Chronic (or long term) arthritis in children is more common than many people think, including many doctors. It occurs in one child in every thousand, which is slightly less frequent than diabetes. It is an inflammatory disease principally affecting the joints but may also affect other organs including the eyes.
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What are the symptons?
Inflammation within the joint causes:
- Thickening of the joint lining
- Release of toxic substances
- An increase in joint fluid
To the patient this means a swollen joint, pain and joint stiffness. Any joint may be affected and any number of joints at one time.
Stiffness and pain makes movement of a joint (or joints) difficult. If the knee, hip or ankle is involved there may be difficulty walking long distances or climbing stairs. Hand, wrist or elbow involvement may make prolonged writing and dressing difficult.
The degree of inflammation of arthritis fluctuates from day to day (see autoimmunity). Pain, stiffness and swelling may appear better or worse some days and may disapper altogether for a while. This may cause confusion for parents, teachers and family doctors not use to seeing children with arthritis.
Inflammation itself, plus pain and swelling, will affect a young person's mood, appetite and sleep. During bad periods a child may become lethargic and irritable. This may be further exacerbated by frustration.
Other effects of arthritis depend upon the:
- Joints involved
- Extent of the arthritis
- Form of the arthritis
There are similarities between JIA and the adult disease rheumatoid arthritis, but JIA has a different course and outcome in the long term.
What forms are there?
There are several forms of JIA. Their names are derived from the number of joints affected or associated features:
This is when 4 or fewer joints are involved. These are often large joints, such as the knee and ankle.
Oligo JIA is the commonest form of JIA and typically affects girls aged 2-6 years. Sometimes after 6 months or longer more than 4 joints become affected. In this case the arthritis is called extended oligioarticular JIA, but behaves like polyarticular JIA. It is not possible to predict in whom this will occur.
Eye inflammation is more common in oligoarticular arthritis and all patients must be seen by an ophthalmologist (eye doctor) on a regular basis. This will pick up eye inflammation (uveitis) early and prevent future problems with sight.
Patients who continue to have 4 or fewer joints affected commonly require less treatment than those whose diagnosis changes to extended oligoarticular JIA. From the teenage years onwards they may also have long periods of full remision. They may even grow out of it altogether.
Extended oligoarticular JIA often continues into adulthood, but modern treatments are good at controlling it.
This is when 5 or more joints are involved, including small joints of the hand and feet, the neck etc. Polyarticular disease tends to continue into adulthood, but treatment usually prevents long term harm.
In older girls, rheumatoid factor may be present in the blood denoting a more aggressive form of arthritis, although with modern treatment this does not mean a worse outcome. Far from it.
Enthesitis Related Arthritis
This typically affects boys older than 6 years of age. Girls may be affected.
Arthritis occurs in association with swelling of the tendons, especially at the insertion point of tendons into bones (enthesitis). Sites typical for enthesitis include:
- The heel
- The arch of the foot
- Around the hip
Commonly there is a family history of similar types of arthritis or other inflammation such as inflammatory bowel disease.
Enthesitis can be particularly uncomfortable and may be more difficult to treat than arthritis. It is especially important to monitor the hips and back although, with physiotherapy support, the outcome is usually good.
An MRI may be requested if inflammation of the back is suspected . Eye inflammation, called uveitis, may occur suddenly causing pain sufficiently severe to consult a GP or eye specialist urgently.
The patient or a close family member may have psoriasis or nail pitting. Psoriasis is a flaky skin condition that commonly affects the elbows, knees, scalp and forehead.
If there is arthritis of a finger or toe there is usually swelling of all joints of the digit, resulting in a sausage appearance.
This arthritis may also be associated with enthesitis and eye inflammation similar to that of enthesitis related arthritis (above).
This is where arthritis is associated with regular fevers and rash. The rash is often a pale pink and comes and goes. The fever tends to occur just once or twice a day with the child seemingly much improved in between times. Any number of joints may be involved.
In some patients this form of arthritis may only last a few months and never return. In others the inflammation may prove difficult to treat. In these patients, growth may be affected and the outer lining of the heart may become inflamed.
Arthritis associated with inflammatory bowel disease
This is similar to enthesitis related arthritis. It may occur many months or years before the bowel becomes involved. Outcome of joint inflammation is usually good once the bowel inflammation is controlled.
