Artritis idiopática juvenil

For a doctor to diagnose your child with juvenile arthritis, symptoms must have started before age 16. Doctors usually suspect juvenile arthritis, along with several other possible conditions, when they see children with persistent joint pain or swelling, unexplained skin rashes, and fever associated with swelling of lymph nodes or inflammation of internal organs. A doctor also considers a diagnosis of juvenile arthritis in children with an unexplained limp or excessive clumsiness.

There is no single test that a doctor can use to diagnose juvenile arthritis. A doctor will carefully examine your child and consider his or her medical history and the results of several tests that help confirm juvenile arthritis or rule out other conditions. Specific findings or problems that relate to the joints are the main factors that go into making a juvenile arthritis diagnosis.

Symptoms

When diagnosing juvenile arthritis, a doctor must consider not only the symptoms your child has, but also the length of time these symptoms have been present. Joint swelling or other joint changes that the doctor can see must be present continuously for at least 6 weeks.

You can help your child’s doctor correctly diagnose juvenile arthritis by keeping a record of your child’s symptoms and changes in the joints, noting when they first appeared and when they are worse or better.

Family History

It is very rare for more than one member of a family to have juvenile arthritis. But children with a family member who has juvenile arthritis are at a slightly increased risk of developing it as well. 

Research shows that juvenile arthritis is also more likely in families with a history of any autoimmune disease. One study showed that families of children with juvenile arthritis are more likely to have a member with an autoimmune disease such as rheumatoid arthritis, multiple sclerosis, or thyroid inflammation (Hashimoto’s thyroiditis) than are families of children without juvenile arthritis. For that reason, having an autoimmune disease in your family may raise the doctor’s suspicions that your child’s joint symptoms are caused by juvenile arthritis or some other autoimmune disease.

Lab Tests

Lab tests, usually blood tests, cannot alone provide the doctor with a clear diagnosis. But a doctor can use these tests to help rule out other conditions and classify the type of juvenile arthritis that your child has. A doctor may order blood tests for:

• Anticyclic citrullinated peptide (anti-CCP) antibodies. Anti-CCP antibodies may be detected in healthy people years before onset of clinical rheumatoid arthritis. They may predict the eventual development of undifferentiated arthritis into rheumatoid arthritis.
• Rheumatoid factor (RF). Rheumatoid factor, an autoantibody that is produced in large amounts in adults with rheumatoid arthritis, also may be detected in children with juvenile arthritis, although it is rare. The RF test helps the doctor differentiate among the different types of juvenile arthritis.
• Antinuclear antibody (ANA). An autoantibody directed against substances in the cells’ nuclei, ANA is found in some juvenile arthritis patients. However, the presence of ANA in children generally points to some type of connective tissue disease, helping the doctor to narrow down the diagnosis. A positive test in a child with oligoarthritis markedly raises his or her risk of developing eye disease in the future.
• Erythrocyte sedimentation rate (ESR or sed rate). This blood test, which measures how fast red blood cells fall to the bottom of a test tube, can tell the doctor if inflammation is present. Inflammation is the key sign of juvenile arthritis and a number of other conditions.

X-Rays

Your child’s doctor will order x-rays if he or she suspects injury to the bone or unusual bone development. Early in the disease, some x-rays can show changes in soft tissue. In general, x-rays are more useful later in the disease, when bones may be affected.

Other Tests

Because there are many causes of joint pain and swelling, the doctor may use other lab tests to help rule out other conditions before diagnosing juvenile arthritis. Some of these conditions include:

• Physical injury.
• Bacterial or viral infection.
• Lyme disease.
• Inflammatory bowel disease.
• Lupus.
• Dermatomyositis.
• Some forms of cancer.

The main goals of treatment are to:

• Preserve a high level of physical and social functioning.
• Maintain a good quality of life.

To achieve these goals, doctors recommend treatments that:

• Reduce swelling.
• Maintain full movement in the affected joints.
• Relieve pain.
• Prevent, identify, and treat complications.

Most children with juvenile arthritis need a combination of medication and other treatments to reach these goals.

Medications

• Nonsteroidal anti-inflammatory drugs (NSAIDs). Aspirin, ibuprofen, naproxen, and naproxen sodium are examples of NSAIDs. They are often the first type of medication doctors prescribe for juvenile arthritis. All NSAIDs work similarly by blocking substances called prostaglandins that add to inflammation and pain. However, each NSAID is a different chemical, and each has a slightly different effect on the body. For unknown reasons, some children seem to respond better to one NSAID than another. NSAIDs should only be used at the lowest dose possible for the shortest time needed.

  You can buy some NSAIDs over the counter, while several others, including a subclass called COX-2 inhibitors, need a prescription.

  All NSAIDs can have significant side effects, so consult your child’s doctor before giving any of them. Your child’s doctor should monitor your child if he or she takes NSAIDs regularly to control juvenile arthritis.

  Side effects of NSAIDs include stomach problems; skin rashes; high blood pressure; fluid retention; and liver, kidney, and heart problems. The longer a person uses NSAIDs, the more likely he or she is to have side effects, ranging from mild to serious. Many other medicines cannot be taken when a person is taking NSAIDs because NSAIDs alter the way the body uses or eliminates these other medicines.

• Disease-modifying antirheumatic drugs (DMARDs). If NSAIDs do not relieve symptoms of your child’s juvenile arthritis, the doctor may prescribe this type of medication. DMARDs slow the progression of juvenile arthritis, but because they may take weeks or months to relieve symptoms, they often are taken with an NSAID. Although there are many different types of DMARDs, many doctors prescribe one called, methotrexate.

