Juvenile Arthritis.
Last updated Wednesday, December 22, 2004
Management and treatmentTreatment Many approaches to treating juvenile arthritis are available.
The goals of treatment for juvenile rheumatoid arthritis are to:
- control inflammation
- relieve pain
- prevent or control joint damage
- maximize functional abilities
To reach these goals, the treatment program usually includes:
- medications
- exercise
- eye care
- dental care
- healthy diet
Other types of treatment, such as surgery, may be necessary. Some
physicians have also found that pain can be lessened by combining
medical treatment with techniques such as progressive muscle
relaxation, meditative breathing, and guided imagery.
Health care team Your child's health care team may include different specialists who
work together to offer your child a complete treatment program.
Pediatric arthritis centers found in many major medical centers offer
this care in one location. If you do not live near such a center, your
child's physician will refer you to the specialists she needs.
Your child's regular doctor
Works with your child's pediatric rheumatology team to help your
child. If you do not live near a pediatric rheumatology center, this
doctor can consult by telephone with the nearest center. The doctor who
already knows your child's medical history is usually the best person
to see first. This doctor can work with general medical problems, such
as colds or normal childhood ailments.
A doctor who specializes in childhood arthritis
If you live near a pediatric arthritis center, your regular doctor
may refer you for a consultation, or for continuous care. Board
certification of pediatric arthritis specialists began in 1992. If
there is no Board-eligible or certified pediatric arthritis specialist
in your area, your doctor may refer you to an adult arthritis
specialist with experience and some training in the care of children.
Nurse
Often serves as the link between the patient, the physician, the
school, and other members of the health team to coordinate care.
Provides additional education about JRA, its treatment, and resources.
Physical therapist
Helps with mobility problems. Measures joint motion and strength and
prescribes special exercises, leg splints, shoes or other assistive
devices to make walking and moving easier.
Occupational therapist
Helps with hand and arm function. Measures arm motion and strength
and prescribes special exercises, hand splints, or other assistive
devices to help with daily living skills such as dressing, bathing or
writing.
Medical social worker
Helps with the personal, emotional, family, or financial problems which may occur with any chronic disease.
Ophthalmologist
Checks for signs of eye problems and treats eye disease.
Pharmacist
Answers questions about medications and their side effects and cost.
Psychologist
Counsels on the emotional difficulties of JRA. May also give
psychological tests and help your child with her pain control program.
Dietitian
Assesses growth, teaches nutrition and meal planning, and prescribes special diets as needed.
Orthopedist (Surgeon)
Specializes in diagnosing and treating diseases of bones and joints and performs joint replacements if needed.
Dentist, Orthodontist, Oral Surgeon
Specialists in dental care who can help if arthritis in the
temporomandibular joint results in a small jaw with crowding or
deformation of the teeth.
Psychiatrist
A medical doctor who can assist with emotional problems. Diet Children with JRA sometimes have nutritional problems associated with their illness such as:
- lack of appetite leading to weight loss and poor growth in height
- excessive weight gain
Although there is no special diet for children with arthritis, and no special foods that will cure the disease, proper nutrition
can improve your child's overall health and promote normal growth. A
registered dietitian can help you make sure your child eats properly by
teaching you ways of improving your child's diet.
Poor appetite
Loss of appetite often occurs when a child is in a flare. Some children
with JRA might feel too sick or too tired to eat. To help your child:
- Encourage her to eat a well-balanced diet at
regular meal intervals and include planned snacks even when she may not
feel much like eating.
- Try to reduce the amount of
food she needs to eat by increasing the nutrient content of each bite
of food or drink she eats. For example, add melted cheese, gravies,
margarine, dips, and offer whole milk. This can help prevent weight
loss and poor growth.
Weight gain
Children with JRA may limit their physical activity if their joints are
stiff and painful. As a result, the child may gain too much weight. Corticosteroids
can also cause a child to gain weight. Excess weight is unhealthy
because it puts more stress on joints such as knees, hips, and ankles.
Appropriate exercise combined with eating a well-balanced diet that
includes planned snacks based on the basic four food groups can help
your child keep a normal body weight.
Note: Taking medicines, particularly NSAIDs, with food helps prevent damage to the stomach and upper part of the intestine.
Exercise and therapy Exercises are a very important part of treatment for JRA. For children with arthritis, the purpose of regular exercise is to:
- keep joints mobile
- keep muscles strong
- regain lost motion or strength in a joint or muscle
- make everyday activities like walking or dressing easier
- improve general fitness and endurance
There are two kinds of exercise your child might do: therapeutic exercise and sports/recreational activities.
