An Online Wellness Magazine produced by The University of Texas Health Science Center at Houston (UTHealth)

Children and Arthritis

Though somewhat rare, children can experience painful inflammation and stiffness of the joints

When her 13-year-old son Cole started limping on and off for several months and resisted going anywhere that required a lot of walking, Dana Blount knew something was wrong. “He had a seventh-grade physical and he could not bend over to touch his knees, much less his toes,” she recalls.

Adds Cole, now 14, “I had a lot of pain in my hamstrings and lower back. I could hardly walk correctly without my leg starting to flare up.” He also had joint stiffness in the morning that did improve as the day progressed.

Although a chiropractor was able to relieve back pain that caused the limping, Cole continued to feel the need to limp. Dana then took Cole to a pediatric hip specialist, who prescribed physical therapy. However, it only made matters worse. Consequently, the specialist referred Cole to Ankur Kamdar, M.D., a pediatric rheumatologist at McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth).

Getting a diagnosis

In order to make a diagnosis, Kamdar obtained Cole’s complete medical history. He also performed a physical examination to help diagnose his condition. This included examining every joint to determine which joints were affected by either swelling, pain upon touch or limited range of motion — such as being unable to flex or fully extend a joint. Finally, the Blounts had an answer to what was afflicting Cole — juvenile idiopathic arthritis (JIA), the most common type of juvenile arthritis.

While Dana was glad to get a diagnosis, it was heartbreaking news — knowing that Cole would have to live with this condition long-term. “I didn’t know much about JIA,” she says. “I knew kids could get it, but I didn’t know how rare it was.”

Kamdar explains that JIA is a heterogeneous disease, which means that the different genes a child gets from his or her parents can play a role in getting the disease. Environmental triggers may also play a role. But the exact cause of JIA is unknown.

Juvenile arthritis is an umbrella term used to describe the many autoimmune and inflammatory conditions or pediatric rheumatic diseases that can develop in children under the age of 16. Juvenile arthritis can also be seen in other conditions, such as systemic lupus erythematosus, dermatomyositis and juvenile scleroderma. Nearly 300,000 children in the United States have arthritis, according to the Arthritis Foundation.

The various types of juvenile arthritis share some symptoms, such as pain, joint swelling and redness and warmth around joints. However, each type also has its own symptoms — while some affect the musculoskeletal system, a child might only have minor or no joint symptoms at all. Juvenile arthritis can also affect the skin, eyes, muscles and gastrointestinal tract.

Treatment available

No cure for juvenile arthritis exists. However, if diagnosed early and treated aggressively, it is possible to enter remission. The purpose of treatment is to relieve inflammation, control pain and improve quality of life. Most treatment plans involve a combination of medication, physical activities, eye care and eating healthy.

If a patient has mild JIA, for example, Kamdar will prescribe a medication classified as a nonsteroidal anti-inflammatory drug (NSAID) to relieve pain and swelling, such as ibuprofen or naproxen.

If NSAIDs don’t work, then Kamdar prescribes medications designed to slow the progression of joint damage from arthritis called disease-modifying anti-rheumatic drugs (DMARDs). Methotrexate is one of the most common drugs in this category. These medications are typically used for mild to moderate JIA.

If DMARDs aren’t effective, Kamdar recommends taking a biologic agent, which is a targeted therapy that blocks certain proteins involved in inflammation. The US Food and Drug Administration has approved these medicines for moderate and severe JIA. One example is adalimumab, which blocks overproduction of a certain protein called tumor necrosis factor (TNF), which plays a role in causing inflammation and arthritis. These types of medications only became available over the last 15 years.

Cole’s initial treatment consisted of weekly injections of methotrexate. “This helped reduce the pain somewhat,” Dana says. “But during the seventh week, the treatment started failing.” As a result, Kamdar added adalimumab injections every other week.

“This immediately started dropping his pain level,” says Dana, adding that it continues to lessen Cole’s pain substantially. “Dr. Kamdar has been helpful throughout the process, explaining everything in detail and making himself available via email to me at any time. He always responds to my questions and concerns.” Kamdar advised they attend the Juvenile Arthritis Conference, which they plan to do in order to learn more about the disease.

Findings on anti-TNF medications

Oftentimes, rheumatologists and parents alike are concerned about the risk of significant infections with the use of anti-TNF medications. Recent research has noted that there doesn’t seem to be an increased risk of infections that require hospitalizations when taking anti-TNF medications.  

Researchers looked at several thousand insurance claims for children admitted to a hospital with JIA and infection, and compared their rates of infection to children taking methotrexate, a DMARD agent, to those on methotrexate and an anti-TNF medication. “Infection rates were similar, suggesting that the additional medication did not increase risk for serious infection,” Kamdar points out. “This is something that I share with my patients and their parents, who may have concerns about taking an anti-TNF medication. This is helpful to know in their decision-making process.”

When your child has arthritis

If your child has arthritis, Kamdar advises listening to them regarding their pain and other symptoms. In addition to treatment for physical ailments, it is important to address the disease’s emotional and social effects.

“Try to let them be as normal a kid as possible,” he says. “They can participate in sports as tolerated without significant restrictions. My goal is to have them lead as normal a life as possible.”

Kamdar may recommend a child do physical therapy if they have severe pain, such as pain in the knee joint. If the pain is too severe, however, a child may have to limit what sports they play. 

“I often recommend aqua therapy,” Kamdar says. “Movement is good for arthritis.” That was good news for Cole, who has been an avid swimmer since he was a toddler.

“I like that swimming benefits my body’s muscles,” says Cole, who competes in the sport in a summer league. However, JIA has severely affected his ability to swim and he hasn’t found any other sports that he can participate in. “It’s almost impossible to kick or do a flip turn without feeling pain,” he says. Walking also continues to be challenging at times.

“Swimming is a good activity because you’re buoyant and aren’t putting significant weight on the affected joint,” Kamdar says.

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