A term referring to a variety of conditions characterized by inflammation of one or more joints.
Arthritis is commonly regarded as a disease of the elderly, but there are several varieties that primarily affect children, including juvenile rheumatoid arthritis, infectious arthritis, and juvenile ankylosing spondylitis.
Juvenile rheumatoid arthritis (JRA)
The most common form of arthritis in children is juvenile rheumatoid arthritis, also known as JRA or Still's disease. Affecting over 65,000 young people in the United States—roughly 1 in 1,000—it can affect children as young as two years old. The condition occurs in "flareups" that can last from a few weeks to several years, alternating with periods of remission. JRA, like other types of arthritis, is thought to be an autoimmune disease, in which antibodies that are supposed to protect the body from foreign invaders turn against its own tissues, primarily the joints. The synovium, a thin membrane surrounding the joints, becomes inflamed, swelling and producing too much fluid. The results are pain, swelling, and stiffness, as well as warmth and redness of the skin. Genetic factors can also play a role in the disease. Its onset—or succeeding flare-ups—can be triggered by infection, injury, or emotional stress. Birth defects and diet are not thought to be connected with the disease. There are three types of JRA: pauciarticular onset JRA, polyarticular onset JRA, and systemic onset JRA.
Pauciarticular onset JRA, the least serious type, affects 45% of children who have JRA. Four or fewer joints are involved, and each joint is affected on only one side of the body (i.e., one knee instead of both). Often the affected joints are large ones, such as a knee, hip, or ankle.
A small percentage of children with this condition develop an eye inflammation (iritis). Other symptoms include gradual weight gain and fatigue. Pauciarticular onset JRA is usually found in girls under the age of 10 years.
Polyarticular onset JRA affects five or more joints, either large or small, on both sides of the body. About 25% of children with JRA have this more serious form of the disease. It often affects the joints of the hands and fingers. Like pauciarticular onset JRA, it is accompanied by an intermittent low-grade fever, which is generally worse in the evening. Children with this type of arthritis are usually older than those with the pauciarticular onset variety. Other symptoms include a rash, enlarged lymph nodes, and subcutaneous nodules (painless movable lumps under the skin that last up to a few months and then disappear). In addition, children with polyarticular onset JRA—like adults with rheumatoid arthritis—often have an RH factor (rheumatoid fator) in their blood. The disease is generally more severe in people with this "RH positive" factor: the symptoms are worse and the joint damage more severe and long-lasting.
Systemic onset JRA is the most serious form of juvenile rheumatoid arthritis. It affects numerous joints as well as other organs, possibly including the liver, spleen, kidneys, lungs, and lymph nodes. It is also accompanied by serious anemia and a high ("spiking") fever that rises to between 103-105°F (39-41 °C) for several hours once or twice a day. Another characteristic symptom is a distinctive salmon-colored rash with irregular borders that can move from one part of the body to another within minutes. This form of JRA can also affect the pericardium (the sac around the heart), causing inflammation and a buildup of fluid.
Treatment
Treatment of juvenile rheumatoid arthritis consists of a combination of medication and physical therapy, which can help control the symptoms and prevent further damage but cannot actually cure the disease itself. In many cases, the preferred medication is aspirin in large doses, which decreases the extent of the inflammation. However, side effects rule out this course of treatment for one out of every six children with JRA. Fortunately, a number of other medications belonging to the same general type as aspirin (nonsteroidal anti-inflammatory drugs—NSAIDS) are available to combat the effects of JRA. These include ibuprofen (Advil, Motrin, etc.), Tolectin, Naprosyn, Feldene, Nalfon, and others.
For serious flare-ups that do not respond sufficiently to NSAIDS, various other medications may be used. Cortisone, given orally or as an injection at the site of inflammation, achieves the most dramatic improvement but is used with caution and generally only as a last resort due to potentially serious side effects and the fact that increasingly larger doses are needed in order for the drag to retain its effectiveness. Several slower-acting antirheumatic drugs, including gold salts, d-penicillamine, and hydroxychloroquine, work over a period of months to stop the breakdown of joint tissue. Methotrexate, a commonly prescribed cancer medication, has been effectively used as a fast-acting drag for severe cases of JRA.
