Arthritis in children is an autoimmune illness where, for unknown reasons, the immune system becomes confused and attacks healthy cells rather than invading foreign bodies such as bacteria or viruses.
It is commonly diagnosed between ages 1 and 4 years, but can occur at any age.
Image: iStock
Key points
- About one in 1000 children has arthritis in their early years.
- There are many different types of arthritis. Your child's symptoms and treatment will depend on which type they have.
- Many children will be free of arthritis symptoms before adulthood, while others will still need treatment as adults.
- Treatment and good management offer a positive outlook for many children with arthritis, though some children may have long-term problems.
- A rheumatologist will guide you and your child through your treatment options.
Causes
The cells in the body that the immune system attacks, are in the connective tissues that make up the lining of the joints (synovium). As these types of cells also exist outside of the joints, arthritis can affect other parts of the body as well. Some possible causes of the disease include:
- Genetics: Research suggests that for some types of JIA, genetics may be involved. However, these conditions are not regarded as hereditary. So if you have one child with arthritis, it does not mean your other children will also have arthritis. It also does not mean that your child’s children will develop JIA.
- Infection: Another theory is that some form of infection may trigger the start of JIA. However, JIA cannot be spread from child to another; it is not infectious.
- Dietary and emotional factors do not appear to play a role in the development of JIA.
Diagnosis
There is no single test to diagnose juvenile idiopathic arthritis (JIA). Instead, it involves a number of steps. These include:
- Taking a detailed medical history of the child and their biologically related family members (where possible).
- Physical examinations.
- Laboratory tests (eg, blood and urine).
- Other tests such as x-rays of the joints.
Some tests may be ongoing or have to be repeated several times. This helps the doctor to look for changes in your child’s symptoms over a time period. If JIA is suspected, your child should be referred to a rheumatologist, ideally a specialist in paediatric (childhood) arthritis, who would confirm the diagnosis and then start treatment.
Reaching a diagnosis can take time, and the waiting period can be very frustrating. This is understandable, but it's important to keep on with the process until the diagnosis is made. The rheumatologist can then make sure your child receives the best treatment to manage the symptoms and reduce the potential damage caused by JIA.
At some point, your child will be asked to have a number of tests as part of the diagnosis or management of the arthritis. There is nothing to be alarmed about, these are routine. Some of the more common tests include:
- FBC (full blood count) – a blood test to check for anything abnormal that might be important in managing the illness
- RF (rheumatoid factor) – an antibody detected by blood test. This is an indicator of the kind of JIA your child has
- ESR (erythrocyte sedimentation rate) – a blood test that detects how much inflammation there is in the body
- CRP (C-reactive protein) – also a test that detects inflammation
- ANA (anti-nuclear antibody) – this test is used to do two things: it helps identify the type of arthritis your child has; and, it is an important indicator of your child’s risk of developing eye problems
- X-ray – takes pictures of your child’s joints to see how they change with time
- MRI or CT scans (magnetic resonance imaging or computed tomography) – they do much the same as x-ray but in greater detail. They can also show changes in non-bone structures around the joints (like ligaments and tendons)
- HLA-B27 – a blood test that helps determine the type of arthritis your child may have.
Is JIA curable?
The outlook for children with JIA is usually very positive:
- Most children with JIA will not have active symptoms by the time they become adults.
- With appropriate management, most children with JIA will grow up without any lasting effects of their arthritis.
There is no way to predict which outcome your child will have. Some forms of JIA have a greater chance of permanent remission (where the condition will not return). Your child’s rheumatologist can give you more information about this.
Good medical care is vital for all children with any form of JIA. Good overall care, both during and between flares:
- can minimise the effects of illness
- helps keep lives as ‘normal’ as possible, now and in the future.
Possible complications of arthritis
Frozen joints
Arthritis-affected joints that are not kept mobile can stiffen into abnormal positions and then will no longer work properly. This can also lead to joint damage and severely restrict your child’s ability to do most normal daily activities for the rest of their life.
A small number of children with JIA may need to have surgery if the damage to their joints becomes too severe or restrictive. This may include joint replacements, joint fusions, the realignment or reconstruction of damaged joints and surgery to release joints that have ‘frozen’. Your child’s rheumatologist can give you more information.
