Stepping Up To The Challenge of Childhood Arthritis
The leaden ache of arthritis weighs heavily on both body and emotions. Even for adults, coping with the relentless persistence of pain can be a daily ordeal.
For children too young to understand why there is so much hurt in their world, it can be even more difficult. Why does the simple play other kids enjoy bring them so much pain?
Although arthritis is more commonly associated with the wear of years, according to the Arthritis Foundation, juvenile arthritis and rheumatic conditions are among the most common childhood diseases in the United States.
A few years ago, there were no pediatric rheumatologists in Alabama. The doors in the rheumatology department of Children’s Hospital were built extra wide to allow easy access for the wheel chairs of young patients who were unable to walk.
Now, those patients no longer need wheel chairs. The Department of Rheumatology at Children’s Hospital has grown to five pediatric rheumatologists who are using the latest advances in medication and treatment to care for children across Alabama and the southeast.
“The most common condition we see in children is juvenile idiopathic arthritis,”
Director of Pediatric Rheumatology Randall Cron, MD, PhD, said. “Around 97% of the time, this form of arthritis differs from what occurs in adults in that we don’t see a rheumatoid factor. Diagnosing the disorder and beginning treatment as soon as possible is especially important in growing children. Untreated, they are not only in pain, but growth can be affected so that one leg can become longer than the other, and contractures may prevent muscles from developing as they should.”
The second most common condition pediatric rheumatologists at Children’s Hospital of Alabama are likely to encounter is lupus.
“It rarely occurs before the age of ten, and we see it most often in girls near puberty,” Cron said. “It could be that lupus occurs earlier in patients with worse genetic influences. There tends to be more kidney involvement in younger patients, which can be harder to treat.”
The key to effective treatment in pediatric arthritis, lupus and other rheumatic conditions is understanding how to use medications safely. Children are not simply small adults, and their bodies can react very differently. Arthritis medications can also be strong, which makes some physicians reluctant to prescribe them for children.
“In the past decade and a half, medications have come a long way. New drugs are coming out every year targeting different proteins,” Cron said. “They are typically used first in adults or in other conditions, and then in children. Pediatric rheumatologists are more accustomed to working with these medications in children, and perhaps more comfortable prescribing the appropriate medication at the appropriate dose.
“With the new medication, when children are diagnosed and treated early, you might see them playing soccer or basketball and never know they have arthritis.”
The cause of most forms of juvenile arthritis is unknown, and management varies depending on the specific condition. Primary goals of treatment are to control inflammation and swelling, relieve pain, prevent joint damage and maximize function.
NSAIDs, corticosteroids, and anti-rheumatic drugs such as methotrexate may be used, and Biologic Response Modifiers (BRMs), such as anti-TNF drugs that inhibit cytokine proteins, can be injected or given as an infusion.
In addition to 2,000 patient visits per year, the Department of Rheumatology does 200 outpatient infusions per month. They care for patients from toddlers to 18-year-olds, with the most common presentation at two years of age.
“Kids try to ignore the problem and just live their lives, so pediatricians often have to rely on family for input,” Cron said. “A limp that doesn’t go away in a few days isn’t normal in a younger child. Swollen joints or morning stiffness that gets better in a warmer environment are also symptoms that may indicate a problem.”
In addition to patient care, four members of the rheumatology team are involved in translational research and one in basic research.
“There has been an explosion in basic and translational research that has led to phenomenal progress in new options to treat arthritis. Our team has grown to five doctors, but there is still a national shortage of pediatric rheumatologists, especially in the southeast,” Cron said. “Since we have a waiting list, we go through referrals trying to identify cases that need to be seen as soon as possible.”
To help alleviate the shortage of specialists in the field, the department has created a fellowship program.
“We have one fellow in training now, and we hope to be training more in the future,” Cron said. “There are a lot of children who need a lot more doctors trained in pediatric rheumatology.”
Randall Cron, MD, PhD, with a patient.