Online Health Chat with Dr. Andrew Zeft

July 9, 2012

Introduction

Cleveland_Clinic_Host: Does your child complain about aching legs or sore joints? Like chicken pox and strep throat, growing pains can be a rite of passage for children. Growing pains typically occur between the ages of 3 and 7 years, and are often described as an ache or throb in the legs, knees, head or abdomen. Some children are predisposed to growing pains, which produce real discomfort for many children and can be more intense after a day of vigorous activity. Children typically feel the pains at night, with symptoms subsiding in the morning. Often, massage of the affected area and Tylenol® with a bit of food helps children feel better.

However, certain pains—especially persistent pain and tenderness in the joints—can mean something more serious, such as juvenile arthritis, bone infections or rheumatic fever. If your child develops certain symptoms, it’s important to notify your pediatrician immediately. Worrisome symptoms that might indicate something more serious than growing pains include:

  • Persistent pain, pain in the morning or tenderness, or swelling and redness in a joint
  • Joint pain associated with injury
  • Limping, weakness or unusual tenderness

For More Information

Cleveland Clinic Children's Hospital Center for Rheumatology provides a complete spectrum of care for children and adolescents who present with a wide range of rheumatic disorders, including joint swelling, juvenile arthritis, acute or chronic limp, or evidence of an autoimmune disease. A wide range of specialized, multidisciplinary pediatric services are available to the child and family with a rheumatic disorder, including nursing, physical and occupational therapy, orthotics, pediatric ophthalmology and orthopedics. Expert consultations are also readily available in pediatric radiology, gastroenterology, pulmonology, neurology, nephrology, cardiology, and other sub-specialty services. Children requiring inpatient rehabilitation services can be treated at the nationally recognized Cleveland Clinic Children's Hospital for Rehabilitation.

Cleveland Clinic is a regional, national, and international resource, and is regularly ranked among the top five hospitals in the United States by U.S.News & World Report. The Department of Rheumatic and Immunologic Diseases is also rated among the two best programs in rheumatology in the United States.

In addition to providing pediatric patients with quality, family-centered care, we also offer rheumatology care for children and adolescents outside of the country. The Cleveland Clinic International Center regularly arranges visas, travel and accommodations for families who require extensive outpatient evaluations and/or inpatient management.


For Appointments

Cleveland_Clinic_Host: If you would like more information on the Cleveland Clinic Children's Hospital Center for Rheumatology or general information on juvenile arthritis visit us online at clevelandclinicchildrens.org. For general pediatric information, visit our website or to make an appointment with any of our pediatricians or pediatric specialists, please call 216.444.KIDS (5437) or call toll-free 800.223.2273, ext. 5437.

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About the Speakers

Andrew Zeft, MD, also has a dual appointment in the Department of Rheumatic and Immunologic Disease and in Medical Subspecialty Pediatrics. He earned his medical degree from the Medical College of Wisconsin, in Milwaukee, Wis, and completed his pediatric residency at Tulane University Hospital & Clinics in New Orleans, La. He completed his pediatric rheumatology fellowship at Seattle Children’s Hospital, Research and Foundation, in Seattle, Wash., and is certified by the American Board of Pediatrics in general pediatrics and pediatric rheumatology.

Dr. Zeft has presented, published and participated in research on a variety of pediatric rheumatology subjects, including juvenile idiopathic arthritis and pediatric granulomatosis with polyangiitis (GPA) (formerly, Wegener's granulomatosis).. His clinical interests include juvenile dermatomyositis, vasculitis, juvenile rheumatoid arthritis, localized scleroderma, systemic lupus erythematosus and other rheumatologic conditions that affect children.


Let’s Chat About Joint Pain

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Andrew Zeft,MD. We are thrilled to have him here today for this chat on Your Child's Joint Pain. Let’s begin with some of your questions.

Amplified Musculoskeletal Pain

lrelibrarian: My 18-year-old daughter has had non-symptomatic joint pain for years. Joints affected have been hips, knees and shoulders―sometimes with swelling. Currently, she complains of extreme groin pain and muscle spasms, and says that her leg becomes 'stuck' when the pain is at its worst. Last night it took her 10 minutes to cross roughly 6 feet of the living room floor. Aided by a crutch, she would take a tiny step, and then crawl the toes of her left foot across the carpet to move her leg. If her leg moved too fast or got caught on the carpet, the pain was extreme. We have taken her to many orthopedic exams, but no diagnosis past 'growing pains.' Yesterday’s appointment gained us a lecture from the orthopod about how it was pathetic that a teenager needed to be brought to the appointment in a wheelchair, that she needs to build muscle to support her joints. She is very slender, and not obese. He did take x-rays of her hip that were unremarkable, and ordered blood work to look for a potential systemic cause for the pain. Two years ago, he ordered a right hip arthrogram, which, again, were unremarkable. Do you have any advice or suggestions that I can start investigating to help my daughter? The prospect of her upcoming out-of-state college is making me nervous! Thank you.
Dr__Zeft: The degree of pain, long duration of symptoms with normal labs, and the implied response by the orthopedic physician suggests to me your child may have issues with amplified musculoskeletal pain of childhood. Frequently, children are screened by a rheumatologist to rule out rheumatic disease. If appropriate, they are then cared for by a team who are skilled in helping children with problems within the spectrum of chronic pain (example is the program here at Cleveland Clinic Children's Hospital for Rehabilitation in Shaker Heights, Ohio). Children can improve significantly and have good outcomes.

