Juvenile idiopathic arthritis: Symptoms and treatments

Arthritis is probably something most of us associate with getting older, but the truth is it can affect younger people too, including children and teenagers.
 
The most common type of arthritis that affects children is juvenile idiopathic arthritis (formerly called juvenile rheumatoid arthritis)  This can be diagnosed in children and teenagers aged 16 years or younger who’ve had joint problems for six weeks or longer that haven’t been linked with any other health condition (other problems that can cause joint pain and stiffness in children include growing pains, lupus, Lyme disease, diabetes, thyroid disorders, sports injuries and leukaemia).

What is juvenile arthritis?

Rather than a condition caused by wear and tear of the joints – as with osteoarthritis – juvenile idiopathic arthritis is classed as an autoimmune disorder. This means the symptoms are caused by the immune system mistakenly attacking parts of the body (with juvenile idiopathic arthritis the immune system attacks the joints).
 
Thankfully juvenile idiopathic arthritis isn’t common, with between one and two in every 1,000 children affected at any one time and one to two in every 10,000 children developing it each year (i). The condition overall is more common in girls, though some types are more common in boys (ii) (see Different types of juvenile idiopathic arthritis below for more details).
 

What causes juvenile idiopathic arthritis?

We know juvenile idiopathic arthritis is an autoimmune condition. In this case, the immune system triggers the release of inflammatory chemicals that attack the lining around a joint, called the synovium. As a result, the synovium becomes very inflamed, which makes the joint feel stiff or painful, or both.
 
Why this happens, however, isn’t clear (idiopathic means the cause is unknown). One of the most widely accepted theories, however, is that the immune system may behave in this way because of environmental and genetic factors.
 
Some of the genes thought to be involved in juvenile idiopathic arthritis belong to a family called the human leukocyte antigen (HLA) complex, as scientists have discovered some normal variations of several HLA genes may affect a child’s risk of developing the condition (iii). Several other genes have been associated with juvenile idiopathic arthritis risk too, but this doesn’t mean juvenile idiopathic arthritis always runs in families – though a child with a brother or sister affected by the condition is thought to have an estimated risk that’s 12 times higher than the general population (iii).
 
Meanwhile, environmental factors that scientists think may play a part in the condition’s development include exposure to antibiotics and having been born by caesarean section (iv).
 

Juvenile Idiopathic arthritis symptoms

There are several different types of juvenile idiopathic arthritis, with common symptoms including:
 

• Joint pain and/or stiffness (often first thing in the morning or after a period of inactivity)

• Swollen joints that feel warm or hot to the touch

• Excessive tiredness

• Eye problems such as blurred vision or eye pain

• Skin rashes

• High-temperature

 

How long do the symptoms last?

The symptoms of juvenile idiopathic arthritis often tend to come and go. When the inflammation gets worse, it’s called a flare-up. How long each flare-up lasts varies widely, with some lasting for just a few days and others for months.
 
For most, the condition is a long-term one. With treatment, however, there can often be periods of remission where there are very few to no symptoms and no joint inflammation. During these times a child may not need any treatment, but if their symptoms come back they’ll usually need to be treated again. According to Patient UK, remission can last for weeks, months, years or even be lifelong (i).
 
If left untreated, however, juvenile idiopathic arthritis can cause complications including growth problems, osteoporosis and delayed puberty, as well as long-term joint problems. Some children with juvenile idiopathic arthritis may develop emotional and behavioural problems because of having to deal with pain and taking time off school frequently to attend hospital appointments.
 

How is juvenile arthritis diagnosed?

As joint pain can be the symptom of a number of issues, it can be hard for doctors to diagnose juvenile idiopathic arthritis. There is no single test that can confirm a diagnosis, but blood tests in combination with imaging scans can help rule out other illnesses that exhibit similar signs and symptoms.

 

Types of juvenile arthritis 

 

Oligoarthritis (Olgioarticular JIA)  

Also called oligoarticular juvenile idiopathic arthritis, this is the most common type, accounting for around two thirds of cases (v). According to Patient UK, oligoarthritis is usually diagnosed in children aged six years or younger, and is more common in females (ii). Often causing milder symptoms than some other types, oligoarthritis affects from one to four joints during the first six months – typically the larger joints such as the knees, ankles and elbows.
 