Therapeutic exercises
Therapeutic exercises make it easier for your child to walk and
perform other activities of daily living, like opening jars and
writing. Range of motion exercises keep joints flexible and are
especially important for children who have lost motion in a joint, or
whose joints have become fixed in a bent position called a contracture.
Strengthening exercises build muscles.
A physical or occupational therapist will show your child how to
perform therapeutic exercises at home. Most exercises must be done
every day. Hot baths, hot packs and/or cold treatments before exercise
can make the therapy easier. The therapist can show you how to make the
exercises part of play activities if your child is very young.
Sports & recreational activities
Recreational activities help your child to exercise her joints and
muscles, develop important social skills, and have fun. But remember
that recreational activities cannot take the place of therapeutic
exercise. Activities that exercise the joints and muscles without
putting too much stress on them, like swimming, should be encouraged.
Sports and recreational activities are important for children with
arthritis to develop confidence in their physical abilities. Try to let
your child pick her own sport or activity of interest, while guiding
her toward one that will not hurt her joints.
Strong muscles and joint protection are the keys to participating in
sports. Although contact sports are never recommended, even aggressive
sports like soccer and basketball may not be off limits for your child.
Ask your doctor or therapist for guidelines. Your child may be able to
do special exercises to "train" for the sport she likes. Protective
equipment can further reduce the risk of injury. Medications
Several kinds of medications are used to control inflammation and relieve the pain of arthritis. Your child's doctor will generally try non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin before adding, if necessary, a more potent anti-rheumatic drug or corticosteroid.
Generally, NSAIDs reduce swelling and pain in the joints, but do not by
themselves stop the slow breakdown of joint tissue which may occur in
polyarticular JRA. These drugs, however, are effective in treating JRA
in many children. The more powerful anti-rheumatic drugs can often,
over time, stop the breakdown of joint tissue. But these drugs also may
have more serious side effects.
All drugs may have side effects, but the effects vary from
child to child. One child may respond well to one drug, while another
with a similar condition may not benefit or may suffer side effects
from the same medication. It is very important that the child's urine,
blood, and liver function are tested at regular intervals to make sure
everything is normal.
Because many drugs take weeks or months to show any benefit,
the physician may keep a child on a particular drug for some time
before trying another, unless there are serious side effects.
An important message about arthritis medications: don't change the amount or stop them without first asking your doctor.
Non-steroidal anti-inflammatory drugs (NSAIDs)
Your child's physician will probably prescribe a non-steroidal (containing no steroids) anti-inflammatory (reducing inflammation) drug
as a first step to control swelling and pain. NSAIDs are helpful in all
types of JRA. They work by limiting the release of irritating chemicals
by the white blood cells. NSAIDs can also be effective in lowering
fever.
NSAIDs commonly used to treat JRA are ibuprofen (sold under
trade names like Advil, Nuprin and Motrin), naproxen (Naprosyn), and
tolmetin.
Most NSAIDs are equally effective, but a particular child may respond better to one than to another.
Dose: These drugs may be given as a pill or liquid. The dose varies, depending on the specific NSAID used.
NSAIDs can have side effects including:
- stomach pain, nausea and vomiting
- anemia
- headache
- blood in the urine
- severe abdominal pain and peptic ulcer
- fragility and scarring of the skin (especially Naproxen)
- difficulty in concentrating in school, in some cases
Aspirin
Aspirin may be used to:
- control swelling and pain in joints
- reduce fever in children with systemic JRA
Dose: Children with JRA for whom aspirin is prescribed must
take large amounts of it three or four times a day. Young children
should not suck or chew on the aspirin because this may erode the
chewing surfaces of the teeth and irritate the gums. Instead, try
pre-crushing the dose and having the child swallow it in a small amount
of a favorite food such as applesauce or yogurt.
Aspirin may have the following side effects:
- Stomach pains or stomach bleeding (giving aspirin with food or an antacid may help)
- Toxic reactions. Both you and your child should be aware of these signs:
- rapid or deep breathing
- ringing in the ears
- decrease in hearing
- drowsiness
- nausea
- vomiting
- irritability
- unusual behavior
- black, tarry stools
- Reye's Syndrome, which is a rare disease that
sometimes occurs in children who have the chicken pox or the flu, and
who are also taking aspirin. The symptoms of Reye's syndrome include:
- frequent vomiting
- very painful headaches
- unusual behavior
- extreme tiredness
- disorientation
If your child is taking aspirin and develops chicken pox or
flu, she should stop taking the aspirin for a while. Your doctor will
tell you what to do if this happens.