Physical therapy is an important part of the treatment for JRA. In the past, children with JRA were kept in bed, sometimes in full body casts, leading to muscle and joint atrophy, as well as other problems—both physical and emotional—caused by immobility and isolation. Even if the arthritis itself was outgrown in adulthood (as it often is) the person was left with lifelong deformities that could only be treated by joint replacement. Today physicians and therapists regard this type of long-term damage as largely preventable through exercise—which strengthens and stretches the muscles surrounding the affected joints to prevent them from becoming weak, tight, or shorter from lack of use, and can also prevent a potential bone deformity called contracture. Although exercising can be painful and difficult for a child with stiff and swollen joints, it is extremely important to maintain a regular exercise schedule, either at a physical therapy facility or at home (or a combination of both). Several different types of exercise are helpful. Active exercise, consisting of activities such as knee bends, sit-ups, and toe-touching, strengthens the muscles. Passive exercise, in which another person moves the child's muscle groups through a range of motions, such as flexing and extension, helps maintain flexibility and prevents shortening of the muscles. Strength can also be attained through active resistive exercise in which the child moves a part of the body against resistance from another person. Aerobic exercises such as bicycling, swimming, and using rowing machines help maintain endurance. Swimming, as well as other forms of underwater exercise, are especially recommended because they relieve the joints of weightbearing pressure.
Although exercise is an indispensable part of the treatment for juvenile arthritis, daily periods of rest are also required. As a further treatment measure, heat is applied to relax muscles and help loosen stiff joints. Heat can help children with JRA through the period of morning stiffness they usually experience, and it can reduce pain and spasms from exercise. Moist heat may take the form of a warm bath, whirlpool, hot tub, hot pack, or heated paraffin bath. Saunas, ultrasound, sleeping bags, and diathermy (electrically produced deep heat) are effective sources of dry heat. Heated water beds can also provide comfort for a child with JRA. Some physicians have JRA patients wear a splint or brace to prevent deformity.
Often, the brace is worn only at night to decrease interference with daily activities.
School-age children with JRA
Most children with JRA continue to attend school, although some amount of flexibility is necessary on the part of the school and the teacher. Many children with JRA have a hard time moving about early in the day due to morning stiffness and may also need special permission to walk around the classroom for short periods from time to time to avoid further stiffness from inactivity during the day. In other cases, they may need to be excused from certain activities, especially sports involving those joints affected by the illness, and may also need to be excused for periods of rest during the school day. Children and adolescents with JRA want and need to participate as much as possible in ordinary activities both in and out of school. In many cases they don't want to tell others about their illness for fear of seeming different from their peers. Counseling can help children with JRA, as well their families, cope with the emotional strain caused by the condition. Many adolescents have been helped by participation in support groups run by local chapters of the Arthritis Foundation.
In approximately 75% of JRA patients, the disease goes into permanent remission by late adolescence or early adulthood. With systemic onset JRA, affected organs such as the liver or spleen do not suffer permanent damage from the condition, and the rash and spiking fever are gone within five years or less. Once the systemic symptoms are over, this type of JRA generally turns into one of the other two types. Children with polyarticular onset JRA are more prone to permanent damage and loss of function than those with the pauciarticular form. It is especially important for these children to follow a regular exercise program to minimize any long-term effects of the disease.
Infectious arthritis
Arthritis in children can be caused by viruses, fungi, or bacteria (usually staphylococci or streptococci) that lodge in a joint. Lyme disease, which is carried by an infected tick, is a form of infectious arthritis. Both infants and older children can contract infectious arthritis. Common symptoms, like those of juvenile rheumatoid arthritis, are pain, swelling, and inflammation of the joints. When the hip joint is involved, as is frequently the case, extensive damage can result, so prompt diagnosis and treatment are essential. The condition is treated with antibiotics and drainage of the affected joints. Arthritis that results from viruses such as influenza, mumps, or hepatitis, usually clears up spontaneously when the infection is over. Symptoms may be treated with aspirin and other anti-inflammatory medications.
Juvenile ankylosing spondylitis
Juvenile ankylosing spondylitis primarily affects the spine, although it may first attack the joints and be mistaken for JRA. It is more common in boys than girls and tends to be inherited. Like JRA, treatment can only ease the inflammation and prevent eventual deformity rather than cure the disease itself.
American Juvenile Arthritis Foundation Address: 1314 Spring Street, N.W.
Atlanta, GA 30309 Telephone: (404) 872-7100
(Publishes AJAO Newsletter quarterly.)
The Arthritis Foundation Address: 1314 Spring Street, N.W.
Atlanta, GA 30309 Telephone: toll-free (800) 283-7800.