Osteoporosis
Children who have JIA are also more likely to experience a thinning of their bones as they get older. This is a condition called osteoporosis and it results in the bones being susceptible to breaking or fracturing.
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Treatment
Management of children with arthritis includes medicines to relieve pain, reduce inflammation and symptoms, and some medicines may also slow the progression of the disease.
Children with arthritis are often under the care of a healthcare team, headed by a rheumatologist. In addition to medicines, having a mix of activity and restful periods each day and incorporating suitable exercise, such as swimming to help muscles and joints, is also recommended.
Finding the best treatment options
There are many different treatments available for juvenile idiopathic arthritis (JIA). What works for one child may not work for another. Finding the right treatment for your child can involve a process of trial and error. While this can be frustrating for all involved, it is important you stick with the process to ensure your child gets the best possible treatment.
This process may need to be repeated if your child experiences a progression of the illness, a flare-up or just because their body has become used to a certain medicine and it no longer works as well as it did. Ultimate goals include putting the illness into remission and giving your child the greatest chance of entering adulthood with as little joint damage as possible.
The aim of any JIA treatment or management plan is to:
- reduce the symptoms (such as stiffness, pain and inflammation)
- enable your child to lead the most normal life possible
- slow or stop the progression of the illness.
Team approach
To achieve the best possible outcome, the management of your child’s arthritis will involve a team effort. This team may include:
- rheumatologist (paediatric)
- paediatrician
- GP
- physiotherapist
- occupational therapist
- ophthalmologist (specialist eye doctor)
- podiatrist
- dentist
- pharmacist
- counsellors
- teachers
- parents, brother and sisters, extended family.
The make-up of your child’s team will depend on the type of JIA, how active the disease is, what joints are involved, and how the illness is impacting on your child’s wellbeing. Your child’s rheumatologist will usually coordinate this team, but other team members may also recommend specialist or healthcare professionals they feel would help your child.
Exercise and play
Exercise is important for good health in all children, including those with JIA. However, the wrong exercises can result in increased pain, and cause further joint damage. Your child’s doctors and therapists can advise you on suitable exercises.
Swimming can be excellent as the buoyancy provided by the water takes most of the weight off the painful joint, and allows greater freedom of movement. Swimming can improve muscle strength and joint movement. Added to this, in water your child doesn’t feel as if they are exercising. It’s fun and they can do it with friends and family. Warm water pools or spas are best as the warm water also helps the muscles relax.
Overall, your child should be encouraged to live their life as normal as possible. This helps increase their self-esteem and feelings of control over their illness. Bad experiences do not always mean you should stop any particular activities. Talking with your child about possible changes is always recommended. This shared decision-making adds to the child’s feelings of control over the disease and their commitment to the path ahead. Ideally, the eventual goal is to teach the child to manage their own illness.
Rest periods
JIA can cause tiredness, so it is important your child gets rest, including a good night’s sleep and maybe a rest period during the day.
Rest does not necessarily mean lying in bed. Rest can be listening to music, reading a book, drawing a picture or any other non-physical activity. Alternating between active and passive activities throughout the day can help your child to participate in their normal daily routines.
Medicines
Medicines play a major role in the management of JIA. Some are tablets taken by mouth, while others are given as an injection. In some cases the injection may be directly into a joint. Medicines are an important part of the treatment of JIA and your child may need to take more than one type of medicine.
Prescription medicines
Most medicines will need to be prescribed by your child’s doctor. But some, such as simple pain relievers, may be purchased at a pharmacy or supermarket (over-the-counter products).
Medicines used to treat JIA aim to:
- alter or slow the progression of the illness
- control inflammation
- relieve pain
- reduce fever
- reduce other symptoms of the disease
- assist in the maintenance of your child’s ‘normal’ growth.
As a parent you may feel anxious about the prospect of your child taking these medicines. Your child may not want to take these medicines either, particularly when their symptoms improve. However, many of the medicines used today not only reduce the symptoms but also slow the progress of the illness. For these medicines to be effective, it is important they are taken exactly as your child’s doctor prescribes. Many of them need to continue even when the child’s symptoms improve, so they maintain the improvement and also lessen the risk of damage to the joints.
Like all medicines, they can have side effects. These are usually easily recognised. While your child is on these medicines, the doctors will be closely watching for any of these side effects. To make sure any potential problems are detected and rectified as early as possible, your child may need to have regular tests, such as blood tests.
