Diseases & Conditions

Juvenile rheumatoid arthritis

Juvenile rheumatoid arthritis (JRA) — which causes joint inflammation for at least six weeks in children 16 years old or younger — is the most common type of childhood arthritis. In most cases, symptoms of juvenile rheumatoid arthritis may fade after several months or years.

Juvenile rheumatoid arthritis can be complicated. There are several types of juvenile rheumatoid arthritis, classified based on the joints affected, symptoms and test results.

Treatment of juvenile rheumatoid arthritis focuses on preserving physical activity to maintain full joint movement and strength, preventing damage and controlling pain.

If you're a parent or caretaker, watch for signs and symptoms of juvenile rheumatoid arthritis, particularly in young children.

Symptoms depend upon the category of JRA, and the main categories of JRA are:

• Pauciarticular JRA. This affects four or fewer joints — typically larger joints, such as the knees. This is the most common form of JRA.
• Polyarticular JRA. This affects five or more joints — typically small joints, such as those in the hands and feet. Polyarticular JRA often affects the same joint on both sides of a child's body.
• Systemic JRA. Also known as Still's disease, systemic JRA affects many areas of the body, including joints and internal organs. This is the least common form of JRA.

Signs and symptoms of juvenile rheumatoid arthritis may include:

• Joint swelling, with pain and stiffness. This may be more pronounced in the morning or after a nap. Commonly it affects the knees and the joints in the hands and feet. Children may complain of pain, or you might notice them limping.
• Fever and rash. These can be associated with many medical conditions, but if they're persistent, they may signal systemic JRA. Fever and rash caused by systemic JRA may appear and disappear quickly.
• Swelling of lymph nodes. This sign may occur in children with systemic JRA.
• Eye inflammation. This problem, which occurs mostly in children with pauciarticular JRA, initially produces no signs or symptoms in most of those affected. Routine eye examinations are recommended because eye inflammation may result in blindness.

Like other forms of arthritis, JRA is characterized by times when symptoms are present (flares) and times when symptoms disappear (remissions).

Doctors believe that juvenile rheumatoid arthritis is an autoimmune disorder. This means that the body's immune system attacks its own cells and tissues. It's unknown why this happens, but both heredity and environment seem to play a role.

It may be that a virus or bacterium triggers the development of juvenile rheumatoid arthritis in children with certain genetic profiles. These genetic profiles are detected in some children with juvenile rheumatoid arthritis and are considered genetic markers for juvenile rheumatoid arthritis. However, not all children with the markers develop juvenile rheumatoid arthritis, and children without the markers can develop the condition.

Take your child to your primary care doctor if your child:

• Shows signs of joint swelling, stiffness or pain
• Limps for no obvious reason

Also, if your child has a fever of 102 F that persists for longer than two or three days, take him or her to the doctor. A fever that signals juvenile rheumatoid arthritis may come and go one or two times during a day and last a few hours each time. It's frequently noted in the afternoons or evenings.

After a diagnosis
If your child has received a diagnosis of juvenile rheumatoid arthritis, take him or her to your doctor regularly to monitor the development of the disease and its treatment.

Children with pauciarticular JRA need regular screening for eye inflammation. A child diagnosed before age 7 with pauciarticular arthritis should have his or her eyes checked every three months if a blood test shows the child is anti-nuclear antibody (ANA) positive. Anti-nuclear antibodies are proteins generally found in people who have connective tissue or autoimmune disorders, such as arthritis.

If your child is ANA negative, your doctor will recommend an eye screening schedule based on your child's risk of developing eye problems.

Treatment for juvenile rheumatoid arthritis focuses on helping your child maintain a normal level of physical and social activity. To accomplish this, doctors may use a combination of strategies to relieve pain and swelling, maintain full movement and strength, and prevent complications.

Medications
For some children pain relievers may be the only medication needed. Others may need help from medications designed to limit the progression of the disease. Typical medications used include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs). These medications, such as ibuprofen (Advil, Motrin, others) and naproxen (Aleve, Naprosyn), reduce pain and swelling. Because children can develop side effects such as bleeding and liver and stomach problems, be sure to use these medications under a doctor's supervision.

• Celecoxib (Celebrex). This drug is part of a class of NSAIDs known as COX-2 inhibitors, which are believed to be gentler on the stomach. The Food and Drug Administration has approved celecoxib for children age 2 and older with JRA. Celecoxib hasn't been studied in children younger than 2 and in those with the systemic form of the disease.

  Side effects may include cough, cold, upper respiratory tract infection, abdominal pain, headache, fever, nausea, diarrhea and vomiting. COX-2 inhibitors have been found to increase the risk of heart problems in adults. Studies are being conducted to determine whether celecoxib increases heart risks in children.

• Disease-modifying antirheumatic drugs (DMARDs). Doctors use these medications when NSAIDs alone fail to relieve symptoms of joint pain and swelling. They may be taken in combination with NSAIDs and are used to slow the progress of juvenile rheumatoid arthritis. Commonly used DMARDs for children include methotrexate (Rheumatrex) and sulfasalazine (Azulfidine).

  Side effects of methotrexate may include nausea, mouth sores and liver problems. Methotrexate may also lower the number of white blood cells in your blood, leading to an increased risk of infection. Side effects of sulfasalazine may include gastrointestinal problems, such as nausea, vomiting and diarrhea, as well as headache and sore throat.

• Tumor necrosis factor (TNF) blockers. These biologic response modifiers block an immune system protein called tumor necrosis factor, which acts as an inflammatory agent in some types of arthritis. By targeting this protein, TNF blockers can help reduce pain, morning stiffness and swollen joints. Two TNF blockers used for treating JRA are etanercept (Enbrel) and infliximab (Remicade).

  Some people experience side effects during or shortly after these drugs are injected, including chest pain, dizziness and difficulty breathing, as well as redness, itching and swelling at the injection site. Additional side effects of biologic response modifiers may include abdominal pain, headache, respiratory infections such as tuberculosis, and other infections. These medications may also increase your risk of demyelinating disorders, conditions that damage the protective covering (myelin sheath) that surrounds nerves in your brain and spinal cord.

• Corticosteroids. These prescription medications are for children with more severe juvenile rheumatoid arthritis. They're used to control symptoms until a DMARD takes effect or to prevent complications, such as inflammation of the sac around the heart (pericarditis). Corticosteroids, such as prednisone, may be administered by mouth or by injection. But they can interfere with normal growth and increase susceptibility to infection, and generally should be used for the shortest possible duration. Stopping long-term use of corticosteroids suddenly can be dangerous, so it's important to follow a doctor's instructions on usage.

Therapies
Your doctor may recommend that your child work with a physical therapist to help keep joints flexible and maintain range of motion and muscle tone. A physical therapist or an occupational therapist may make additional recommendations regarding the best exercise and protective sports equipment for your child. A therapist may also recommend that your child make use of special supports or splints to help protect joints and keep them in a good functional position.