muscles and joints. Non- steroidal anti-inflammatory drugs (NSAIDs), such as Ibuprofen and naproxen, are commonly used to treat the disease's pain and inflammation.
In some cases, doctors will prescribe "disease-modifying" drugs such as methotrexate, in addition to an NSAIDs, to limit the progression of JIA. Usually, small doses of methotrexate are prescribed to relieve arthritis symptoms. Physicians are likely to prescribe it when an NSAID alone is not controlling joint inflammation.
"Treatment has tremendously improved," Sheets says. "Twenty years ago, we did not have the drugs we have today, so children were taking aspirin as their pain reliever."
Emotional Treatments for JIA
Children usually do not like to be considered "different" and may feel sad or angry about having arthritis. It is also difficult for youngsters, especially teens, to seek assistance with simple tasks such as getting dressed. Some kids are forced to discontinue some of their favorite activities. They may resent other children, including their siblings, for not having the disease.
Parents can help manage the child's disease by administering their medication and supervising some physical activities. For most patients, activities such as muscle-strengthening exercises need to be done regularly. But it is vital to remain cautious of some activities such as biking because it may put weightbearing stress on the joints.
Psychologists and social workers can help by emphasizing to the child that he did not cause the arthritis. They help kids cope, lead a healthy social life and continue with their activities. Therapy can assist children with pain management because children and teens often prefer discussing their illness with someone other than a family member.
Childhood arthritis continues into adulthood for most patients. For some, the pain and stiffness go into remission, a period when the disease isn't cured but instead seems to disappear. This period, however, doesn't last and symptoms manifest during a flare.
According to Dr. Sheets, most children with oligoarticular arthritis, the type with the best prognosis, remit and the majority are able to continue everyday activities. For some other forms of childhood arthritis, however, the chance of remission and the long- term prognosis are more difficult to predict.
Celia Taghdiri is afreelance writer who lives in California. This article was adapted from her original piece that was published in the San Diego Union-Tribune.
Copyright Pediatrics for Parents, Inc. Jul 2008
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