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Does Juvenile Rheumatoid Arthritis Affect Physical Appearance?

Some children with JRA may look different because they have growth problems. Depending on the severity of the disease and the joints involved, growth in affected joints may be too fast or too slow, causing one leg or arm to be longer than the other. Overall growth may also be slowed. Doctors are exploring the use of growth hormones to treat this problem. JRA also may cause joints to grow unevenly or to one side.

Children with JRA also may look different because of medication. Corticosteroids, a type of medication sometimes used to treat JRA, can result in weight gain and a round face. When the doctor stops giving the medication, these side effects may disappear.

How Is Juvenile Rheumatoid Arthritis Diagnosed?

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 patient and considering the patient's medical history and the results of laboratory tests that help rule out other conditions.

· Symptoms: One important consideration in diagnosing JRA is the length of time that symptoms have been present. 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: Laboratory tests, usually 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 to help classify the type of JRA that a patient has. Blood may be taken to test for RF or ANA, and to determine the erythrocyte sedimentation rate (ESR).

• ANA is found in the blood more often than RF, and both are found in only a small portion of JRA patients. The RF test helps the doctor tell the difference among the three types of JRA.

• ESR is a test that measures how quickly red blood cells fall to the bottom of a test tube. Some people with rheumatic disease have an elevated ESR or "sed rate" (cells fall quickly to the bottom of the test tube), showing that there is inflammation in the body. Not all children with active joint inflammation have an elevated ESR.

· X Rays: 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.

· Other diseases: Because there are many causes of joint pain and swelling, the doctor must rule out other conditions before diagnosing JRA. These include physical injury, bacterial 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.

Who Treats Juvenile Rheumatoid Arthritis? What Are the Treatments?

A pediatrician, family physician, or other primary care doctor frequently manages the treatment of a child with JRA, often with the help of other doctors. Depending on the patient's and parents' wishes and the severity of the disease, the team of doctors may include pediatric rheumatologists (doctors specializing in childhood arthritis), ophthalmologists (eye doctors), orthopaedic surgeons (bone specialists), and physiatrists (rehabilitation specialists), as well as physical 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:*

*Brand names included in this fact sheet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.*

· Nonsteroidal anti-inflammatory drugs (NSAIDs): Aspirin, ibuprofen (Motrin, Advil, Nuprin) and naproxen or naproxen sodium (Naprosyn, Aleve) are examples of NSAIDs. 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.

If the doctor prefers not to use aspirin, other NSAIDs are available. For example, in addition to those mentioned above, diclofenac and tolmetin are available with a doctor's prescription. Studies show that these medications are as effective as aspirin with fewer side effects. An upset stomach is the most common complaint. Any side effects should be reported to the doctor, who may change the type or amount of medication.

Disease-modifying anti-rheumatic drugs (DMARDs):

If NSAIDs do not relieve symptoms of JRA, the doctor is likely to prescribe this type of medication. DMARDs slow the progression of JRA, but because they take weeks or months to relieve symptoms, they often are taken with an NSAID. Various types of DMARDs are available. In the past, doctors prescribed hydroxychloroquine, oral and injectable gold, sulfasalazine, and d-penicillamine; however, doctors are now much more likely to use methotrexate for children with JRA.

· Methotrexate: Researchers have learned that this type of DMARD is safe and effective for some children with rheumatoid arthritis whose symptoms are not relieved by other medications. Because only small doses of methotrexate are needed to relieve arthritis symptoms, potentially dangerous side effects rarely occur. The most serious complication is liver damage, but it can be avoided with regular blood screening tests and doctor followup. 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 side effects.

· Corticosteroids: In children with very severe JRA, stronger medicines may be needed to stop serious symptoms such as inflammation of the sac around the heart (pericarditis). Corticosteroids like prednisone may be added to the treatment plan to control severe symptoms. This medication can be given either intravenously (directly into the vein) or by mouth. Corticosteroids 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. Once the medication controls severe symptoms, the doctor may reduce the dose gradually and eventually stop it completely. Because it can be dangerous to stop taking corticosteroids suddenly, it is important that the patient carefully follow the doctor's instructions about how to take or reduce the dose.

In addition to medications, physical therapy 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 physical therapist can design an appropriate exercise program for a person with JRA. The physical therapist also may recommend using splints and other devices to keep joints growing evenly.