Dr Ajesh Maharaj
Rheumatologist
Westville - Durban

MB.BS.IMS.BHU(Varanasi);
H.Dip.Int.Med(SA);
FCP(SA) Cert in Rheumatology(SA)

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Juvenile Idiopathic Arthritis

Arthritis in Children

Parents are frequently surprised to know that children can get arthritis. They are also often told that there is very little which can be done, but this is un-true as these days a great deal of help is available.

What is Arthritis?

A joint is where two bones meet and allows movement. A membrane called the synovium, which secretes a lubricating fluid, lines the joint space. Arthritis is an inflammation of this lining membrane.

When the synovium becomes inflamed, it causes pain, redness, heat, swelling, and loss of function. It is thus similar to inflammation in any other part of the body such as tonsillitis or appendicitis. It may be acute, (severe and sudden) or chronic (slow and lasting a long time).

There are thus two large groups of arthritis:
A - Acute
B - Chronic

Acute arthritis in children is usually associated with a bacterial infection, which leads to blood poisoning, (septicaemia) and bone infection (osteitis) This is a very serious infection and the child is severely ill.

Early treatment with antibiotics and sometimes surgery is essential. Occasionally arthritis may follow viral infection. (German measles)

Chronic arthritis is much less dramatic, the parent often becoming aware that the child is off-colour, has swelling of a joint/joints and is walking with a limp or may be very stiff in the mornings.

Today we call any chronic arthritis in children under the age of 16 years, that lasts longer than six weeks, Juvenile Idiopathic Arthritis (JIA). In the past this was called Juvenile Chronic Arthritis (JCA) or Juvenile Rheumatic Arthritis (JRA). It can occur at any age and girls are more often affected than boys.

Types of Juvenile Idiopathic Arthritis (JIA)

Idiopathic means that we do not know the cause, but various types are recognised and this determines the long-term outcome and the type of treatment. A Paediatrician or Rheumatologist will do various tests to try to sort out what type of arthritis the child has.

There are four major types of JIA, which depend on the number of joints involved and the results of certain tests.

Blood tests and x-rays are necessary as there is no single test, which makes the diagnosis. It will be a combination of the history, examination, special investigations and the response to treatment that will help to classify the type of arthritis. This is very important in deciding what treatment the patient will need and what the ultimate outcome will be.

Treatment

A range of different medicines is used in JIA:

Non Steriodal Anti Inflammatory Drugs (NSAIDS) e.g Brufen, Voltaren, Celebrex which help to dampen down the inflammation. There are a large number of these drugs on the market and the doctor will have to find the one that suits the patient best.

Cortisone

If the inflammation is more severe, Cortisone (Prednisone) may need to be injected into the affected joints or Prednisone given by mouth. In many cases, disease modifying anti-inflammatory drugs may be needed (DMARDS). Most important of these is Methotrexate. This medicine is potentially toxic and is thus given only once a week, but is one of the most powerful drugs to control joint inflammation. Extra vitamins are often prescribed and regular blood tests are necessary to keep a check on the progress of the disease.

Biologics

When conventional medicines fail to control disease, biologics offer a very real hope of remission and prevention of deformity for all. These are drugs which work in children, parents should visit their rheumatologist to discuss if and when they they might be needed.

Biologics can be effective in 1-2 weeks, but because of their excessive cost:-

  1. They are not available within the public health service.
  2. Very early use of methotrexate can modify the disease significantly and preclude the need for biologics which would only be used in non responders. Speak to your Doctor about the advisability and affordability of ‘biologics’ for your child.

Antibiotics play no role in the management.

As the condition is chronic, treatment is for a very long time, often many years.

There is no cure for arthritis. But the body has a natural tendancy for the inflammation to resolve spontaneously. The medical treatment helps to hasten the process and prevent joint destruction and deformities.

Some children develop eye complications with their arthritis and regular eye examinations are necessary.

Referral to a Physiotherapist and an Occupational Therapist is very important to help with pain relief and muscle strengthening exercises and thus cope with everyday life.

Splinting, heat treatment, electrical therapy may all be helpful to relieve pain and prevent deformities. Schooling is important and the teacher should be part of the management team. Participation in all school activities should be encouraged.

Surgery (such as joint replacement) is seldom needed in the childhood age range, but it may be done when the patient has stopped growing.

Outcome

Most children get over the arthritis, but this may only be after some years of treatment. Quite a number of the children may be left with some form of handicap. Unfortunately there are a small number of children who never recover and are left with severe disabilities. Early accurate diagnosis and treatment is thus very important.

Every patient can be helped

Parents may wish to contact:-

  1. Arthritis Foundation: Membership entitles you to useful information, educational material, leaflets, books etc. Regular meetings are held and lectures given to help sufferers with arthritis.
  2. The Association for the Physically Disabled is willing to make its resources available in the form of useful appliances, swimming and art classes, career guidance, training centre facilities and general support.