Benign Nocturnal Pains of Childhood

Jebosley: Our 3-year-old wakes up crying in pain, approximately every 10 to 14 days. Either one of her knees or ankles is usually affected . The joint is not red, warm or swollen. She is in severe pain when it happens. We give her 1/2 tsp. ibuprofen; she wakes up the next day and is fine. She has a positive ANA, but I was told it is really negative because the titer is 1:80. Could this be growing pains or something else?
Dr__Zeft: Your child's symptoms are most suggestive of "benign nocturnal pains of childhood", or in less technical terms, may be described as growing pains. I would not say the ANA is negative, since it was positive, but it is not uncommon for ANA to be low titer in children. It can be either reactive following viral illness or else of low titer or not clinically significant.

steward4: Technically speaking, what is happening when a child is experiencing ‘growing pains’?
Cleveland Clinic Physician: The short answer is no one really knows. In-depth research (of growing pains) has failed to demonstrate any problems with blood flow, bone, muscle or nerves to explain this pain. Growing pains should be used to explain pain only when the following conditions are met: the child’s age is between 3 and 8 years; the pain occurs on both sides; the pain is in the leg; and it occurs at night. Growing pain should not be used to explain any persistent swelling, limp or morning stiffness.

Treatment of Growing Pains

goodwindani: What the best treatment options for growing pains?
Dr__Zeft: Classic growing pains, termed ‘benign nocturnal pains of childhood’, may improve with an evening dose of over-the-counter Motrin®.

Jebosley: Can growing pains make children's joints hurt, or do they just affect the long part of legs and arms?
Dr__Zeft: Classic "benign nocturnal pains of childhood" involve extremities nonspecifically, but cases could involve joint pain.

Musculoskeletal Pain in Adolescents

goodwindani: I have a 13-year-old athletic son. What are the best treatment options for growing pains?
Cleveland Clinic Physician: As a rule, 13-year-olds do not have growing pains. If he has pain related to activities, then I would suggest he see a sports medicine or pediatric rehabilitation doctor (physiatrist) for assessment and possible physical therapy. If he has persistent swelling, morning stiffness of more than 30 minutes, or difficulty using his joints, then he should be seen by a rheumatologist.

one_up: My son complains about joint pain a lot, I used to think that it was just the result of too much weight lifting and exercise combined with not enough stretching, but now I’m wondering if it’s something more serious like arthritis. What are the common symptoms and signs you see in teens who have juvenile arthritis? What are our best next steps if he seems to be exhibiting these signs?
Cleveland Clinic Physician: Symptoms of arthritis in children include the following: persistent swelling of a joint which lasts for 3 or more days, stiffness of joints in morning lasting more than 30 minutes most days of week, and loss of function or inability to participate in all regular activities. Also, children with arthritis do not usually complain of pain as a primary problem; their pain is usually less worrisome than the other symptoms.

Diagnosis of Juvenile Arthritis

totter: Do doctors mainly use lab tests to determine if a child has juvenile arthritis, or are there other ways to determine for certain that a child has juvenile arthritis?
Dr__Zeft: Typically, it is a clinical diagnosis. Laboratory tests can be helpful to the physician in clarifying or classifying the diagnosis. The gold standard for determining whether someone has synovitis (tissue inflamed in inflammatory arthritis) is an MRI. But, clinically, this is often not necessary to make the diagnosis, which is typically obtained from history and physical examination with lab tests to supplement the finding.

boppin: How young can someone be diagnosed with arthritis?
Dr__Zeft: The systemic JIA subtype may present at a very young age of less than 1 year. Less commonly, seronegative oligoarticular or polyarticular JIA presents after first birthday. However, it can present earlier, even at about 8 months of age.

Jebosley: What can cause joint pain and/or bursitis to be migratory and occur in one joint at a time (example one side of jaw, one shoulder, one ankle, one hip, etc.)? The migratory joint pain in our 3-year-old child has lasted over 18 months and has been on and off.
Dr__Zeft: Bursitis is not common in childhood, so this may not be occurring on your child, unless it is another term you are using for arthritis. Migratory arthritis that is chronic could potentially be reactive in nature or related to another problem, if there are other symptoms.

