Juvenile (idiopathic) arthritis Juvenile arthritis

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Dr Jeffrey Chaitow,
Paediatric Rheumatologist and Head
Department of Rheumatology
The Children’s Hospital at Westmead
NSW Australia

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What is juvenile (idiopathic) arthritis?

Juvenile arthritis is a term applied to the inflammation of joints in children who are under the age of l6 (at the time of disease onset). It includes those with mild and those with severe disabilities. In all instances, effective treatment is aimed at minimising the impact of arthritis in the home, school and community areas of their life and to accomplish and succeed just like their peers.

Arthritis may form part of many other diseases or it can be a disease itself. The cause of arthritis in children, as in adults, remains unknown. This is what the term idiopathic means. There are many myths associated with this disease, including that it is a reaction to certain dietary triggers (such as oranges or tomatoes) or that it is an allergic reaction to other foodstuffs or substances in the environment. This is totally without scientific basis, and children with arthritis should be encouraged to eat a normal, healthy diet without any food restriction.

Children with juvenile (idiopathic) arthritis (also previously known as juvenile chronic arthritis or juvenile rheumatoid arthritis) may have a few joints involved (oligo articular), many joints involved (poly articular) or may have associated high fevers, rashes and be generally unwell (systemic onset or Still’s disease).

This type of arthritis is the most common subgroup.

Children in this group tend to be young girls, often of preschool or kindergarten age, who may have just one or two swollen joints, such as a knee and/or an ankle. They are likely to have complete or nearly complete mobility, but may have a limp and sometimes be stiff in the mornings on rising, or after sitting in one position for a period of time. They usually initially require anti-inflammatory medication (eg naproxen or ibuprofen). Approximately 30–40% of these young girls have an associated inflammation in the eye (uveitis) for which they require regular drops to keep the pupil dilated and steroid drops to diminish inflammation.

Many joints are affected in cases of poly articular juvenile chronic arthritis, including the small joints of the hands and the wrists, as well as larger joints such as elbows, shoulders, knees, and ankles. Some children may have obvious deformities; others may just experience swelling or painful movement of the joint. A group of these children – more commonly adolescent girls – have the same disease as adult rheumatoid arthritis.

Children with Still’s disease are most unwell, and may have many months of high spiking temperatures up to 40°C.

The temperatures are usually best controlled by taking ibuprofen, although often the children will be taking additional cortisone medication. The anti-inflammatory medication needs to be given on a regular basis to control fever and joint symptoms; the cortisone may be given each day or every second day.

Cortisone side effects include excess weight gain, increased appetite, a rounded, moon face and thinning or brittling of the bones. Rarer complications in this subtype of arthritis include inflammation around the heart (pericarditis) or lungs (pleurisy). Nutritious food intake is especially to be encouraged in this subgroup of children. They often feel unwell and so they neglect their nutrition, losing muscle bulk due to protein wasting. Building up their muscles is an important part of stabilising their joints.

The older onset group, which has previously been termed juvenile ankylosing spondylitis, tends to include adolescent boys, who may have stiffness of the hips, knees or ankles and sometimes, as they get older, a stiffening of the spine.

Associated diseases

There are numerous diseases which have arthritis as part of the general condition. These include:

  • Systemic lupus erythematosis – manifested by a sun-sensitive facial rash, swollen joints, intermittent fevers and inflammation of the kidneys (nephritis).

  • Ulcerative colitis and Crohn’s disease – also termed inflammatory bowel disease – involving chronic inflammation of the bowel.

  • Psoriasis – a scaly skin rash, which may also have arthritis as part of the disease (see Skin conditions article).

Medication

As mentioned above, children with arthritis often take anti-inflammatory medication such as Naprosyn (naproxen), Voltaren (diclofenac) or Brufen (ibuprofen) or Nurofen. Stronger cortisone medication may be necessary in children with more severe disease and disability.

‘Second line agents’, which is generally stronger medication needing closer medical monitoring, may include methotrexate, salazopyrine, and new very effective ‘biologic’ medication such as etanercept, which is given by injection once or twice a week. Children on these medications will be closely monitored by their general practitioner, paediatrician and/or paediatric rheumatologist.

Many children will receive, under anaesthetic, cortisone injections into their joints periodically. This is a rapid and effective way of maintaining function in stiff swollen joints.

Physiotherapy and occupational therapy

When a child’s joints become painful or lose their range of movement, splints are often prescribed.

These support the joints firmly and maintain the wrist, hand or knee in a position of function to prevent further contraction of the joint.

Range of movement and strengthening exercises are performed with the physiotherapist and at home. Hydrotherapy (exercise in a warm pool) is also recommended.

The treatment team, especially the occupational therapist, will be willing to do a home and school assessment. They can provide valuable tips on modifications that may need to be made around the classroom, from widened pencil grips, comfortable writing desk position, to ramps for wheelchairs.