Juvenile rheumatoid arthritis is a chronic joint disorder that affects children or young person, resulting in painful joints and limited range of motion. Besides affecting the overall health physically, it can also have a negative impact on the child emotions or their social development, parent-child relationships, tendency of over-dependence and other factors.
Though usually medications can help in symptomatic relief, occasional flare-ups can still happen due to their changes in their life stages, lifestyle, eating habits or even psychological factors. As such, JRA as compare with arthritis in adult patients is a far more complex issue.
What Is Juvenile Rheumatoid Arthritis (JRA)
It can be defined as inflammation of the joints in children under 16 years of age for six weeks or longer. It is characterized by pain, swelling and stiffness of different joints. If not treated properly, it can results in serious joint damages. It is also known as juvenile idiopathic arthritis (JIA) and still`s disease.
Classifications Of Juvenile Rheumatoid Arthritis
Juvenile rheumatoid arthritis is mainly classified into 3 types.
- Pauciarticular or Oligoarticular: 50% of the cases fall into this category. Generally, only few joints are affected and mostly girls who are under below 8 years are more likely to be affected. This disease runs a mild course and may also disappear altogether. In some cases, the eyes may be affected and requires treatment from an eye specialist.
- Polyarticular: This type affects five or more small joints on either side of the body. It is more common in girls and forms 30% of the cases. Besides, it can also affect the large joints.
- Systemic: It forms 20% of the cases of juvenile rheumatoid arthritis. At least one joint is affected, but there are other systemic symptoms like rash and inflammation of internal organs like the heart, liver, spleen and lymph nodes. High fever may be experienced for more than 2 weeks. This type of JRA may continue into adulthood if not treated properly.
Prevalence Of Juvenile Rheumatoid Arthritis
The worldwide prevalence of the disease is estimated to be about 1 to 6 per 10,000 population with marginal variations between countries.
Risk Factors Of Juvenile Rheumatoid Arthritis
- Girls: They are more likely to get JRA than boys. The exact reason is not known.
- Family history of eye disorders: It could be linked to the chronic inflammatory nature of the disease as in JRA.
- Arthritis of the back (ankylosing spondylitis): There could be a link to the autoimmune nature of the disease which is also implicated in JRA.
- Inflammatory bowel disease: It is characterized by chronic inflammation of the bowels which could be linked to the joint inflammation also.
- Family history of psoriasis: It could be linked to autoimmunity as in JRA.
Causes Of Juvenile Rheumatoid Arthritis
- Autoimmunity: JRA is thought to be an autoimmune disease where the body attacks its own cells and tissues.
- Genetic: It is believed that some children have genes that make them more susceptible to get the disease.
- Viral origin: It is suspected that some virus in the environment acts as a trigger to provoke the disease in children by altering the immune response.
- Idiopathic: The exact cause of the disease is not known.
Signs And Symptoms Of Juvenile Rheumatoid Arthritis
Juvenile rheumatoid arthritis can affect any joint in the body, large or small. The joint becomes inflamed (swollen) and stiff. There is pain, and movements are restricted. In many cases the symptoms are mild and do not progress. However in severe cases it can cause serious joint and tissue damage and also affect bone development and growth.
About half of the children will continue to suffer from active arthritis over a long time, unless they receive proper treatment. Children who have the antibody called IgM rheumatoid factor (RF) in their blood have a more severe form of the disease. The symptoms differ with the type of disease. In the pauciarticular type, only one joint is usually affected. The arthritis is mild and the symptoms may lessen over time and may eventually disappear. The eye may be affected which needs specialist treatment.
In the polyarticular type, five or more smaller joints are affected on both sides of the body. It runs an indolent course and needs continuous monitoring. In the systemic type, there is swelling, pain and limited motion in at least one joint. In addition there is high fever, rash and inflammation of the internal organs of the body like the heart, liver, spleen and lymph nodes lasting for two weeks or more. This is the most severe form of the disease and needs aggressive treatment.
Other arthritic diseases affecting children:
- Rheumatic arthritis: It is caused due to hypersensitivity to infection by streptococcus bacilli usually of the throat. It is a fleeting, polyarticular type of arthritis which passes away without residual damage. However the heart may be affected severely.
- Reactive arthritis: Children who have suffered from diarrhoea may develop a form of arthritis usually involving one or two large joints, which usually passes away after a few days.
- Psoriatic arthritis: Those children who are suffering from the skin disease called psoriasis may suffer from arthritis of the associated joint. Usually, the treatment is directed at the primary disease (psoriasis) which helps in resolving arthritic joints.
- Septic arthritis: Children who suffer an injury near a joint can develop this serious disorder due to infection of the joint. However, it required aggressive medical treatment.
- Lyme disease: This is caused by a tick bite and confined to certain areas only.
Diagnosis Of Juvenile Rheumatoid Arthritis
A complete medical examination including the history, physical examination, blood tests and x-rays would help the doctor in diagnosing and confirming the condition.
