Juvenile Rheumatoid Arthritis (JRA), Part 2 — Treatment, Restrictions and Implications for School

Treatment

Early diagnosis and appropriate treatment of a child with JRA ensures the best possible opportunity for a good outcome. Treatment depends on the type and severity of arthritis. The goals of treatment are to:

  1. control inflammation
  2. relieve pain
  3. prevent joint limitation
  4. prevent joint damage
  5. maximize function

Treatment usually includes medication, exercise, activity guidelines, eye care, dental care and proper nutrition. Joint supports and splinting might be used for specific joint problems.

Medications

When a child is first diagnosed with arthritis, a steady regimen of medication will start, and may continue for several years or longer. Often, nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line of treatment. There are over 25 NSAIDs currently on the market. Not every child will respond to a particular NSAID. The doctor may need to try several to find one that works, and which the child tolerates. Each trial of medication may last several weeks to be certain the tested drug controls pain and inflammation. Generally, NSAIDs should be taken with food. Most are taken once or twice a day and so would not be taken at school. Frequently, a child's symptoms can be managed on NSAIDs alone. Commonly used NSAIDs are ibuprofen, Naprosyn®, piroxicam and Celebrex®.

If the arthritis symptoms are not controlled with first-line drugs, then disease-modifying anti-inflammatory drugs (DMARDs) are started. These medications do not produce immediate relief of pain and inflammation; rather, they produce beneficial effects, which modify the natural progression of joint disease, such as joint or bone destruction. Because they are more powerful, they require frequent monitoring with laboratory tests. Common DMARDs are methotrexate, hydroxychoroquine, sulfasalazine, and biologics such as Enbrel® and Humara®. There are other DMARDs that may be used. Glucocorticoids are more potent agents, which have more side effects. They may be used for a quick response in children with severe disease or organ involvement. Glucocorticoid doses are usually tapered, while slower-acting drugs become effective. Other drugs may be added for specific symptoms, such as iritis (inflammation in the eye).

Possible medication side effects

NSAIDs may upset the stomach and should generally be taken with meals. They require occasional laboratory monitoring. DMARDs may have other side effects, and require regular laboratory monitoring. Glucocorticoids have many side effects, such as weight gain, thinning of the bones, mood swings, slowed growth and reduced resistance to infection. Children with active disease on some of the DMARDs and glucocorticoids may not be able to have regular immunizations, and may be at risk when exposed to certain infections and diseases such as chicken pox.

Physical, dietary and other restrictions

  • No specific foods affect arthritis, but all children with a chronic disease need a varied and healthy diet.
  • A child with arthritis might have initial weight loss, and would need extra calories to regain lost weight.
  • All chronically ill children should receive additional calories, because any active disease increases the body's caloric requirement.
  • All children should have a balanced diet with an adequate amount of iron and calcium for age.
  • Steroids increase appetite. A child on glucocortocoids needs to limit calories and salt to prevent excessive weight gain.
  • Depending on the joints involved, the child might need to limit walking, standing and running. Even sitting might require modification.
  • A child with arthritis should be allowed to set independent, personal limits on activities, according to the severity of joint symptoms each day.
Adolescents at school.

Implications for school

Most children do very well at school. However, many will need some degree of modification or accommodation in their activities. Arthritis itself does not interfere with learning, but the pain and stiffness of arthritis can distract the student and prevent concentration. Many children find mornings to be the most difficult time of the day because of stiffness. Some children need extra time to get ready for school. Students in secondary school might benefit from having a study hall scheduled for first hour. This simple change can prevent stress for the student.

A child with severe arthritis of the hands will have significant difficulty with any written assignment. Such a student might need to complete a subset of the assigned problems, such as every other math problem, and require additional time to complete written tests. Having a second set of books at home will alleviate the need to carry a heavy backpack.

Physical education (PE) classes are frequently the greatest challenge for students with arthritis. Most of the activities are fun, and the student wants to participate as much as possible. Stretching and slow exercises are best. Avoid exercises that jerk, bounce or stress the joints. For example, jumping jacks, jumping rope, and distance running can be harmful for children with arthritis in the legs. Pushups, crab walking, and rope climbing can be harmful for children with arthritis in the arms and shoulders. Sports involving contact or collision with another player or a hard object also might be problematic. Students can practice and learn the necessary skills using softer balls, such as a beach ball or a Nerf® ball. A child might benefit from walking instead of running laps. Bear in mind that all accommodations are individual, and should follow communication with the student, parents, teachers, and doctor.

Students with arthritis are likely to benefit from a Section 504 Plan, or perhaps the student should be evaluated to determine whether being classified as Other Health Impaired (which would lead to an IEP) might be beneficial. These plans permit accommodations such as allowing additional time to complete assignments, starting school an hour later in the morning, permitting rest periods in the nurse's office, and providing help with assignments after an absence. A Section 504 Plan may enable the student to continue to succeed in school, with needed accommodations and modifications in place. The main office of any school district will be able to direct parents and guardians to the appropriate person in the district and the school to assist in the development of these plans.

With permission of the student and parent, a conference between the school, hospital, healthcare providers, parent and student is recommended. The meeting allows all parties to discuss the student's needs as well as the interventions that will allow for continued school success. Educating peers and classmates about arthritis may also produce an environment that is more accepting of individual differences, benefiting all students.

Arthritis in children is often a hidden disease. Other people cannot see pain, limited mobility or lack of energy. Arthritis is not static, but rather it changes without warning. As the symptoms wax and wane, so will the child's limitations. Unfortunately, children avoid drawing attention to themselves, and might not complain, even if they have significant pain. A member of the school staff should be assigned to be the student's advocate. This person can act as a liaison, balancing the academic needs of the student and the medical needs of the arthritis. This person is vital in ensuring the student receives the accommodations needed to be successful at school.

KU Kids Healing Place

During treatment for JRA, there are many challenges for the child and family. In addition to the essential medical treatment for JRA, it is important to care for the psychological, social and spiritual needs of the child and family. This type of care, called palliative care, previously had been reserved for only the sickest patients. However, research has demonstrated that palliative care helps maintain normalcy throughout treatment, recovery and life. Today, every child with JRA receives the benefit of palliative care, along with all family members. The KU Kids Healing Place (KUKHP), through the Department of Pediatrics at the University of Kansas Medical Center, focuses on treating all aspects of the child and family, ensuring that each receives the care needed to maintain psychological, social and spiritual well-being during treatment for JRA and on into life. The entire treatment team will work to ensure that the needs of the child are recognized and addressed both in the hospital and in the community, including school, sports, worship and activities. KUKHP partners with school professionals, peers, clergy, coaches, scout leaders and many others to ensure that the child continues to grow and achieve in all environments.


For more information, see:

Part 1 — Introduction, Incidence, Morbidity and Symptoms

Arthritis Foundation

P.O. Box 7669
Atlanta, GA 30357-0669
800-283-7800

Information about children and adolescents with arthritis.

US Bone and Joint Foundation (USBJD)

Information about pediatric arthritis.

Contributed by:

Carol Lindsley, MD
Professor
Division Chief, Pediatric Rheumatology
Department of Pediatrics
University of Kansas Medical Center

Kathy Davis, MSEd, PhD
Associate Professor
Project Director, Connected Kansas Kids
Director, KU Kids Healing Place
University of Kansas Medical Center