Children and Arthritis
There are nearly 300,000 children in America with some form of arthritis
or rheumatic disease. Many forms of arthritis that affect adults occur less
frequently in children, such as lupus, dermatomyositis and scleroderma. Juvenile
rheumatoid
arthritis (JRA) is the most common form of arthritis in children.
The most
common symptom of all types of JRA is persistent joint swelling, pain, and
stiffness that typically is worse in the morning or after a nap and lasts
for more than 6 weeks in a child age 16 years or younger. The pain may limit
movement of the affected joint, although many children, especially younger
ones, will not complain of pain. JRA commonly affects the knees and joints
in the hands and feet. One of the earliest signs of JRA may be limping in
the morning because of an affected knee.
Typically, there are periods when
the symptoms of JRA are better or disappear and times when symptoms are worse
(flare-ups). JRA is different in each child. Some may have just one or two
flare-ups and never have symptoms again, while others experience many flare-ups
or even have symptoms that never go away.
Some children with JRA may have
growth problems. Depending on the severity of the disease and the joints
involved, growth in affected joints may be too fast or too slow, causing
one leg or arm to be longer than the other. Overall growth may also be slowed.
Doctors are exploring the use of growth hormones to treat this problem. JRA
also may cause joints to grow unevenly or to one side.
There are three types
of juvenile rheumatoid arthritis:
Pauciarticular JRA
Pauciarticular (few
joints) affects four or fewer joints. It is the most common form of JRA;
about 50 percent of all children with JRA have this type. Usually, it affects
large joints (knees, ankles or elbows). Other joints such as wrists, spine
and even small finger or toe joints can also be affected. Unlike, polyarticular,
it affects a particular joint on one side of the body rather than both sides
at the same time.
There are two different types of pauciarticular JRA. One
type that usually affects girls under age 7 is associated with the development
of eye inflammation (chronic iridocyclitis or uveitis) in about one-third
of these children. These children should be tested for antinuclear antibodies
(ANA), which indicates to the rheumatologist and the ophthalmologist whether
your child has a higher risk of developing uveitis (when the ANA is positive
the risk is higher). Unfortunately, this eye condition is silent, so only
proper monitoring by an eye doctor who is familiar with this complication
of JRA may find the changes in the eyes.
The second type usually affects
boys typically after age 8, and tends to involve the lower spine, hips, knees,
ankles and tendons. These children may also develop eye problems, such as
acute uveitis and often causes redness and pain in the eyes. Children with
this subtype may test positive for the HLA-B27 gene, which is common in adults
with ankylosing spondylitis.
Long-term problems due to this type are seen
in some of the children affected, but many children have no long-term consequences.
Chronic damage can occur in the eyes and the eye problems may be much more
persistent than any joint problems. Some children develop chronic joint problems,
and in some, the arthritis spreads to other joints.
Polyarticular JRA
Polyarticular
(many joints) JRA affects more than five joints. About 30-40 percent of all
children with JRA have polyarticular disease. Girls are more affected by
this type than boys; and in teens, it often resembles RA.
Polyarticular arthritis
usually affects the small joints of the fingers and hands, but it can also
affect the knees, hips and ankles, as well as the neck and jaw. It often
affects the same joints on both sides of the body (symmetrical arthritis).
Other possible symptoms include: low grade fever, a positive blood test for
rheumatoid factor (RF), and/or bumps on an elbow or other point of the body
that receives a lot of pressure from chairs, shoes or other objects. Less
often, inflammation of internal organs may occur. Anemia (low red blood cell
count) is a common problem for these children.
Polyarticular JRA has two
subtypes: Some children with polyarticular disease have an antibody in their
blood called IgM rheumatoid factor (RF) and the DR4 genetic type. These children
often have a more severe form of the disease, which doctors consider to be
similar in many ways to adult rheumatoid arthritis. It has the potential
to severely damage joints. The second only involves joints, and children
with this subtype do not have a positive rheumatoid factor and the arthritis
is potentially less severe.
Children with polyarticular JRA are at risk to
develop chronic uveitis, so they should be evaluated by an ophthalmologist.
They may also develop damage to some of their joints, which may cause jaw
pain and discomfort with chewing. This may also affect dental care and eating
habits or how well your child grows. Neck stiffness and difficulty turning
the head side to side may occur. Special x-rays can help your doctor determine
if arthritis has developed in these areas.
Since polyarticular JRA affects
many joints, several different medications may be needed to treat your child
successfully.
Systemic Onset JRA (also called Still's disease)
Systemic onset
JRA, the least common form of JRA, affects many bodily systems. It affects
10-20 percent of all children with JRA -- boys and girls equally. At onset,
symptoms include a high fever and chills that may appear for several weeks
or months, and a rash on the thighs and chest. Other symptoms associated
with this type include inflamed joints; enlargement of the spleen and lymph
nodes; inflammation of the liver and heart; and anemia. For some children
the systemic symptoms of the disease and the fever may disappear after the
first few months of the illness while the joint-related symptoms of arthritis
may remain longer. In about half the children with this type, the illness
seems to disappear within one year. However, the illness can recur unexpectedly
or after a viral infection, such as mononucleosis and chicken pox. In most
children with systemic JRA, medications must be used for months to years
to control the fever, rash and anemia, as well as the arthritis.
Causes of
JRA
There are likely many causes of JRA including genetics and environmental
factors such as a virus or bacterium that trigger the disease in children
with a genetic predisposition. JRA is an autoimmune disorder, which means
that the body mistakenly identifies some of its own cells and tissues as
foreign. The immune system, which normally helps to fight off harmful, foreign
substances such as bacteria or viruses, begins to attack healthy cells and
tissues. The result is inflammation--marked by redness, heat, pain, and swelling.
Doctors do not know why the immune system goes awry in children who develop
JRA. Scientists suspect that something in a child's genetic makeup gives
them a tendency to develop JRA; then an environmental factor, such as a virus,
triggers the development of JRA.
Prevalence
JRA can occur in boys or girls
of any age, but it most commonly begins during the toddler or early teenage
years, according to the Arthritis Foundation. Certain types and subtypes
are more prevalent in either boys or girls, but it generally affects more
girls than boys. Certain subtypes are more likely to occur in children of
a particular age.
How Is It Diagnosed and Treated?
Doctors usually suspect
JRA, along with several other possible conditions, when they see children
with persistent joint pain or swelling, unexplained skin rashes and fever,
or swelling of lymph nodes or inflammation of internal organs. A diagnosis
of JRA also is considered in children with an unexplained limp or excessive
clumsiness.
No one test can be used to diagnose JRA. A doctor diagnoses JRA
by carefully examining the patient and considering the patient's medical
history, the results of laboratory tests, and x rays that help rule out other
conditions, such as Lyme disease, inflammatory bowel disease, lupus, dermatomyositis,
and some forms of cancer.
The main goals of treatment are to preserve a high
level of physical and social functioning and maintain a good quality of life.
To achieve these goals, doctors recommend treatments to reduce swelling;
maintain full movement in the affected joints; relieve pain; and identify,
treat, and prevent complications. Most children with JRA need medication
and physical therapy to reach these goals. Some alternative or complementary
approaches may help a child to cope with or reduce some of the stress of
living with a chronic illness, and can be incorporated into the treatment
plan. However, it is important not to neglect regular health care or treatment
of serious symptoms.
Helping Your Child Adjust
JRA affects your entire family
who must cope with the special challenges of this disease. JRA can strain
a child's participation in social and after-school activities and make schoolwork
more difficult. There are several things that family members can do to help
the child do well physically and emotionally.