Examples include crohn's disease and ulcerative colitis.
Arthritis associated with other inflammatory diseases
May occur with lupus (SLE), vasculitis, Juvenile Dermatomyositis (JDM) or other inflammatory diseases.
How is it treated?
This depends on the extent of arthritis, including the:
- Number of joints involved
- Extent of the problems the patient is facing.
In all patients, physical therapy is as important as medication to ensure appropriate muscular support of the joints and comfortable movement.
We share information with our patients and their families so that they understand why we use certain treatments.
Coping with a chronic (long term) disease can also produce additional stresses on the patient and their family and talking through these and other problems with our psychologist may be helpful.
This is typically managed with steroid injected directly into the joint (intra-articular steroids). These injections greatly ease pain and stiffness and help physiotherapy to get the joint back to normal.
Simple medication such as ibuprofen is also commonly used. Repeat injections may be undertaken but it is felt that if control is not adequate it is likely that methotrexate or sometimes sulphasalazine will be used.
Uveitis is managed with steroid eye drops and sometimes steroid injections. If the inflammation of the eye is severe or failing to respond to eye drops, other oral medication (commonly methotrexate) is used.
See our A-Z of medicines for information about specific drugs.
It is recognised that early treatment with methotrexate is very beneficial and has revolutionised the outcome of JIA.
While waiting for methotrexate to take effect (upto 16 weeks) steroids are often injected into the joints. If there are a lot of joints involved sometimes steroids will be given via the vein (intravenous steroids) or by mouth (oral steroids) for a prolonged period. We always discusss the options available with our patients and their families.
Methotrexate can be given by mouth or by injection and the route chosen will depend upon patient preference and the severity of arthritis. If treatment with methotrexate is inadequate, the dose will be increased or the patient may be swapped to injectable form. Additional steroid injections may be required.
Patients who do not respond adequately to methotrexate will be offered the new Biologic therapies such as etanercept. Physical therapies remain ongoing throughout this period. The aim is always to minimise the potential for side effects whilst maximising the benefits.
See our A-Z of medicines for information about specific drugs.
Other Help & Support
We offer assistance in many other ways to ensure that the impact of arthritis on our patients' day to day activities and wellbeing is as small as possible. This may involve support for:
- Going on holiday
- Sporting activity, including PE
- Future planning including career
- Health promotion in terms of diet, alcohol, smoking
- Liaising with other medical services
What is the outcome?
The outcome for all forms of JIA has improved considerably due to the treatments we now use and the way we use them.
Some patients, especially those with oligoarticular JIA, may go into long term remission (grow out of the disease) during their mid teens.
It appears that most patients can expect a good outcome, growing up free of discomfort and with normal joint appearances.
By far the majority of patients can expect to live full and healthy lives enjoying sport and a full family working life when older. Furthermore for the few other patients there are new drugs coming online that are likely to help where current therapies may not.
What do I do if I suspect I/my child has JIA?
We recommend recording the symptoms and any event that may have occurred at the beginning. This may help your GP.
At the onset of joint swelling it is difficult to tell JIA from other forms of joint swelling. Within the first 4 weeks it is important that other diagnoses are considered including infection, bleeding into the joint and a reaction to a virus or other infection. Joint swelling may also be due to trauma.
If the joint swelling persists without obvious cause your GP may wish to refer you a paediatric rheumatology unit such as ours in Oxford. In the meantime pain and swelling can be treated by simple medication such as ibuprofen and further help can be given through the use of hot or cold compresses or warm baths.
We do not recommend stopping sport but a young person in pain or with stiffness will self-limit their own activity.
What happens upon referral to OxPARC?
We will send you an appointment to attend a clinic where you are likely to see several members of the team, including:
- Occupational therapists
- Nurse specialists
- Ophthalmologist (eye doctor)
- Paediatric rheumatologist (doctor)
We will assess not only the amount of inflammation and difficulty that you/your child is having but also the secondary effects of arthritis on effects on the eye.
In clinic, we supply written information from CHAA and ARC in the form of booklets. We have also added links to this website for further information.
If you find any information that you wish to discuss please let us know.