Oligoarthritis is also the type that’s most likely to cause eye inflammation – a condition called uveitis. This means children with this type – and some other types – of juvenile idiopathic arthritis need regular eye check-ups, as the inflammation doesn’t always cause any symptoms (when present, symptoms can include eye pain and redness as well as blurred vision). If left untreated, however, the eye inflammation associated with juvenile idiopathic arthritis can cause vision problems and even vision loss
 
If four or fewer joints are affected after six months the condition is known as persistent oligoarthritis. If more than four joints are affected after six months, it’s classed as extended oligoarthritis.
 

Polyarthritis  (Polyarticular JIA)

The second most common type of juvenile idiopathic arthritis, this is actually two different types – polyarticular juvenile idiopathic arthritis rheumatoid factor (RF) positive and polyarticular juvenile idiopathic arthritis RF negative. RFs are proteins produced by the immune system that can attack healthy parts of the body and are often associated with autoimmune conditions including rheumatoid arthritis. Indeed, polyarticular juvenile idiopathic arthritis RF positive is considered similar to adult rheumatoid arthritis. 
 
The RF negative type of polyarthritis is most often found in children of preschool age and in those aged between 10 and 13 years old. It’s also more common in girls (i). In both types five or more joints are usually affected, including both large and small joints. In addition to joint swelling and stiffness, symptoms can include slight fever, tiredness and a general feeling of unwellness.
 

Enthesitis-related juvenile idiopathic arthritis   

This type causes inflammation and tenderness in the entheses, which are where the tendons attach to the bones, ligaments and other connective tissues. It typically causes pain in the hips, knees, back, neck and feet, with other possible symptoms including uveitis, psoriasis and bowel inflammation.
 
Enthesitis-related juvenile idiopathic arthritis is thought to be more common in boys, usually developing after the age of 10 years (i). According to Versus Arthritis, children with enthesitis-related juvenile idiopathic arthritis may have a family history of ankylosing spondylitis or inflammatory bowel disease (v).
 

Juvenile psoriatic arthritis

As well as joint inflammation and pain, children with this type of juvenile idiopathic arthritis also develop the skin condition psoriasis, a scaly rash that can affect any part of the body but most often the elbows, knees, scalp and lower back. Any joint can be affected, most commonly the fingers and toes. This type of juvenile idiopathic arthritis can also cause uveitis.
 
Juvenile psoriatic arthritis is thought to affect twice as many girls as boys, with symptoms often starting at around six years of age (joint problems tend to start before the skin rash) (i).
 

Systemic juvenile idiopathic arthritis   

Affecting around 10 per cent of children with juvenile idiopathic arthritis (vi), this type can cause inflammation in the joints as well as all over the body. Other symptoms can include a high fever, a pink skin rash, swollen glands and an enlarged liver or spleen. Very occasionally it can cause pericarditis, which is when the fibrous sac surrounding the heart becomes inflamed, triggering sudden chest pain (typically when lying down).
 
Systemic-onset juvenile idiopathic arthritis usually starts before the age of five years (i) and affects girls and boys equally. Only around a third of children experience joint pain at the start of the condition, with two thirds developing joint problems within a few months (ii). 
 

Undifferentiated juvenile idiopathic arthritis  

 
If a child has symptoms that don’t match exactly with any of the above types – but they do have inflammation in one or more of their joints – they are usually diagnosed with this type.
 
According to the Arthritis Foundation in the US, it’s also possible for a child to start off with one type of juvenile idiopathic arthritis, and then develop symptoms of another type later on (vi).
 

Treatment for juvenile idiopathic arthritis

 
Treatments for juvenile idiopathic arthritis aren’t usually described as a cure, but rather as a means of getting the condition under control and improving a child’s quality of life. The main things a doctor or specialist will be hoping to do when treating a child with juvenile idiopathic arthritis include:
 

• Reducing or stopping inflammation

• Relieving symptoms and controlling pain

• Preventing or reducing damage to the joints and organs as well as other long-term health problem

• Keeping the joints working as well as possible

• Achieving remission

Treatments often include physical therapies such as physiotherapy and occupational therapy. These can include daily exercises to help make the muscles stronger and more flexible, which in turn can help reduce the risk of joint damage. An occupational therapist can also provide aids and other equipment to help a child with idiopathic juvenile arthritis live more independently.
 

Juvenile idiopathic arthritis medications

 
Many children with juvenile idiopathic arthritis take medicines to control their symptoms as well as keep their joints protected against damage. These include:
 

Anti-inflammatories  

 
Medicines called non-steroidal anti-inflammatory drugs (NSAIDs) aim to reduce pain and stiffness in the joints by reducing inflammation.
 

