Cleveland_Clinic_Host: Today's live chat with Dr. Steven Spalding is about Juvenile Arthritis. Joint swelling, stiffness and reduced motion could be a sign of Juvenile idiopathic arthritis (JIA). JIA, formerly known as juvenile rheumatoid arthritis, affects about 1 in 1,000 children, or about 100,000 children in the United States and is a common type of arthritis of children 16 years of age or younger. JIA is a chronic disease that can affect joints in any part of the body. Other areas of the body, especially the eyes, also may be affected by the inflammation. Without treatment, JIA can interfere with a child’s normal growth and development. Dr. Spalding is available to answer your questions.
Steven Spalding, MD, is an Associate Staff Member in the Department for Rheumatic and Immunologic Disease. He is certified by the American Board of Pediatrics in general pediatrics as well as a member of several professional societies, including the American Academy of Pediatrics, American College of Rheumatology and Childhood Arthritis & Rheumatology Research Alliance.
He has presented, published and participated in research on a variety of pediatric rheumatology subjects, including pediatric vasculitis, juvenile arthritis, recurrent fever syndromes, and neonatal lupus.
Dr. Spalding is part of both the Orthopaedic & Rheumatologic Institute and the Pediatric Institute & Children’s Hospital which represents the best of both worlds for our patients. He is quoted as saying "Families often follow a circuitous route to the diagnosis of a child’s rheumatologic condition. Both parents and child initially feel overwhelmed and powerless, especially because many conditions are life-long. As pediatric rheumatologists, we can have a major impact on the way children and families deal with these illnesses by acting as caregivers, educators and advocates. The long-lasting bonds formed and the guidance offered is a ‘win-win’ situation for both physician and family."
Cleveland Clinic pediatric rheumatologists have availability to numerous clinical trials of state-of-the-art treatments for juvenile rheumatoid arthritis, the ability to track patient outcomes in chronic diseases over time, expertise in the diagnosis of complex autoimmune diseases with varying symptoms, skill in the identification and management of periodic fever syndromes, and access to the renowned Cleveland Clinic Center for Vasculitis Care and Research. For more information regarding Juvenile Arthritis at Cleveland Clinic Pediatric Institute and Children’s Hospital, please visit us on our website www.clevelandclinic.org/kids or call us locally 216-444-KIDS (45437) or toll free 800-223-2273 ext 4KIDS (45437).
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Steven Spalding, MD. We are thrilled to have Dr. Spalding here today for this chat. Let’s begin with some general questions about arthritis and how it can affect a younger population.
Juvenile Arthritis Overview
elaine: Are there different types of pediatric arthritis?
Speaker_-_Dr__Steven_Spalding: There are many different types of arthritis in children. First one must differentiate between acute and chronic arthritis, which is based on the duration of time patient has arthritis.
Patients with arthritis lasting less than 6 weeks have acute arthritis while arthritis symptoms lasting more than 6 weeks is classified as chronic. The most common form of chronic arthritis is juvenile idiopathic arthritis (JIA) or what we used to call juvenile rheumatoid arthritis (JRA).
Other forms include Spondyloarthropathies, a group of conditions which cause arthritis in the spine, and arthritis related to other autoimmune conditions like inflammatory bowel disease or lupus.
nystrom: What joints are affected in JIA?
Speaker_-_Dr__Steven_Spalding: Any joint can be involved in JIA. Most children with JIA have involvement in the lower extremities such as knees and ankles. Some children will even have involvement of the jaw, neck or spine.
icanangel: My doctor has suggested moving to a drier and warmer location, to help my son (we live in Ohio). He mentioned Arizona. Would this really help?
Speaker_-_Dr__Steven_Spalding: Weather changes can periodically worsen joint symptoms in children who have arthritis. However, children who are receiving effective therapy should have minimal complaints regardless of weather changes.
Juvenile Arthritis Signs and Symptoms
Brenda: What are the common signs and symptoms of Juvenile Arthritis?
Speaker_-_Dr__Steven_Spalding: Typically parents report they see swelling of joints or decreased function like limping or difficulty holding items. Children with JIA only rarely complain of joint pain. In fact a study showed that only 5 out of 100 who complain of joint pain will be diagnosed with JIA. When I am examining a child for arthritis I look for swelling of joints, joints which are limited in their ability to move, pain with movement, and pain over the joint line.
merrymerry: What really is a flare?
Speaker_-_Dr__Steven_Spalding: A flare is an increase in disease activity. Children who experience a flare of their arthritis complain of increased pain, swelling or loss of function. The symptoms may be similar to when they were first diagnosed with arthritis.
gini: I have a pain in my chest. I went to some doctors, and they told me they are rheumatic pains. They gave me a cream, to apply it on the back side, and on the chest. After I apply it, I have no pains. How can you explain I have rheumatism, at 27 years old only?
Speaker_-_Dr__Steven_Spalding: Most children with arthritis do not complain of pain and chest pain would be an unusual manifestation of arthritis.
connie27ga: I have a 7 y/o son that on a day to day life is fine. But today got up and was not able to walk right. What could be the problem?