More potent anti-rheumatic drugs
The more powerful anti-rheumatic drugs are not usually given
by themselves; they are most often effective when given in addition to
a NSAID. They are usually prescribed when NSAIDs alone have not been
effective or when joint damage occurs, usually in children with
polyarticular disease. These more powerful drugs are often able to
limit the amount of inflammation seen in severe JRA.
Methotrexate
Methotrexate works primarily by decreasing excessive white
blood cell activity. Its use in children is fairly recent. However,
Methotrexate has been found to be effective in treating children with
active polyarticular JRA and some patients with severe pauciarticular
disease.
Dose: Methotrexate is normally given weekly in low doses, usually as a pill taken by mouth. It may also be given by injection.
Possible side effects: In the low doses at which Methotrexate is
usually prescribed, few serious side effects have been reported.
However, regular laboratory monitoring is important. Side effects may
include:
- nausea
- mouth sores
- diarrhea
- low white blood cell count
- lung irritation
- sinus infection
- liver
irritation. Anyone taking Methotrexate, including teenagers, should
avoid all alcohol intake to lower the risk of irritating the liver
- risk of birth defects if taken during pregnancy
Gold
The "gold" used in gold treatment is actually a liquid gold salt. It works by interfering with several different functions of white blood cells.
Gold treatment is used to:
- ease morning stiffness
- control swelling and pain in joints
Dose: Gold is given in two ways--by injection into the muscle, or as
oral gold in a capsule taken by mouth. Injections are usually given
every week for five or six months, then once or twice a month for as
long as necessary. Oral gold (auranofin) is taken daily.
Four to six months may pass before a child responds to gold
treatment. Gold is not effective in all children; when it is, treatment
may need to be continued for many years.
Possible side effects: Gold can have side effects which may
make it necessary to stop treatment. Regular laboratory tests are
needed to detect any adverse reactions. Side effects may include:
- skin rash
- mouth sores
- kidney problems
- a low blood count
- anemia
Hydroxychloroquine (Plaquenil)
Hydroxychloroquine, sold under the trade name Plaquenil, is
another drug found to work in some children with polyarticular JRA and
other forms of arthritis. Plaquenil is used to control swelling and
pain in joints. While not helpful in all cases, Plaquenil may be useful
in an individual child, particularly when Methotrexate or gold have not
been completely effective.
Plaquenil is used to control swelling and pain in joints.
Dose: Plaquenil is given in pill form for many months. Your doctor will
determine the correct amount. Plaquenil is used to control swelling and
pain in joints.
Possible side effects may include:
- upset stomach
- skin rash
- eye damage (A child taking this drug should be checked every six to 12 months by an ophthalmologist.)
Keep this drug out of reach of small children. An overdose of this medication can be fatal.
Corticosteroids
Corticosteroid drugs
are used to treat JRA, especially the systemic form, when it is very
severe and has not responded to other drugs. Corticosteroids used to
treat JRA include prednisone and cortisone. These drugs contain
cortisone and are not related to the synthetic male-hormone steroids
some athletes use.
Corticosteroids are used to:
- control swelling and pain in joints
- control pericarditis, pleuritis, continuous high fever, or severe anemia
- control iridocyclitis (when given as an ointment or eye drops)
Corticosteroids work swiftly and effectively. However, because of their side effects, they are used with caution.
Dose: If corticosteroid drugs are prescribed, the lowest
possible dose will be used for the shortest length of time. Usually,
the drug is taken by mouth as a pill or liquid, or it can be given
intravenously directly into a vein. It can also be given as an
injection into the joint itself, or into a muscle or vein. Other types
of steroids include eye drops used to treat iridocyclitis and steroid
creams for skin problems.
Possible side effects: Corticosteroids taken as a pill or
intravenously for long periods of time may cause severe problems such
as:
- high blood pressure
- osteoporosis (softening of the bones)
- slowing of the child's growth rate
- reduced resistance to infection
- sudden mood swings
- increased appetite and weight gain
- increased risk for ulcers
Surgery Surgery is rarely used to treat JRA early in the course of the disease. However, surgery can be used to:
- relieve pain
- release joint contractures
- replace a damaged joint
If surgery is necessary, your doctor may consider joint replacement or soft tissue release as treatment.
Joint replacement
In joint replacement surgery, a child's entire joint is replaced
with an artificial joint. This procedure is used mainly in older
children whose growth is complete and whose joints are badly damaged by
arthritis. This operation is usually used to replace the hip, knee, or
jaw joints. It can reduce pain and improve function.