Steroids  

 
Used as injections, tablets, drops and creams, these also help reduce inflammation in the joints, eyes and skin. Steroid tablets can often be used to treat inflammation in other parts of the body too, including the pericardium (the sac surrounding the heart).
 

DMARDs  

 
Short for disease-modifying anti-rheumatic drugs, DMARDs are used to reduce inflammation and joint damage. The most common DMARD used for children with juvenile idiopathic arthritis is methotrexate.
 

Biological therapies  

 
These are newer medicines that can help reduce the symptoms of juvenile idiopathic arthritis as well as reduce joint damage, and are often used when other treatments – such as DMARDs – don’t work. The main biological therapy used for juvenile idiopathic arthritis is etanercept.
 
Meanwhile, children with juvenile idiopathic arthritis who have uveitis will usually be treated with eye drops to reduce the inflammation, though they may also need to take DMARDs or biological therapies if the eye drops alone aren’t effective.
 

Living with arthritis

An effective treatment plan for a child or teenager with juvenile idiopathic arthritis will also include healthy lifestyle advice, including guidance about exercise.
 
Regular exercise is important and according to Versus Arthritis there’s no evidence to suggest it can make juvenile idiopathic arthritis worse (vii). Staying active helps keep a child’s joints mobile and prevents pain and stiffness, plus it can help them sleep better and boost their mood. Exercises that don’t put too much pressure on the joints may be especially helpful, including:
 

• Swimming

• Cycling

• Pilates 

• Yoga

During a flare-up it’s still important to stay active. However, it may be a good idea to avoid high-impact activities – if in doubt, speak to a physiotherapist who can advise you on particular types of exercises that can be good for your child when they’re having a flare-up.
 
Other things that may help include the following:
 
Sleep well   It’s not always easy to get a good night’s rest if you’re living with any form of arthritis, as the pain can make it difficult for you to fall asleep. Not sleeping well, however, can make a child’s symptoms worse and make them tired and moody during the daytime. If your child is having problems with sleep, speak to your GP or specialist. There are also plenty of tips to help your child get a better night’s sleep in guide to children’s health: sleep.
 
Maintain a healthy weight   Being overweight may make the symptoms of juvenile idiopathic arthritis worse, says Versus Arthritis, as it may cause extra inflammation (vii). Staying active can help keep a child’s weight in the normal range, as can eating a healthy balanced diet (see below for more details).
 
Rest up   During a flare-up it’s important to get plenty of rest and to only take part in light activity. Resting can help reduce inflammation, plus it can help if your child is experiencing fatigue. Try to make sure they take plenty of breaks throughout the day so that they have a good balance between rest and activity (this is often called pacing). 
 
Practise relaxation   Teaching your child how to relax can help stop them focusing on pain and lower their stress levels. Some of the things you could try include meditation, deep breathing exercises and visualisation techniques. Other ways to distract them from their symptoms include activities they enjoy such as drawing, painting, reading or listening to music.
 
Try heat treatments   Stiff, tender joints and muscles can often be relieved with the application of heat – try using a heat pad or hot water bottle for example, or give your child a warm bath. During the night you could help keep their joints and muscles warm by using an electric blanket.
 

Arthritis and diet 

Currently there’s no specific diet that’s clinically proven to help reduce the symptoms of juvenile idiopathic arthritis, but eating a nutritious diet can support a child’s overall health and well-being. Try basing their diet around whole foods rather than processed ones, and focus on making sure they get plenty of fruit and vegetables (aim for the recommended five portions a day).
 
Getting plenty of calcium and vitamin D is also important, as it can help keep their bones strong – something that may be an issue if your child is taking steroid medication. Foods that contain calcium include dairy products and fortified dairy alternatives (soya milk, for example), nuts, kale and broccoli. Alternatively, you may decide to give them a calcium supplement to make sure they’re getting all the calcium their bones need (try a chewable tablet that they’ll like the taste of).
 
Vitamin D is found in fortified foods too, as well as in red meat, liver, egg yolks and oily fish. Our best source of vitamin D, however, is exposure to sunlight (our skin makes its own vitamin D when exposed to the sun’s rays). This may not necessarily be a problem for most children during the summer months, but at other times of the year many people are thought to be low or even deficient in vitamin D because of the lack of sunlight. This is why the UK government recommends everyone – including children aged one year and older – should consider taking a daily vitamin D supplement during the autumn and winter months (viii).
 