Speaker_-_Dr__Steven_Spalding: It is not unusual for children to have intermittent joint pain in the mornings, especially after having been very active in the evening. Children your son's age may have 'loose' joints and may experience pain after being very active. A single morning where your child briefly limps is not concerning. However, if you notice the limp occurring more frequently or if the limp lasts more than 30 minutes or if there is any swelling of the joints, then he or she should be evaluate by your pediatrician.
kellys: Is blood in the urine common with JRA? My daughter always has at least a trace amount in her urine (microscopic). Her Dr says it has to do with the Calcium ratio. Do you agree with this and what can be done about it?
Speaker_-_Dr__Steven_Spalding: Blood in the urine can be found a minority of children with JIA. The blood may be a result of medications, or inherited conditions such as kidney stones.
I would suggest speaking to your pediatrician or a Pediatric Nephrologist to discuss diet modifications which may help lower the Calcium ratio.
Juvenile Arthritis Diagnosis
bw1014: How is it diagnosed?
Speaker_-_Dr__Steven_Spalding: Blood tests and x-rays have no role in the diagnosis of arthritis in children. The diagnosis of arthritis is based solely physical examination, namely the findings of joint swelling, pain with motion, limited movement of joints, or pain over the joint line. If a patient has a combination of these findings in the proper historical context then he or she can be diagnosed with arthritis.
Juvenile Arthritis: Is it Genetic?
MimiGram: Is JA genetic?
Speaker_-_Dr__Steven_Spalding: There are certain genetic traits which may predispose a patient to develop arthritis but these genetic markers are not found in all patients with arthritis and not all patients with these genetic traits develop arthritis.
pleading: Can JRA go away and never come back as the child grows older?
Speaker_-_Dr__Steven_Spalding: Approximately fifty percent of all children who have arthritis will continue to have symptoms as adults. However, if your child has arthritis in 4 or fewer joints, the chances of going into extended periods of disease inactivity are approximately 60-70%.
bNulty: My daughter’s aunt (paternal) had Lupus. I know she was ANA positive. Is there any proof of rheumatoid diseases being hereditary?
Speaker_-_Dr__Steven_Spalding: No. There is no proof that these conditions are hereditary.
chris: How is the arthritis identified in an infant?
We use the same techniques to detect arthritis in infants as we do in other children. Although it can be more difficult given their limited ability to communicate.
Medications for infants come in both liquid and injectable forms. Response to therapy is measured by caregiver observation and the physician's physical exam.
Juvenile Arthritis Causes
Angela914: What causes Juvenile Arthritis? Is there any way to prevent it?
Speaker_-_Dr__Steven_Spalding: The causes of JIA are complex. Researchers have found certain genetic traits which may predispose individuals to develop arthritis but not all patients with these genetic markers develop arthritis. Researchers also believe there must be a trigger to cause arthritis in these individuals.
So far, there has been no conclusive evidence that any particular virus, bacteria, or chemical triggers arthritis in children. Whatever the cause, the result is that the immune system, which is supposed to protect us from germs, instead attacks the joint tissue resulting in inflammation.
Currently there is no cure for arthritis but we have many effective treatments.
Juvenile Arthritis: Treatment Options
dwb219: What treatment options are there?
Speaker_-_Dr__Steven_Spalding: The treatment options available for children with arthritis expand every year. We use drugs like ibuprofen and naproxen to control pain in children with arthritis. We also will use localized injections of steroids into more problematic joints. Sometimes this is done under anesthesia. Children with more severe forms of arthritis will require medications to suppress the immune system, most commonly a drug called methotrexate. If we are unable to control a patient's arthritis with these measures then we may use drugs which are administered via shots or by IV.
jackiesmom: What do you suggest for medicine to stop deformities in a 12 yr old?
Speaker_-_Dr__Steven_Spalding: That would depend on which medications have been tried and the type of arthritis. Generally speaking, if someone has developed deformities, we would recommend biologics such as Remicade® or Enbrel®.
beth: My child has arthritis in his jaw. What treatment options are available?
Speaker_-_Dr__Steven_Spalding: Arthritis in the jaw can be difficult to effectively treat. Often times it fails to respond to conventional treatment like Methotrexate or the biologics like Remicade® and Enbrel®.
In these cases, we refer children to our Pediatric Radiologists who can inject the jaw joints with steroids using imaging guidance. Don't worry, the child is sedated.
pitterpat: My daughter has bad poly JRA with severe mouth ulcers. What is the cause and best treatment?
Speaker_-_Dr__Steven_Spalding: Mouth ulcers can be a side effect of Methotrexate. If your child is on this medication, she should be on Folic Acid and some children need higher doses of Folic Acid to prevent mouth sores.
trolley: Can you discuss what reactive arthritis is?
Speaker_-_Dr__Steven_Spalding: Rheumatologists use the term Reactive Arthritis to describe a chronic form of arthritis which was previously referred to as Reiter's Syndrome.