Jebosley: Can JA (juvenile arthritis) or RA (rheumatoid arthritis) joint pain be nonsymmetrical, or is it always symmetrical? What can cause joint pain or bursitis to be migratory and occur in one joint at a time (for example, one side of the jaw, one shoulder, one hip, etc.)?
Dr__Zeft: JIA (juvenile idiopathic arthritis) is often nonsymmetrical, the more common form of which is oligoarticular arthritis. Polyarticular JIA may be symmetrical, more like rheumatoid arthritis (RA). The answer to your second question depends on the length of time of symptoms, etc.

klinel: My daughter has juvenile arthritis and complains about how painful it is brushing and flossing her teeth. Could this be a result of her arthritis, or could it simply be growing pains as her adult teeth start to fill out?
Dr__Zeft: This should not be directly from her arthritis. Gum pain most commonly is from poor dentition or gingivitis. Nonsteroidal medication, like naproxen, does predispose (patients) to bruising. I would not attribute this (pain) to teeth filling out. Occasionally, gum bleeding can be a sign of a bleeding or hematologic condition.

Hereditary Nature of Juvenile Arthritis

jupin: My husband had juvenile arthritis and we’re thinking about starting a family, but we are concerned that our child will be more likely to also carry the disease. Is that true? Is it hereditary?
Dr__Zeft: There is a hereditary component. The risk of your child developing arthritis is based on the number of genetic polymorphisms passed on, which increase the risk or make him or her more susceptible. Juvenile idiopathic arthritis (JIA) has been shown to occur in approximately 1 in 1,500 children. Research data from the University of Utah reveals a 20-fold higher risk in siblings of JIA patients. I am not aware of data reporting the risk if one's father has JIA. More likely than not, your future child will not develop JIA though, even though your husband has it.

englander: My wife is pregnant with our second child and our first child, now 8 years old, has juvenile arthritis. Is there a chance our second child could also have the disease?
Dr__Zeft: There is a chance, but more likely he or she will not. Epidemiologic data from the University of Utah has reported an increased risk of developing JIA (juvenile idiopathic arthritis) in a sibling of a patient is 20 times greater than the "normal" population, yet this is still not likely since JIA occurs in only about 1 in 1,500 children.

Post-streptococcal Inflammatory Arthritis

done: Post-streptococcal inflammatory arthritis―can a child have a full recovery from this?
Cleveland Clinic Physician: Yes. Children can have a full recovery from post-streptococcal inflammatory arthritis and never have another episode. However, any child who has had post-strep arthritis is at risk to develop arthritis with later strep infections.

do_it: My son had rheumatic fever when he was 9 years old. Can this have future effects on joints?
Dr__Zeft: It should not. The joint manifestations of rheumatic fever typically are acute and not long lasting.

Treatment for Juvenile Arthritis

buty: My 13-year old has his juvenile arthritis treated solely by medication. Is that normal? Are there other forms of treatment we should be looking into for him?
Cleveland Clinic Physician: Medications are an important aspect of any juvenile idiopathic arthritis (JIA) treatment regimen. However, medications should not be the only approach to a child's arthritis. We frequently recommend physical therapy and occupational therapy for our patients. In addition, having a chronic condition like arthritis can be stressful so many patients choose to meet with a psychologist for stress management techniques. Finally, some patients will also see one of our integrative medicine physicians for complementary antiinflammatory and pain management therapies.

jodo: My son is 11 years old and has RA (rheumatoid arthritis). What are some of the treatment options you use at Cleveland Clinic? He has been on methotrexate (MTX), Enbrel® and Humira®. He keeps getting worse, with little relief and new sites becoming afflicted. He is seeing his doctor in about a month. What other options are out there?
Cleveland Clinic Physician: Our center focuses on using objective measures of disease activity, cutting edge therapies and complementary services to develop patient-centered treatment plans. Our first step would be to make sure that the complaints are due to active arthritis. Sometimes children with JIA (juvenile idiopathic arthritis) continue to have pain or disability even when their arthritis is inactive. Our center relies on imaging tools like MRI and ultrasound to assess for ongoing joint inflammation prior to changing arthritis medications. If symptoms are proven to be related to active arthritis, then we would escalate the degree of anti-inflammatory treatment based on the family's risk tolerance. We also have several research studies open at our center which provide access to innovative research medications designed to treat arthritis. If there are no objective signs of active arthritis, then we would recommend services, such as physical therapy, occupational therapy, pain medicine and psychology, to help children with their symptoms. For your son specifically, we would consider agents like infliximab (Remicade®), abatacept (Orencia®), certolizumab (Cimzia®), and tocilizumab (Actemra®) in addition to increasing his methotrexate and adding low-dose oral steroids like prednisone.

