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How Do I Know If My Child Has It?

Doctors usually suspect JRA, along with several other possible conditions, when they see children with persistent joint pain or swelling, unexplained skin rashes and fever, or swelling of lymph nodes or inflammation of internal organs. A diagnosis of JRA also is considered in children with an unexplained limp or excessive clumsiness.

No one test can be used to diagnose JRA. A doctor diagnoses JRA by carefully examining the child and considering the medical history, the results of laboratory tests, and X-rays that help rule out other conditions.

• Joint swelling or pain must last for at least 6 weeks for the doctor to consider a diagnosis of JRA. Because this factor is so important, it may be useful to keep a record of the symptoms, when they first appeared, and when they are worse or better.
• Laboratory tests, including blood tests, cannot by themselves provide the doctor with a clear diagnosis. But these tests can be used to help rule out other conditions and classify the type of JRA a patient has. Blood may be taken to test for rheumatoid factor and antinuclear antibodies (ANA), and to determine the erythrocyte sedimentation rate (ESR), called "sed rate."
• X-rays are needed if the doctor suspects injury to the bone or unusual bone development. Early in the disease, some X-rays can show cartilage damage. In general, X-rays are more useful later in the disease, when bones may be affected.
• Because there are many causes of joint pain and swelling, the doctor must rule out other conditions before diagnosing JRA. These include injury, bacterial or viral infection, Lyme disease, inflammatory bowel disease, lupus, dermatomyositis, and some forms of cancer. The doctor may use additional laboratory tests to help rule out these and other possible conditions.

What Are the Treatments?
Rheumatologists have special expertise in caring for patients with JRA. Pediatric rheumatologists are trained in both pediatrics and rheumatology and are best equipped to deal with the complex problems of children with arthritis and other rheumatic diseases. However, there are very few such specialists, and some areas of the country have none at all. In such circumstances, a team approach involving the child's pediatrician and a rheumatologist with experience in both adult and pediatric rheumatic disease provides optimal care for children with arthritis. Other important members of the team include physical therapists and occupational therapists.

The main goals of treatment are to preserve a high level of physical and social functioning and maintain a good quality of life. To achieve these goals, doctors recommend treatments to reduce swelling; maintain full movement in the affected joints; relieve pain; and identify, treat, and prevent complications. Most children with JRA need medication and physical therapy to reach these goals.

Several types of medication are available to treat JRA:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) include aspirin, Advil, and Aleve, and prescription drugs. They often are the first type of medication used. Most doctors do not treat children with aspirin because of the possibility that it will cause bleeding problems, stomach upset, liver problems, or Reye's syndrome. But for some children, aspirin in the correct dose (measured by blood test) can control JRA symptoms effectively with few serious side effects.
• Disease-modifying anti-rheumatic drugs (DMARDs) are often used if NSAIDs don't provide sufficient relief. DMARDs slow the progression of JRA, but because they take weeks or months to relieve symptoms, they often are taken with an NSAID. Methotrexate is usually the only such drug used for JRA.
• Corticosteroids, or steroids, such as prednisone may be used in children with very severe JRA. They can help stop serious symptoms such as inflammation of the lining around the heart (pericarditis). This medication can be given either directly into the vein or by mouth. Steroids can interfere with a child's normal growth and can cause other side effects, such as a round face, weakened bones, and increased susceptibility to infections.
• Biologic agents such as Enbrel may rarely be given to children in whom other drugs do not work. It blocks the actions of tumor necrosis factor, a naturally occurring protein in the body that helps cause inflammation. Clinical trials of other biological agents are underway to determine if these agents can also offer a benefit to children with JRA.
• Physical therapy is an important part of a child's treatment plan. It can help 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 a child with JRA. The specialist also may recommend using splints and other devices to help maintain normal bone and joint growth.
• Some alternative or complementary approaches, such as acupuncture, may help a child cope with or reduce some of the stress of living with a chronic illness. If the doctor feels the approach has value and will not harm the child, it can be incorporated into the treatment plan. However, it is important not to neglect regular healthcare or treatment of serious symptoms.

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