Childhood Juvenile Arthritis 

It may begin with  a swollen knuckle, a spiking fever, or an unexplainable rash. But no matter what symptoms appear, hearing the word "arthritis"  in a diagnosis for your child can be unexpected and confusing. 

Arthritis is an inflammation of the joints that is characterized by swelling, heat, and pain. Nearly 300,000  children in the United States have some sort  of arthritis. Arthritis can be short-term — lasting for just a few weeks or months, then going away forever — or it can be chronic and last for months or years. In rare cases, it can last a lifetime. 

The most prevalent form of juvenile arthritis is juvenile rheumatoid arthritis, or JRA.  It affects approximately 50,000 children in the United States. JRA also called juvenile idiopathic arthritis (JIA) because it is very different from adult rheumatoid arthritis. 

What Causes JRA? 

It's not known exactly what  causes JRA in kids. Research indicates that it is an autoimmune disease. In autoimmune diseases, white blood cells lose the ability to tell the difference between the body's own healthy cells  and harmful invaders like bacteria and viruses. The immune system, which is supposed to protect the body from these harmful invaders, instead releases chemicals that can damage healthy tissues and cause inflammation and pain. 

To effectively manage and minimize the effects of arthritis, an early and accurate diagnosis is essential. By understanding the symptoms and characteristics of each type of JRA, you can help your child maintain an active, productive lifestyle. 

Types of Juvenile Rheumatoid Arthritis 

Typically, juvenile rheumatoid arthritis appears between the ages of 6 months and 16 years. The first signs often are joint pain or  swelling and reddened or warm joints. Many rheumatologists (doctors specializing in joint disorders) find that the greater the number  of joints affected,  the more severe the disease and the less likely that the symptoms will eventually go into total remission. 

The three major types of juvenile rheumatoid arthritis are: 

• Oligoarticular JRA,  which affects four or fewer  joints. Symptoms include  pain, stiffness, or swelling in the joints. The knee and wrist joints  are the most commonly affected. An  inflammation of the iris (the colored area of the eye) may occur with or without active joint symptoms. This inflammation, called iridocyclitis, iritis, or uveitis, can be detected early  by an ophthalmologist. 
• Polyarticular arthritis,  which affects more girls than boys. Symptoms include swelling  or pain in five or more joints. The small joints of the hands are affected as well as the weight-bearing joints such as the knees, hips, ankles, feet, and neck. In addition, a low-grade fever may appear, as well as bumps or nodules on the body on areas subjected to pressure from sitting or leaning. 
• Systemic JRA,  which  affects the whole body. Symptoms include high fevers that often increase  in the evenings and then may suddenly drop to normal. During the onset  of fever, the child may feel very ill, appear pale, or develop a rash. The rash may suddenly disappear  and then quickly appear again. The spleen and lymph nodes may also become enlarged. Eventually many of the body's joints  are affected  by swelling, pain, and stiffness. 

Signs and Symptoms 

The first signs of arthritis can be subtle or obvious. Signs may include limping or a sore wrist, finger, or knee. Joints may suddenly swell and remain enlarged. Stiffness  in the neck, hips, or other joints can also occur. Rashes may suddenly appear  and disappear, developing in  one area and then  another. High fevers that tend to spike in the evenings and suddenly disappear are characteristic  of systemic juvenile rheumatoid arthritis. 

Diagnosis 

To diagnose JRA, the doctor will take a detailed medical history and conduct a thorough physical examination. The doctor  may order X-rays  or blood tests to exclude other conditions that can produce similar symptoms. 

Other tests that may be done include: 

• CBC (complete blood count), a common blood test used to evaluate all the basic cellular components of blood, including red blood cells, white blood cells, and platelets. Abnormalities in the numbers and appearances of  these cells can be useful in  the diagnosis of many medical conditions. 
• Blood culture, a test  to detect bacteria that cause infections in the bloodstream. This may  be done to rule out infections. 
• Bone marrow examination, a test that allows doctors to look at blood where it's formed (in the bone marrow) to rule out conditions such as leukemia. 
• Erythrocyte sedimentation rate, which checks how rapidly red blood cells settle to the bottom of a test tube. This rate often increases in people when inflammation is occurring in the body. 
• A test for rheumatoid factor,  an antibody produced  in the blood  of children with some forms of JRA. But it's much more commonly found in adults with rheumatoid arthritis. 
• ANA (antinuclear antibody), a blood test to detect autoimmunity. It's also useful in predicting  which children are likely  to have eye disease with JRA. 
• A bone scan, to detect changes in bone and joints to evaluate  the causes of unexplained bone and joint pain. 

In some cases,  the doctor may want an orthopedic surgeon to examine your child's joints and take samples of joint fluid or synovium (the lining of the joints)  for examination and testing. 

Doctors also may test for certain infections such as Lyme disease that may cause similar symptoms  or occur along with  the arthritis. 

Treatments 

In many cases, JRA may be treated with a combination of medication, physical therapy, and exercise. In specific situations,  your child may require injection of corticosteroids into the joint or surgery. Your child's health care providers, including the primary care physician, rheumatologist, and physical therapist, will work together to develop the best method of treatment. 

The goals of treatment are to relieve  pain and inflammation, slow down  or prevent the destruction of joints, and restore use and function of the  joints to promote optimal growth,  physical activity, and social and emotional development in  your child. 

Medications 

For inflammation  and pain, the doctor or pediatric rheumatologist may prescribe nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen (such as Advil or Motrin). These drugs may help reduce inflammation and pain by limiting the release of harmful chemicals from white  blood cells. 

Higher or lower dosages may be needed, depending upon your child's response  to the medication. The doctor or rheumatologist should explain  what the medication  is meant to do and what side effects, if any, your child may experience. It's important for your child to continue taking the medication until the doctor says to stop. 

If NSAIDs do  not control inflammation of the joints, your doctor may prescribe other medications such as methotrexate. You can also ask for information about newer treatments  that might be available. 

Physical Therapy 

An appropriate physical therapy program is essential in the management of any type  of arthritis. A physical therapist will explain the importance of certain activities and recommend exercises suited to  your child's specific condition. The therapist may recommend range-of-motion exercises to restore flexibility in stiff, sore joints and other exercises to help build strength and endurance. 

Regular Exercise 

When pain strikes, it's natural for  your child to want to sit still. But it's important to maintain a regular exercise program. Muscles must be kept strong and healthy so they can help support and protect joints. Regular exercise also helps to maintain range of motion. 

At home and at school, your child should maintain regular exercise and  physical fitness programs. Safe activities include walking, swimming,  and bicycling (especially on indoor stationary bikes). Always be certain  your child warms up the muscles through stretching before exercising. Making exercise  a family activity can increase  the level  of fun and enthusiasm. 

Consult  the doctor  and physical therapist about sports restrictions. Some, especially impact sports, can be hazardous to weakened joints and bones. In addition, make sure your child eats a balanced diet that includes plenty  of calcium to promote bone health.