brand: Why do insurance companies deny certain medications? What can be done to get them to approve them?
Cleveland Clinic Physician: I serve as the pediatric representative on the Insurance Subcommittee of the American College of Rheumatology. We are frequently asked to review drug coverage policies by insurance companies to provide feedback and suggestions. For the most part, insurance companies base their coverage policies on the indications assigned to a drug by the U.S. Food and Drug Administration. These indications are based on the drug companies doing large and expensive studies to prove their drug works for a particular condition. Up until recently, many drug companies did not include children in their study, due to financial and regulatory reasons (children are considered a high-risk population, so there is more oversight required, which leads to more cost). The U.S. Congress passed a bill several years ago that requires all drug companies seeking to get a drug approved for a specific condition to include children in their studies. Hopefully, in the future this will be come less of an issue.

freddie: What are the side effects for a child on prednisone? Is there anything that can be done to decrease the severity?
Dr__Zeft: The side effects are different for those children on either short-term versus long-term courses of prednisone.

  • Short-term side effects include: hunger, weight gain, flushing of cheeks and/or skin, hypertension, racing thoughts and sleep disturbance
  • Long-term side effects include: growth delay, osteopenia, skin stretch marks and cataracts

Patients can take supplemental calcium and vitamin D to help prevent osteopenia (low bone density). Also, taking the steroid dose in the morning, if it is the only daily dose, can help with sleep disturbances. For weight gain, eating ‘empty calories’ of low calorie vegetables can help lessen the degree of weight gain.

glotto: What are the benefits and risks of infusions as treatment?
Cleveland Clinic Physician: The risks and benefits of infusions are largely based on the specific drug rather than the infusion procedure itself. All of the drugs given by intravenous (IV) infusion are very safe and side effects are rare. For instance, Remicade® is an infusible drug given to treat arthritis and has been on the market for close to 12 years. Children being treated with this drug can sometimes have allergic reaction during the infusion. However, at our center we have performed more than 400 Remicade® infusions in the last 4 years without an allergic reaction.

Alternative Treatment for Juvenile Arthritis

billy: Are there alternative treatments for juvenile RA (rheumatoid arthritis) that work?
Dr__Zeft: There is not evidence that alternative therapies outside the spectrum of those typically used in JIA (juvenile idiopathic arthritis) therapy (disease-modifying or biologic therapy) are efficacious. More effective alternative therapies traditionally are biologic therapies not yet approved for treating JIA, but may be under clinical research investigation.

Juvenile Arthritis and Athletics

julie: My son is an incoming high school freshman and is going out for the football team this year. I’m a bit worried about what the stress of two-a-days might have on him since he has juvenile arthritis. Should I be alerting his coaches and trainers, and telling them to limit his participation if he starts to complain of pain?
Cleveland Clinic Physician: If your son's arthritis is under good control and he has no loss of function as a result of his arthritis, then there would be no real medical concern to restrict him from participating in these activities. If he has been or is being treated with oral steroids like prednisone, then I would suggest doing a bone density study prior to his participation. This would help identify the loss of bone calcium from steroids, which would increase his risk of fracture.

Climate Effects on Arthritis

donys: I’ve heard that environment and climate can have an effect on arthritis. Is that true? What type of effects might it have?
Dr__Zeft: Patients with inflammatory arthritis not uncommonly complain of stiffness and discomfort on days of high barometric pressure. Smoking in adults has an effect on rheumatoid arthritis disease susceptibility and also affects disease activity. There is evidence that atmospheric particulate matter exposure may have an effect on childhood arthritis, but this data is not conclusive.

Arthritis Support Groups

petti: My family lives in the northern Ohio area and my daughter has juvenile arthritis, do you know of any local support groups that can help her and us as a family through this disease?
Cleveland Clinic Physician: Thankfully, you have several options. The Northeastern Ohio Chapter of the Arthritis Foundation (www.arthritis.org) has several functions every year dedicated to children and families dealing with juvenile arthritis. In addition, our group offers shared medical appointments for children and families with JIA (juvenile idiopathic arthritis). These appointments occur every 2 to 3 months and last for 2 hours. During the appointment, there is an educational portion on a topic related to JIA (diet, exercise, medications, research and infections), an activity for the children, time for the parents to interact, and a medical visit with a provider. These shared medical visits are the first of their kind in children with JIA, and are very popular with parents in our clinic.


Closing

Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Andrew Zeft, MD is now over. Thank you for taking the time to answer our questions today about Your Child's Joint Pain.
Dr__Zeft:  Thank you for all of the great questions.


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