Look for a supplement that contains 10 micrograms of vitamin D in each dose – if your child doesn’t like taking tablets, vitamin D drops are available.
 

Arthritis supplements

 

Folic acid  

 
If your child is taking methotrexate their doctor may recommend a folic acid supplement, since methotrexate can affect how the body processes folate (folate – found in a range of foods, including dark green leafy vegetables, peas, broccoli, Brussels sprouts, chickpeas, kidney beans and fortified breakfast cereals – is the natural form of folic acid). If you want to buy a folic acid supplement for your child, one easy option is to choose a multivitamin and mineral formulation – in chewable tablet form, for instance – that contains a good level of the nutrient.
 

Fish oils  

 
The omega-3 essential fatty acids found in oily fish are widely thought to help reduce inflammation, with some studies even suggesting they may be beneficial for people affected by arthritis (ix). Chewable omega-3 tablets are available and may be a wise choice for a child who doesn’t like taking ordinary tablets.
 

Turmeric  

 
Best known as one of the spices that give curry its distinctive flavour, turmeric contains an active ingredient called curcumin that’s often used by natural health practitioners to treat pain, inflammation and stiffness. Indeed, studies have shown curcumin may help reduce joint pain and swelling, with one trial suggesting it may be more effective than conventional anti-inflammatories (x).
 

Anthocyanidins 

 
These are potent antioxidant compounds that help remove damaging molecules called free radicals in the body. This may be useful since free radicals are thought to cause cell damage that increases the risk of inflammation and inflammatory diseases. You can find them in foods such as blueberries, cranberries, raspberries, blackberries, red grapes, red cabbage, red onions and aubergines. Antioxidant supplements are also available, including formulations that contain anthocyanidins.
 

Need more information on juvenile arthritis?

 
There’s further help for parents who have a child or teen with juvenile idiopathic arthritis. Try contacting one of the following charities or organisations if you need more information or support:
 
Versus Arthritis
 
JIA-at-NRAS (part of the National Rheumatoid Arthritis Society)
 
CCAA (England and Wales)
 
Juvenile Arthritis Research
 
If you need information about a variety of children’s health issues, try taking a look at the children’s health section of our pharmacy health library.
 

References:

1. Available online: https://patient.info/bones-joints-muscles/rheumatoid-arthritis-leaflet/juvenile-idiopathic-arthritis

2. Available online: https://patient.info/doctor/juvenile-idiopathic-arthritis-pro

3. Available online: https://medlineplus.gov/genetics/condition/juvenile-idiopathic-arthritis/#references

4. Horton. DB., Shenoi S., Review of environmental factors and juvenile idiopathic arthritis. Open Access Rheumatol. 2019;11: 253-267. Available online: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6842741/

5. Available online: https://www.versusarthritis.org/about-arthritis/conditions/juvenile-idiopathic-arthritis/

6. Available online: https://www.arthritis.org/diseases/juvenile-idiopathic-arthritis

7. Available online: https://www.versusarthritis.org/about-arthritis/young-people/managing-your-symptoms/

8. Available online: https://www.nhs.uk/conditions/vitamins-and-minerals/vitamin-d/

9. Rajaei E. et al., The Effect of Omega-3 Fatty Acids in Patients With Active Rheumatoid Arthritis Receiving DMARDs Therapy: Double-Blind Randomized Controlled Trial. Glob J Health Sci. 2015 Nov 3;8(7):18-25. Available online: https://www.ncbi.nlm.nih.gov/pubmed/26925896

10. Chandran B. and Goel A., A randomized, pilot study to assess the efficacy and safety of curcumin in patients with active rheumatoid arthritis. Phytother Res. 2012 Nov;26(11):1719-24. Available online: https://onlinelibrary.wiley.com/doi/10.1002/ptr.4639

11. Amiraraj JF., Novel Highly Bioavailable Curcumin Formulation Improves Symptoms and Diagnostic Indicators in Rheumatoid Arthritis Patients: A Randomized, Double-Blind, Placebo-Controlled, Two-Dose, Three-Arm, and Parallel-Group Study. J Med Food. 2017 Oct;20(10):1022-1030. Available online: https://www.ncbi.nlm.nih.gov/pubmed/28850308

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