However, pediatricians and other health care providers use the term reactive Arthritis is a term used to describe arthritis occurring around the time of an infection. Typically, Reactive Arthritis resolves within 6-10 weeks and does not recur.
Treatment for Reactive Arthritis related to an infection is largely supportive consists of pain control and anti-inflammatory medications.
Spondyloarthropathies: Ankylosing Spondylitis
peabody: I have heard that Ankylosing Spondylitis is a form of Rheumatoid Arthritis (RA). I have also heard that RA and Ankylosing Spondylitis (AS) are two different types of diseases. Can you please help clear this up for me?
Speaker_-_Dr__Steven_Spalding: Both RA and AS are forms of chronic arthritis. AS is a subtype of a group of disorders called the Spondyloarthropathies which have a preference for causing arthritis in the back in young men.
In contrast RA does not frequently involve the back and affects women more frequently than men.
Juvenile Arthritis: Systemic Onset Arthritis
flowerpower: I was diagnosed with JRA when I was 6. I had high fevers and accompanying seizures. My 3 year old son has also been diagnosed with JRA and is now also having febrile seizures. Is there any correlation?
Speaker_-_Dr__Steven_Spalding: There is a subtype of JIA called Systemic Onset Arthritis. In this type of JIA, children experience arthritis, high fevers and rash. However, febrile seizures in this group of patients are uncommon. There is a familial tendency toward febrile seizures regardless of a parent or child has arthritis.
However there are inherited disorders of the immune system which can result in recurrent fevers, seizures and arthritis.
These conditions are rare, but Cleveland Clinic is one of the leading centers in diagnosing and treating these conditions.
Juvenile Arthritis and Immunizations
newtonm: Do you feel there is a relationship between vaccinations and RA or JRA?
Speaker_-_Dr__Steven_Spalding: There has been no conclusive evidence to link vaccinations to the onset of arthritis in either children or adults.
newtonm: Would a flu shot be a bad idea for my 12yr old?
Speaker_-_Dr__Steven_Spalding: Any child on medications which suppress the immune response should receive a flu shot annually. It is not too late, even though it is February, but you must be aware that it takes approximately 2-3 weeks for the protective effect to develop.
Juvenile Arthritis and School
Sue: How does a child with Juvenile Arthritis do in school? Should they be restricted from certain physical activities such as P.E?
Speaker_-_Dr__Steven_Spalding: Children with JIA should be able to attend school and their school performance should not be affected by their arthritis. There are times that their physical activities will need to be restricted when their arthritis is more active but we have children with JIA who are athletes and compete at high levels.
poppadan: What can I do as a parent to educate my daughter’s teachers, school nurse and administrators about her Juvenile Arthritis?
Speaker_-_Dr__Steven_Spalding: The best thing you can do is to go in and talk to the teachers 1-on-1. If you feel you did not get what you needed from your child's teacher then I would ask to speak to the principal. In addition, Section 504 of the Americans with Disabilities Act established that no one with a disability can be excluded from participating in federally funded programs or activities, including school. You can request that the school prepare a 504 plan to accommodate your child's specific needs.
Juvenile Arthritis: Finding a Specialist
planejane: My 6yr old daughter was just diagnosed. There is no Pediatric Rheumatologist in our immediate area. If I want to go out of town to see a specialist, I would have to fight with our insurance as to coverage. Is seeing a specialist recommended, or is it OK to see a pediatrician here who treats this?
Speaker_-_Dr__Steven_Spalding: I would strongly recommend seeing a Pediatric Rheumatologist or an Adult Rheumatologist with experience treating children. General Pediatricians do not have formal training in treating this illness.
Your Pediatrician can contact your insurance company and appeal their decision regarding the higher cost of seeing a Pediatric Rheumatologist.
Juvenile Arthritis and Research
margie: Is there any new research being conducted regarding Juvenile Arthritis? Anything with stem cells?
Speaker_-_Dr__Steven_Spalding: There is currently 1 major treatment study examining a novel treatment strategy in children with arthritis. We are participating in this study and have recruited the most number of patients in the country so far. There are several smaller studies looking at treatment of a specific subtype of arthritis called systemic onset arthritis. There has been no research using stem cells in the treatment of patients with JIA.
Juvenile Arthritis and Physical Activity
abcand123: My child doesn't want to be limited in her physical activity due to her JRA. She just goes on despite the pain. What I want to know is could this make things worse? Is she just hurting herself in the long run?
Speaker_-_Dr__Steven_Spalding: We encourage children with arthritis to maintain normal activity levels. This is important for their overall health, emotional well-being, and development. It is a misconception that physical activity in children with arthritis will lead to damage of their joints.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Spalding is now over. Thank you again Dr. Spalding, for taking the time to answer our questions today.
Speaker_-_Dr__Steven_Spalding: We appreciate everyone's time and enthusiasm. Having a child with JIA poses many challenges for families. Caring for a child with JIA requires a team effort between families, physicians and educators. Asking questions, seeking information regarding new treatments and keeping up to date on research is the best way parents can continue to be strong advocates for their child.
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This chat occurred in February 2009.
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