  Researchers have learned that methotrexate is safe and effective for some children with juvenile arthritis whose symptoms are not relieved by other medications. Because children only need small doses of methotrexate for relief of arthritis symptoms, potentially dangerous side effects rarely occur. The most serious complication can be liver damage, which a doctor can help prevent with regular blood tests and check-ups. Careful monitoring for side effects is important for people taking methotrexate. When side effects are noticed early, the doctor can reduce the dose and eliminate the side effects.

• Corticosteroids. If your child has very severe juvenile arthritis, stronger medicines may be needed to stop serious symptoms, such as inflammation of the sac around the heart (pericarditis). Corticosteroids, such as prednisone, may be added to the treatment plan to control severe symptoms. This medication can be given by IV, mouth, or injection directly into a joint. Corticosteroids are powerful anti-inflammatory medicines. Corticosteroids can interfere with your child’s normal growth and can cause other side effects, such as a round face, weakened bones, and an increased chance of having infections. Once the medication controls severe symptoms, the doctor will reduce the dose gradually and, in time, stop it completely. It can be dangerous to stop taking corticosteroids suddenly. Carefully follow the doctor’s instructions about how to take or reduce the dose. For inflammation in one or just a few joints, injecting a corticosteroid compound into the affected joint or joints can often bring quick relief without the systemic side effects of oral or IV medication.
• Biologic agents. If your child has received little relief from other medications, he or she may be given one of a newer class of medications called biologic response modifiers, or biologic agents. These are based on compounds made by living cells. Tumor necrosis factor (TNF) inhibitors are biologic agents that work by blocking the actions of TNF, a naturally occurring protein in the body that helps cause inflammation. Other biologic agents block other inflammatory proteins, such as interleukin-1 or immune cells called T cells. Different biologics tend to work better for the different subtypes of the disease.

All medicines can have side effects. Some medicines and side effects are mentioned in this publication. Some side effects may be more severe than others. You should review the package insert that comes with your medicine and ask your child’s health care provider or pharmacist if you have any questions about the possible side effects.

Other Treatments

• Physical therapy. A regular, general exercise program is an important part of a child’s treatment plan. Exercise can help to maintain muscle tone and preserve and recover the range of motion of the joints. A physiatrist (rehabilitation specialist) or a physical therapist can design an appropriate exercise program for your child. The specialist also may recommend using splints and other devices to help maintain normal bone and joint growth.

• Complementary and alternative therapies. Many adults seek alternative ways of treating arthritis, such as special diets, supplements, acupuncture, massage, or even magnetic jewelry or mattress pads. Research shows that increasing numbers of children are using alternative and complementary therapies as well.

  Although there is little research to support many alternative treatments, some people seem to benefit from them. If your child’s doctor feels the approach has value and is not harmful, you can incorporate it into the treatment plan. However, do not neglect regular health care or treatment of serious symptoms.

Treating juvenile arthritis often requires a team approach that involves your child and his or her family and a number of different health professionals.

Ideally, your child’s care should be managed by a pediatric rheumatologist, who is a doctor who has been specially trained to treat the rheumatic diseases in children. However, many pediatricians and “adult” rheumatologists also treat children with juvenile arthritis. Because there are relatively few pediatric rheumatologists and they are mainly concentrated at major medical centers in metropolitan areas, children who live in smaller towns and rural areas may benefit from having a doctor in their town coordinate care through a pediatric rheumatologist. Many large medical centers now conduct outreach clinics, in which doctors and a supporting team travel from large cities to smaller towns for 1 or 2 days to treat local patients.

Other members of your child’s health care team may include:

• Physical therapist. This health professional can work with your child to develop a plan of exercises that will improve joint function and strengthen muscles without causing further harm to affected joints.
• Occupational therapist. This health professional can teach ways to protect joints, minimize pain, conserve energy, and exercise. Occupational therapists specialize in the upper extremities (hands, wrists, elbows, arms, shoulders, and neck).
• Counselor or psychologist. Being a child or adolescent with a chronic disease isn’t easy, for the child or his or her family. Your child may benefit from sorting out his or her feelings with a psychologist or counselor trained to help children in this situation. Your family members may benefit from counseling as well.
• Ophthalmologist. If your child’s medications or form of arthritis can affect the eyes, catching problems early can help keep them from becoming serious. All children with juvenile arthritis need to have regular exams by an ophthalmologist (eye doctor) to detect eye inflammation.
• Dentist and orthodontist. Thorough brushing and flossing of the teeth can be difficult if your child’s hands are affected by arthritis. If your child’s jaw is also affected by arthritis, he or she may have a hard time opening the mouth for proper brushing. Therefore, your child needs regular dental exams. Because juvenile arthritis can also affect the alignment of the jaw, children with this disease should also see an orthodontist.
• Orthopaedic surgeon. Some children need surgery to help minimize or repair the effects of their disease. Orthopaedic surgeons are doctors who perform surgery on the joints and bones.
• Dietitian. For children with chronic diseases, good nutrition is particularly important. A dietitian can help design a nutritious diet that will benefit the whole family.
• Pharmacist. A pharmacist is a good source of information about medications, including possible side effects and other drugs that could interact with them. If your child has trouble swallowing large pills or taking other medication, the pharmacist may be able to suggest different ways to take the medication or may be able to prepare or help you get kid-friendly versions of some medications.
• Social worker. A social worker can help your child and your family deal with life and lifestyle changes caused by arthritis. A social worker also can help you find helpful resources for your child.
• Rheumatology nurse. A rheumatology nurse likely will be closely involved in your child’s care, serving as the main point of contact with your doctor’s office about appointments, tests, medications, and instructions.
• School nurse. For a school-age child, the school nurse also may be part of your health care team, particularly if your child needs to take medications regularly during school hours.