Diagnosis of Juvenile Idiopathic Arthritis (JIA)
There is no single test that doctors can use to diagnose JIA. However, they may suspect that a child has the disease if he or she is younger than age 16 and has unexplained joint pain, stiffness, or swelling that has lasted for at least 6 weeks. Doctors usually diagnose JIA by ruling out other conditions that have similar features.
The process doctors use involves the following.
Medical History and Physical Exam
During the examination, the doctor usually:
- Asks about your child’s symptoms and when they began. They may also want to know about your child’s family medical history because autoimmune diseases like JIA can run in families.
- Checks your child’s joints and skin.
- Watches your child’s movements for signs of trouble walking, climbing onto the examination table, moving the neck, or raising or closing the hands.
- Shines a small light into your child’s eyes to look for eye problems that stem from uveitis (inflammation of the middle part of the eye), such as glaucoma or cataracts.
- Checks the lymph nodes and abdomen for signs of swelling or sensitivity.
The doctor may order blood tests for:
- Erythrocyte sedimentation rate (ESR or “sed rate”) and C-reactive protein (CRP). These blood tests are measures of inflammation, or so-called inflammatory markers. They are often high in children with systemic JIA, and may be elevated in children with other forms of JIA as well. But they are not specific for JIA and may also be elevated for an unrelated reason such as an infection. In cases where inflammatory markers are elevated because of JIA, doctors can use these tests to monitor if treatments are working.
- Autoantibodies. Antibodies are molecules made by the immune system—for example, in response to infections. Autoantibodies are antibodies that target one's own cells and tissues. Autoantibodies that may be found in children with JIA include:
- Antinuclear antibody (ANA). An autoantibody directed against substances in the cell nucleus, ANA is found in many children with JIA, but children without JIA may also test positive. Those who test positive for ANA are at higher risk of developing eye inflammation and need to follow up more frequently with an eye doctor.
- Rheumatoid factor (RF) and anti-cyclic citrullinated peptide (CCP) antibodies. These autoantibodies are rarely detected in children with JIA. When present, they usually correspond to a diagnosis of rheumatoid factor-positive polyarticular JIA.
- HLA-B27. This gene is a risk factor for enthesitis-related JIA. However, some children who have enthesitis-related JIA test negative for HLA-B27, and not all those who test positive have, or will ever develop, the disease.
- Other lab tests. Doctors may also order a basic panel of tests, including liver and kidney function tests, as well as a complete blood count (CBC). The CBC can tell if your child has anemia (low levels of red blood cells), which can occur in people with systemic JIA or other chronic inflammatory disorders.
The doctor may order the following:
- X-rays, which use a small amount of radiation to assess the structure of bones. They are often the first type of imaging study the doctor orders because they help rule out other causes of joint pain, such as a fracture, infection, or a tumor. As JIA progresses, x-rays can show if there is damage to the joint.
- Ultrasounds, which rely on high-frequency sound waves and are a noninvasive way to visualize joints without using radiation. Unlike x-rays, they can detect fluid and inflammation, which typically occur before any damage can be seen on x-rays.
- Magnetic resonance imaging (MRI), which is a highly sensitive tool for visualizing the joints. MRIs use large magnets to create detailed, three-dimensional images of the joints, including inflammation, cartilage, and bone.
The diagnostic process will determine if your child has JIA, and if so, identify the type he or she has. It will also provide information to help doctors best treat the disease.
Treatment of Juvenile Idiopathic Arthritis (JIA)
The goals of treatment are to:
- Control inflammation.
- Reduce pain and stiffness.
- Prevent joint and organ damage.
- Preserve and improve joint function.
- Promote physical and psychosocial growth and development.
- Achieve remission (little or no disease activity or symptoms).
- Allow for full engagement with normal activities (e.g., school, work, sports, social life, family life).
Most children with JIA need a combination of medicines and a healthy lifestyle, including a balanced diet and exercise, to reach these goals. The specific treatment plan will depend on the child’s age, the type of JIA, and on other factors, such as disease severity. In general, doctors will treat the disease aggressively early on, tapering off medications once remission is reached.
The types of medications your child may be prescribed include:
- Anti-inflammatory and pain medications. These can help alleviate pain and swelling from inflammation. They are often prescribed by the doctor, but some are also available over the counter.
- Disease-modifying anti-rheumatic drugs (DMARDs). These oral medications suppress the immune system on a broad level, helping to prevent progression of the disease and saving the joints from permanent damage. Depending on the drug, they may be taken by mouth or given as injections under the skin. DMARDs are sometimes combined with biologic response modifiers.
- Biologic response modifiers. By blocking specific immune signals that cause inflammation, biologic response modifiers help to prevent progression of JIA, achieve remission, and protect against permanent damage. Depending on the drug, they may be given as injections under the skin or intravenously. These drugs are sometimes combined with oral DMARDs. If doctors prescribe drugs in this class, they are usually inhibitors of TNF-alpha, IL-1, or IL-6, molecules that are known to promote inflammation in JIA.
