Arthritis is often associated with the elderly. However, as Dato’ Dr. Mohammed Shahdan Shahid, rheumatology specialist divulges, his youngest patient is a year and a half old. This condition is termed as juvenile idiopathic arthritis.
While local statistics are unavailable due to the scarcity of paediatric rheumatologists in Malaysia (Dato’ Dr. Mohammed Shahdan has trained under paediatric rheumatology) – the American College of Rheumatology states that approximately 1 in every 1,000 children will develop some type of chronic arthritis. This article aims to explore this condition further and learn if it can be outgrown.
Q: What is juvenile idiopathic arthritis?
Dato’ Dr. Mohammed Shahdan: Juvenile idiopathic arthritis is an inflammatory joint disease that afflicts children below the age of 16 in which their joints are painful continuously for 6 weeks. This are the minimum criteria for an official diagnosis. The patient may experience morning stiffness for more than half an hour; develop a skin rash; fever; back pain; fatigue; and heart problems. Extensive research has been done but specific causes of inflammation are still undetermined. Hence, the term ‘idiopathic’ is used when the mechanisms of the disease are known but it causes unknown.
Q: How does the disease work?
Dato’ Dr. Mohammed Shahdan: All joints have a synovial lining, which is responsible for producing joint fluid. In an inflamed joint, the synovial lining proliferates (meaning it increases rapidly). This leads to the production of a chemical known as interleukin, which can damage the joints, bones, and joint capsules. That is why in severe cases, it can result in ruptured tendons and deformed fingers and knees.
The pain is due to the increase of pressure in the joints. When a patient wakes in the morning, their joints will be stiff upon movement. It can take 2 – 3 hours or even up to midday for them to feel better. If the pain persists, the patient may seek out a doctor who can help remove the excess fluid to alleviate pain.
Q: Can a child outgrow the disease?
Dato’ Dr. Mohammed Shahdan: A child can’t outgrow the disease but with early detection, the disease can be managed. With proper treatment and rehabilitation by a specialist, the process can be controlled and detrimental effects minimised.
Q: What are some extreme consequences of this disease?
Dato’ Dr. Mohammed Shahdan: Some patients would require surgery. There is a patient I have been treating since she was 15. She is 32 now but has had 4 knee joint replacements. In such cases, the disease is very active and erodes the bones to the point where the joints are deformed and the patient finds it difficult to move. To improve mobility and alleviate the pain, surgery is needed. Post-surgery, the patient is advised not to overuse the artificial joint as it has a lifespan of 10 to 15 years. After this, revision surgery is needed.
Q: Besides the obvious pain and potential deformities, what other side effects are there to this disease?
Dato’ Dr. Mohammed Shahdan: An important point to note is that patients will often be referred to as ophthalmologists (eye and vision care specialists). This is because they may develop eye problems – either from the disease itself or medication used to treat it. The most common eye problem is the inflammation of the uvea known as uveitis. If uveitis is severe, it can cause cataracts and even blindness.
Q: Upon diagnosis, what are the next steps to take to treat the condition?
Dato’ Dr. Mohammed Shahdan: Once diagnosed, they will be prescribed NSAID (a nonsteroidal anti-inflammatory drug). A common one that is in syrup form is ibuprofen. If that does not control the pain, hydrocortisone (a steroid) is next. People often panic when it comes to using steroids on children but rest assured, they will only be used for a short period of time and in low dosages. This is intending to make the patient feel as comfortable as possible.
If the combination of NSAID and hydrocortisone does not work, there is Methotrexate – a disease-modifying cancer drug that helps to suppress the synovial cells from proliferating. Only a registered specialist can use it and the dosage is very small. It works slowly and benefits are usually seen after 2 – 6 weeks – which is why it is used in tandem with NSAID and hydrocortisone.
A better alternative if the patient is financially sound or under insurance is Biologic – also a disease-modifying drug. It doesn’t affect your other systems save for the immune system – which means the patient can be prone to infections. That being said, the results are fantastic.
On top of medication, it is also important for doctors to work hand-in-hand with a physiotherapist and psychological counsellor. During an acute phase, the patient will need to see a physiotherapist once or twice a week. Once they get used to the system, they can do the movements prescribed at home. Those who experience deformities will need to see an occupational therapist who will teach them how to function and impart lifestyle modification tips moving forward in life.
Q: Is it genetic?
Dato’ Dr. Mohammed Shahdan: It may run in the family. There is no concrete evidence but I have treated two families that may suggest a link. In the first family, it was the grandmother who had arthritis initially; followed by the mother and her siblings; and lastly the two grandchildren. In the other family, it happened the other way around in which the grandchildren were diagnosed first followed by their mother and lastly, grandmother.
Q: What are some restrictions for children with this disease?
Dato’ Dr. Mohammed Shahdan: Don’t get involved with contact sports and avoid jumping – trampolines are especially hazardous for the knees, elbows, and ankles. If there are no problems with the hips, running should be fine. That being said, light exercise is good and swimming is especially great. In terms of food, there are no restrictions.
Q: What would your advice be to parents of children with this disease?
Dato’ Dr. Mohammed Shahdan: If you have a child (especially those at an age who cannot speak) who consistently cries when they wake up; in the middle of the night; and upon touching their joints (knees, elbows, etc) – don’t waste time. Take them to a paediatrician or specialist – not a general practitioner (GP).
Lifestyle modification should only be done if you notice your child is handicapped. For example, if your child has knee problems and is unable to squat, the toilet seat has to be modified. If they have problems with their hands, the taps at home should not be of the kind that requires twisting. Other contraptions can be bought online – such as bigger utensils or stationeries to help with grip.
Lastly, treat your child normally. Many children with this disease go on to have normal lives – we have had cases in which treated children have gone on to climb mountains. However, when your child is going through a flare – which means the disease is active and their joints are stiff – they must rest and listen to their body.
Q & A with Dato’ Dr. Mohammed Shahdan Shahid,
Rheumatology Specialist,
Prince Court Medical Centre on Juvenile
Idiopathic Arthritis