Soft tissue release
Soft tissue release may sometimes be used to improve the position of a
joint which has been pulled out of line by a contracture--a condition
caused by a tightening and shortening of the tendons. In this
operation, the surgeon cuts and repairs the tight tissues which caused
the contracture, allowing the joint to return to a normal position. Splints or braces Splints are used to keep joints in the correct position and to
relieve pain. If a joint is becoming deformed (bent in the wrong
position), a splint may be used to stretch that joint gradually back to
its normal position. Commonly used splints include knee extension
splints, wrist extension splints, and ring splints for the fingers.
An occupational or physical therapist usually makes the splint. Arm
and hand splints are made from plastic; leg splints are sometimes made
of cast material. A splint is custom-made for your child. The therapist
will adjust the splint as your child grows, or as the joint position
changes.
Splints are usually worn only at night, while sleeping, to keep the joint extended.
It is important for your child to move and use her joints during the
day. At times, however, your child may also wear a different kind of
splint, a functional splint (often called an orthosis or brace) during
the daytime. Long-term management Dental care
The most important aspect of dental care for everyone is the
prevention of dental disease. Some children with JRA may have
difficulty brushing and flossing. Your dentist may suggest various
toothbrush handles, electric toothbrushes, floss holders, toothpicks,
and rinses that will help your child maintain healthy teeth and gums.
Always inform your dentist about the status of your child's disease
and the medications she is taking. Both the JRA and the medications
used to treat it may affect the child's oral health and development.
The dentist will also consider these when he is planning any treatment.
These considerations may be especially important if general anesthesia,
sedation, or oral surgery are being planned. Older children who have
had joint replacements may require an antibiotic before dental
treatment.
The joint in front of the ears, where the lower jaw connects to the
base of the skull, is called the temporomandibular joint (TMJ).
Arthritis may affect this joint in the same way it does others, by
causing pain, stiffness, and altered growth. Jaw exercises and
heat-cold therapy may be recommended for the pain and stiffness. If the
lower jaw does not develop properly, the child with JRA may develop a
severe overbite. Your child's dentist may recommend an early
consultation with an orthodontist if this occurs. Surgery is also
sometimes necessary for this condition.
A child with JRA, especially if she is in a flare, may not always
have the stamina for even routine dental work. If possible, shorter
appointments may be helpful. Also, schedule an appointment at the time
of day your child has the most stamina.
Eye care
An eye inflammation called iridocyclitis or closely-related forms
called anterior uveitis and iritis, are sometimes associated with JRA,
especially the pauciarticular type. Iridocyclitis occurs more often in
young girls with pauciarticular JRA whose blood contains a kind of
protein known as an Antinuclear Antibody (ANA). In iridocyclitis,
certain tissues in the eyes become inflamed. But this inflammation may
not cause any obvious eye symptoms until it has gone on for a long
time. The symptoms of iridocyclitis which might appear after a while
include red eyes, eye pain, and failing vision.
It is important for all children with JRA to have their eyes checked
by an ophthalmologist (an eye doctor who is an M.D.) as soon as they
are diagnosed. The ophthalmologist can detect the problem early and
start treatment to avoid any serious problems.
Children should continue to get periodic eye exams even when the
arthritis is inactive and they have no joint swelling, because
iridocyclitis may still be present.
Your child should visit the ophthalmologist for a complete medical
eye evaluation, including a slit lamp test. This is a simple and
painless procedure that can spot problems before you can tell anything
is wrong. The eye examination may need to be repeated from time to
time, depending on your child's risk for developing the eye problem.
Your doctor will tell you how often your child should be examined. If
iridocyclitis is found early and treated properly, it is unlikely to
cause any trouble. If it is allowed to go on, it can result in impaired
vision or even blindness.
If your child has iridocyclitis, eye drops will be prescribed. One
type of eye drops is used to dilate the pupil (make the black spot in
the center of the eye bigger). This will keep scars from forming on the
pupil. Another kind of eye drop contains a corticosteroid drug which
will decrease the inflammation in the eye tissues. When corticosteroids
are taken in this form, the side effects are not as serious as when the
drug is taken by mouth. If the drops cannot control the iridocyclitis,
your child may need to take an anti-inflammatory medication in pill
form.
Morning stiffness relief
Many children experience a period of stiffness upon getting up each
day. Morning stiffness can be one of the best measures of disease
activity; the longer the morning stiffness lasts, the more active the
disease. Morning stiffness can be relieved by these methods:
- a hot bath or shower
- sleeping in a sleeping bag
- range of motion exercises
- a paraffin bath in a tub of warmed wax which coats the small joints of the hands)
- a
cold pack: though most children do better with warmth, there are a few
who respond to cold (a plastic bag filled with ice or frozen vegetables
works well)
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