- Corticosteroids. When injected into an affected joint, these strong inflammation-fighting drugs usually bring fast relief, though it is not always long lasting. In certain situations, they are given by mouth or intravenously, especially for systemic JIA and occasionally to alleviate severe symptoms from other types of JIA. Because they are powerful drugs with many possible side effects, doctors typically prescribe the lowest dose of steroids necessary and taper off as quickly as possible.
Physical therapy can be an important part of JIA treatment. The doctor may recommend physical therapy to help:
- Relieve pain.
- Improve and maintain range of motion in affected joints.
- Strengthen muscles.
- Prevent injury from sports or other physical activities.
A physical therapist can also teach pain-reducing techniques and develop a home exercise program for your child.
Routine Monitoring and Ongoing Care
Regular medical care is important because your doctor can:
- Monitor how well treatment is working.
- Adjust the treatment as needed. If a medication is not working well or if there are side effects, the doctor may try a different dosage, a different medicine, or a combination of medicines. If the treatment is working very well and the disease is well controlled, the doctor may discuss options for tapering or stopping medicines.
Who Treats Juvenile Idiopathic Arthritis (JIA)?
Treating juvenile idiopathic arthritis typically requires a team approach that involves several different health care providers.
JIA is primarily treated by:
- Pediatric rheumatologists, who specialize in treating arthritis and other diseases in children that involve the joints, bones, muscles, and immune system.
Other members of your child’s health care team may include:
- Mental health professionals, who can help children cope with difficulties in the home and at school that may result from their medical condition.
- Occupational therapists, who teach ways to protect joints, minimize pain, perform activities of daily living, and conserve energy.
- Ophthalmologists, who diagnose and treat diseases of the eyes.
- Orthopaedists, who specialize in the treatment of and surgery for bone and joint diseases or injuries.
- Pediatricians, who provide routine medical care for children.
- Physical therapists, who help to improve joint function.
- Rheumatology nurses, who may serve as the main point of contact with your doctor’s office about appointments, tests, medications, and instructions.
- Social workers, who can help your child and your family deal with lifestyle changes caused by arthritis. A social worker can help you find resources and can serve as a liaison with your child’s school, working with school-based staff to address any issues.
Living With Juvenile Idiopathic Arthritis (JIA)
JIA affects the entire family; all family members must cope with the special challenges of the disease. Having JIA can strain your child’s participation in social and after-school activities and make schoolwork more difficult. Nevertheless, it is important to treat your child as normally as possible.
Certain activities can help improve children’s ability to function on their own and maintain a positive outlook. These include:
- Managing medical care. Ensure that your child receives appropriate medical care and that you and your child follow the doctor’s instructions. Learn as much as you can about the disease and its treatment. Many treatment options are available, and because JIA is different in each child, what works for one may not work for another. If the medications that the doctor prescribes do not relieve symptoms or if they cause unpleasant side effects, you and your child should discuss other choices with the doctor. It can be helpful to keep a day-to-day record of your child’s symptoms and side effects of medications. Being prepared for doctors’ appointments can help reduce the anxiety associated with them.
- Balance rest and exercise. Your child should have more rest when JIA is active and more exercise when it is not. Rest helps to decrease active joint inflammation, pain, and fatigue. In general, shorter rest breaks every now and then are more helpful than long times spent in bed. During symptom-free periods, many doctors encourage playing team sports and other physical activities, which help to maintain strong muscles, joint mobility, and flexibility, while providing social interactions with other children. Swimming is especially helpful because it uses many muscles and joints without stressing the joints. Exercise can also help:
- Improve sleep.
- Decrease pain.
- Keep a positive attitude.
- Maintain a healthy weight.
Talk to your child’s health care provider before beginning an exercise program.
- Care for the joints. Cold packs can help ease the swelling and numb painful joints, while heat treatments, such as hot showers or heating pads, work best for stiff joints and muscles. Wearing a splint (a piece of hard material, usually wrapped in fabric) for a short time around a painful joint can reduce pain and swelling. Talk to your child’s doctor or a physical or occupational therapist before using a splint.
- Partner with your child’s school. Help your child’s school to develop a suitable lesson plan, and educate your child’s teacher and classmates about JIA. Some children with severe forms of the disease may be absent from school for prolonged periods and need to have the teacher send assignments home. Some minor changes—such as having an extra set of books or leaving class a few minutes early to get to the next class on time—can be helpful. With proper attention, most children progress normally through school.
- Encourage a healthy diet. There is no evidence that a special diet helps to treat JIA, but a healthy, balanced diet is important for maintaining overall health.
- Help your child cope with stress. Young people with chronic conditions such as JIA are at greater risk of having emotional or mental health problems, such as anxiety or depression. Having a strong support network of friends and family in place can help a young person through difficult times. Ways to cope with stress can include:
- Doing relaxation, distraction, or visualization exercises.
- Being physically active.
- Seeking expert help from a mental health professional.
- Joining a support group for children with JIA.