Dr. M.J. Bazos, MD Patient Handout



About Your Diagnosis

Juvenile rheumatoid arthritis (JRA) refers to a form of arthritis occurring in children that is different from adult rheumatoid arthritis. Juvenile rheumatoid arthritis will develop in 1 of every 1,000 children. The arthritis is caused by inflammation (changes in the immune system) in the joint that can cause stiffness, warmth, swelling, and pain. Although there is no cure for this type of arthritis, there are many very good treatments, and a substantial number of children will have a complete remission of their condition. There are three types of JRA, and these can be associated with different types of problems. Pauciarticular JRA affects only a few joints (usually less than four joints) and occurs in half of the children with JRA. This type most commonly starts in the preschool years and is more likely to occur in girls. Knees, elbows, and ankles are usual spots for the arthritis to occur. Inflammation in the eyes develops in about half of children with pauciarticular JRA. The eye disease can develop at any point during the course of JRA; thus all children with JRA must be seen by an eye doctor regularly. The inflammation is usually detected by the eye doctor by examining the eyes with a special light (called a slit lamp). Untreated, the eye inflammation can lead to vision loss and scarring, so it is important to continue regular eye examinations. Polyarticular JRA affects many joints and occurs in about 40% of children who have JRA. Often the arthritis involves the small joints of the hands andfingers. Joints commonly affected include the neck,knees, ankles, feet, wrists, and hands. Again, girls are more likely to develop this condition. Some children have a positive blood test called a rheumatoid factor, and their arthritis can be very similar to adult rheumatoid arthritis. Children with polyarticular JRA can also have eye inflammation develop, but this does not occur as often as in the children with pauciarticular JRA. Systemic JRA occurs in about 10% of children with JRA, with boys and girls both affected equally. Often this condition starts with fever, rash, changes in the blood cells, and joint pain. The inflammation of the joints may not develop for many weeks to months, so this type of JRA can be very hard to diagnose at first. Rarely, systemic JRA can involve the heart, lymph nodes, liver, and lungs. Approximately 70,000 children in the United States have some form of JRA. Although certain hereditary and environmental factors may increase an individual’s risk of developing JRA, the exact cause is unknown. Juvenile rheumatoid arthritis is not an infectious illness. In other words, you cannot “catch” it from another individual. To diagnose JRA in a child, a physician obtains a medical history, performs an examination of the joints, and orders laboratory tests and possibly xrays of the joints. Laboratory tests may include an erythrocyte sedimentation rate (ESR), which measures inflammation in the body, a complete blood cell count (CBC), a rheumatoid factor (RF), and an antinuclear antibody (ANA). The RF and ANA are specific proteins found in the blood and may aid a physician in the diagnosis of JRA. However, there is no single blood test that will prove or disprove whether a child has JRA. Juvenile rheumatoid arthritis is a chronic disease that may last for many months or years. However, about 75% of children eventually outgrow this disease. Although there is no cure for JRA, earlier detection, improved medications, and comprehensive treatment greatly improve the chances for a full and active life.

Living With Your Diagnosis
Juvenile rheumatoid arthritis causes joint pain and stiffness that can affect a child’s ability to do daily activities. Stiffness and discomfort are usually worse in the morning, then get better toward the end of the day. The child may hold the affected joint close to the body because of the pain. Arthritis affecting the hands and wrists can affect the ability to write, dress, and carry items. Arthritis affecting the hips, knees, or feet can decrease the ability to walk, play, or stand. If arthritis affects the neck, it can decrease the ability to look around. A child may not want to participate in play activities because of the pain and fatigue. The pain of JRA may also keep the child awake at night, which may increase the fatigue.

The best way to manage JRA is through a combination of medication, therapies, exercise, education, and “pacing” of activities to prevent fatigue. Treatment should be from a physician experienced in the treatment of arthritis. Medications help to decrease the inflammation that causes pain and swelling. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often the first line of therapy. Possible side effects of NSAIDs include stomach upset, ulcers, diarrhea, constipation, headache, dizziness, difficulty hearing, and a rash. If these medications do not adequately control the pain, a physician may prescribe “disease modifying” medications that often are effective in slowing the progresssion of the disease. These medications include gold shots, hydroxychloroquine, and methotrexate. Gold shots and methotrexate may affect the blood, liver, or kidneys and possibly cause a rash. Hydroxychloroquine may affect the eyes and cause a rash. Prednisone, a potent anti-inflammatory drug, is used if the disease cannot be managed by other medications or if the child has serious systemic JRA. Prednisone may cause acne, high blood sugar, increased blood pressure, difficulty sleeping, and weight gain. When used for a long time, prednisone may also slow down a child’s growth rate and cause thinning of the bones. The eye disease is treated with prednisone eye drops, and if severe, may require more potent oral medications. Learning about JRA is essential because your child may have the disease for a long time, and careful management is important to prevent problems. Exercise is important to maintain joint movement and muscle strength. Pacing activities helps manage fatigue. The use of splints can help in resting painful, swollen joints.

The DOs
• Have your child take medications as prescribed.
• Call the doctor if your child experiences any side effects from medications. Learn as much as you can about this condition and its treatments.
• Encourage your child to exercise.
• Encourage your child to participate in the same activities other children of that age are participating in; however, your child should alternate periods of activity with rest.
• Speak to your child’s teachers and school nurse. Ask them what services are available in the school system to help your child manage pain and fatigue.

The DON’Ts
• Wait and see whether a medication side effect will go away. Always call your doctor if you have any questions.
• Give up. If one medication doesn’t work for your child, discuss this with your physician until you find a medicine that helps decrease the pain and stiffness.
• Have your child continue with an exercise program that continues to cause increased pain. This may mean that the program needs to be modified.
• Forget to have regular eye examinations. Children with JRA can have eye inflammation develop. Also, some of the drugs used to treat JRA can cause side effects in the eyes.

When to Call Your Doctor
• Your child has any side effects listed above from any of the medications.
• The medication is not helping the joint pain, stiffness, swelling, or fatigue.
• Your child needs a referral to a physical or occupational therapist for exercise, joint protection, or splinting.