- History: A family history of autoimmune diseases provide clue as to the nature of the arthritis. A chronological description of events, the joints affected, symptoms of pain, swelling and stiffness is usually prompt by the doctor during the consultation.
- Physical Examination: The joints are examined for swelling, tenderness and range of motion. Besides, the muscles near the joints are also examined for atrophy (shrinkage).
- Laboratory Tests: The blood is tested for the presence of RH factor in addition to the routine tests. The joint and tissue fluids are also tested. These tests would help rule out other types of arthritis and can also be used to classify the disease.
- X-rays: The x-rays provide clear images of the bones and help in the diagnosis.
- MRI Scan: This is an advanced tool which can delineate the inside of any joint.
Treatment For Juvenile Rheumatoid Arthritis
Generally, the treatment regime of JRA involves a combination of the following:
- Medical Management: It consists of the following medications given under supervision.
- Non-steroidal anti-inflammatory drugs (NSAIDs): They are often the first type of medications given. These are usually ibuprofen or naproxen and are used primarily to reduce inflammation and relieve pain.
- Disease-modifying agents: If NSAIDs do not relieve the symptoms, the disease-modifying drugs will help slow the progression of the disease. The most commonly used drug is methotrexate. Azulfidine is prescribed sometimes and it has to be taken under strict medical supervision.
- Biologic agents: They are a new class of drugs that slow or stop the progression of the disease. These are usually used only if the disease-modifying drugs are not effective or the patient has arthritis of the sacroiliac joint.
- Corticosteroids: They are strong medications and are used in treating severe juvenile arthritis. Given by mouth (orally) or injected into a vein (intravenously), corticosteroids can reduce serious symptoms. Corticosteroids may be injected directly into the joint. Corticosteroids, however, can cause unwanted side effects such as interfering with a child’s growth and weight gain. They can weaken bones, and increase the susceptibility to infections. Hence they should be used judiciously.
- Surgical treatment
Surgery is usually not indicated in JRA, but may be used occasionally to correct deformity. Joint replacement has no role to play in this condition.
- Physiotherapy and assistive devices
- Exercise: It helps maintain muscle tone and help recover joint range of motion and function. Swimming is a particularly good exercise because it uses many joints and muscles, without putting weight on the joints.
- Splints or orthotics: Splints are useful in children with juvenile rheumatoid arthritis, either at night or during the day, to reduce inflammation and prevent contractures.
- Self-management: This usually involves the parents and the child in learning the strategies to cope with the pain, physical limitations and how to manage the disease. This provides a good opportunity for bonding as well.
Complications Of Juvenile Rheumatoid Arthritis
If proper treatment is not administered, the following complications can occur:
- Muscles and other soft tissues around the joint may become weak.
- Some children may develop growth problems. Joints may grow too fast or too slowly, unevenly or to one side.
- Some children may develop an eye problem called iridocyclitis. This is treatable by an ophthalmologist (eye specialist).
Living With Juvenile Rheumatoid Arthritis
Living with juvenile rheumatoid arthritis is a challenging issue and is never easy. Besides the physical and emotional impact on the child, parent’s emotions are usually affected due to stress, frustrations and tiredness.
Common negative emotions of a child with JRA include:
- Easily frustrated or angry over minor issues.
- Become isolated from siblings in the family or friends in the school.
- Sudden mood swings.
- Trying to gain special attention by acting childish or make unreasonable demands through crying.
- Lack of confidence and become withdrawn in their daily activities.
Common negative emotions experienced by parents include:
- Become tense or stress up due to the uncertainties of the child condition.
- Feeling of guiltiness as they blame themselves for not taking good care of the child.
- Parents can become isolated, quiet and feels alone.
- Frustrations or angry usually due to their little knowledge of the disease.
- Emotional and physically drained while taking care of the child.
- Feel helpless and at times thought of giving up.
- Relationships between parents may become strained when they start blaming or pushing the responsibility to each other.
Generally, though it is a difficult task for parents and the child to live with the disease, it is still possible with some of the following tips below:
- Parents need to be positive and give encouragement to the child.
- Knowledge is everything. Parents must be proactive in getting information of the disease and learn how to manage the child symptoms, pain or other emotional issues.
- Try to get whole family involvement in the usual activities just like before. Having a child with JRA does not mean you have to make major changes to the family lifestyle.
- Be patience and explain to the child about the disease and it does not make him or her different from other kids.
- Try to organize activities or events involving his or her classmates, neighbors or friends. Provide assurance to the child that life still goes on as normal with no major changes. Parents can also take this chance to interact with other parents who can provide a listening ear or support.
With proper treatment and management of the disease, most children with juvenile rheumatoid arthritis progress normally through their growing years. A majority of them are independent and responsible of the disease in their adult life. However, this can only be achieved with an on-going process of managing, preparation, planning and organizing starting from their childhood.