You should always tell your child’s doctor about any new symptoms or changes in your child, as well as anything else that concerns you.
Non-prescription medicines
Some medicines can interact with other medicines. It is important you tell each doctor or healthcare professional your child sees about each and every medicine they are taking, even if the medicine is not being used to treat their arthritis. This also includes any medicine available without prescription, such as over-the-counter pharmacy medicines, natural, herbal and complementary medicines.
All medicines have benefits as well as side effects, but, without medicines, permanent joint damage and a poorer prognosis is more likely.
Finding the right medicine
Until recently, the medicines available to treat JIA have been limited. However, new medicines are now being developed so that doctors have a much larger choice. As JIA can vary greatly from child to child, the larger number of available medicines means doctors are now better able to manage each child’s specific symptoms over tine. The downside is it can take longer to find the best medicines for your child.
The type of medicine(s) recommended for your child will depend on a number of factors, including:
- type of JIA
- severity of the illness
- child’s ability to tolerate the medicine.
Most common types of medicines used to treat JIA
- pain relievers (analgesics)
- non steroidal anti-inflammatory drugs (NSAIDs)
- disease modifying anti-rheumatic drugs (DMARDs)
- corticosteroids
- biological medicines.
Pain relievers (analgesics)
Analgesics are medicines that can relieve mild to severe pain by blocking pain signals from being sent to the brain or by preventing the brain from receiving or working out what these signals mean.
These medicines do not relieve the inflammation present in JIA.
Analgesics for milder pain are available as non-prescription (over-the-counter) brands. In case of severe pain, your doctor will prescribe a pain relief medicine. Your doctor can also advise you which analgesic medicines are appropriate for your child. Analgesics are generally well tolerated.
NSAIDs
NSAIDs (non steroidal anti-inflammatory drugs) are a widely prescribed group of medicines for JIA. They can have significant advantages over analgesics because they can relieve both the inflammation and consequently the pain around the joint. However, NSAIDs do not slow the progression of the illness or reduce the risk of joint damage.
As everyone reacts differently to medicines, your child may need to switch to a different NSAID to find the one that best controls their symptoms with the least side effects. Your doctor or pharmacist can advise you on how these medicines may affect your child.
DMARDs
DMARDs (disease modifying anti-rheumatic drugs) can slow or inhibit the progression of JIA. Although researchers don’t fully understand how some DMARDs work, they believe they hinder the immune system’s attack on joint tissues, which in turn may slow the destruction of joints.
DMARDs are often used as an initial treatment for JIA – in combination with an NSAID. Like NSAIDS, the DMARDs do not stop pain mechanisms, but they do act against the underlying inflammation – and so indirectly reduce levels of pain. It can take several weeks for DMARDs to reach their maximum effectiveness – your child’s rheumatologist can discuss this with you.
Corticosteroids
Corticosteroids are man-made forms of the naturally occurring hormones produced by the body. They can provide rapid and powerful reduction of pain and inflammation for children with arthritis.
Steroids are sometimes injected directly into the joints for local relief during flare-ups. Steroids are usually prescribed in low dose in tablet form. This type of steroid is quite different to the other types of anabolic steroids used in bodybuilding.
Biological medicines
Unlike the older, more traditional DMARDs, biologic medicines have been developed specifically for the treatment of arthritis. They are injected just below the skin or can be injected directly into a vein using a slow infusion (a specialised infusion bag on a stand).
Biologic medicines (eg, etanercept) work by directly targeting the inflammatory process that has become over-stimulated and is attacking the joints. Your doctor will be able to give you more information about biologic medicines and when their use is suitable in JIA.
Knowing about the medicines
For each medicine prescribed, you child’s rheumatologist should talk to you about:
- risks and benefits
- what the medicine is called
- why the medicine is needed and how it can benefit your child
- how it works
- how the medicine should be taken (dose, frequency, etc)
- what side effects it may have and what to do if they occur
- what tests (if any) are needed while taking this medicine
- how long it takes to achieve the maximum benefit
- how long your child will need to stay on the medicine
- when and how the doctor will review the progress of the medicine.
If you do not feel you are fully informed about any of the points above and you have other questions or concerns about the medicines being used by your child, don’t be afraid to discuss these with the doctor who prescribed the medicine.
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