Juvenille Rheumatoid Arthritis (JRA), Part 2 — Treatment, restrictions, and implications
for school
Treatment
Early diagnosis and appropriate treatment ensure children the best possible
opportunity for a good outcome. Treatment depends on the type and severity
of arthritis. The goals of treatment are:
- control inflammation
- relieve pain
- prevent joint limitation
- prevent joint damage
- maximize function
Treatment usually includes medication, exercise, activity guidelines,
eye care, dental care, and proper nutrition. Joint supports and splinting
may be used for specific joint problems.
Medications
When children are first diagnosed with arthritis they will start regular
medicine. Most children will need to take regular medication for several
years or longer. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the
first line of treatment. They may need to be taken for several weeks to
see if they help control pain and inflammation. Not all children respond
to a particular NSAID. The doctor may need to try more than one to find
one that works, and that the child tolerates. Generally NSAIDs should
be taken with food. Most are taken once or twice a day so would not generally
be taken at school. Many children’s symptoms are managed on NSAIDs
alone. Commonly used NSAIDs are Ibuprofen, Naprosyn, Celebrex, and Vioxx.
There are over 25 NSAIDs to choose from. 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
pain or anti-inflammatory relief but they produce beneficial effects to
modify the natural progress of joint disease such as joint or bone destruction.
Because they are more powerful they require frequent laboratory tests
for monitoring. Common DMARDs are Methotrexate, Hydroxychoroquine, Sulfasalazine,
and biologics such as Enbrel and Remicade. There are also other DMARDs
that may be used. Glucocorticoids are more potent agents and have more
side effects and are used for a quick response in children with severe
disease or organ involvement and are usually tapered as slower acting
drugs become effective. Other drugs may be added for specific symptoms,
such as iritis, which is 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 on many of
the DMARDs and glucocorticoids may not be able to have regular immunizations
and may be as risk when exposed to certain infections and diseases such
as chicken pox.
Physical/dietary/other restrictions
No specific foods affect arthritis but children with a chronic disease
need a varied and healthy diet. Many children have weight loss initially
and need extra calories because active disease requires more calories.
All children should have a balanced diet with an adequate amount of iron
and calcium for age. Some children are on steroids, which increases appetite,
and they need to limit salt and food amounts to limit weight gain. Depending
on which joints are involved children may need to limit walking, standing,
running or modify sitting. They should be allowed to self limit activities
depending of their joint symptoms that day. Some children with arthritis
are sensitive to sun or the medication they are on makes then sensitive
to the sun and they should use sunscreen when outside and wear a hat in
bright sun.
Implications for school
Most children do very well at school but many need changes in some activities.
Arthritis does not make it hard to think or learn, but the pain and stiffness
of arthritis may make it hard to concentrate at times. Mornings are difficult
because many children are very stiff and have trouble moving easily until
they are loosened up. It may take them a long time to get ready for school.
If this is a persistent problem it is best to schedule a study hall first
hour in secondary school so they are not so stressed if they are late.
If they have severe arthritis in their hands they may need to limit writing,
such as doing every other math problem or just the answers. They may also
need extended time on tests. Students in secondary school often need a
second set of books at home because they are not able to lift and carry
heavy books in a backpack. P.E. classes are the most challenging for students
with arthritis. Most of the activities look fun and kids want to do what
others are doing-not just sit on the side. Stretching and slow exercises
are best. Exercises that jerk or bounce the joints or put a lot of pressure
on the joints with arthritis are not good. Jumping jacks, jumping rope,
and distance running are usually not good activities for children with
arthritis in their feet or legs. Push ups, crab walking, and rope climbing
are not good for children with arthritis in their hands or arms. Sports
that involve contact with a person or hard object such as football, soccer,
and volleyball may also not be good. Children can practice with a Nerf
or beach ball and still learn the skills. They nay need to walk rather
than run laps. All accommodations are individual and should be decided
after communication with the student, parents, teachers, and doctor.
Arthritis in children is often a hidden disease. Much of the time you
cannot see it in the joints. You cannot see pain or lack of energy. Since
the symptoms change the limitations that children have may also change.
Children with arthritis do not wan to draw attention to themselves so
they usually do not speak up and say that they are having a problem. Students
need one person at school to work with who can communicate with the rest
of the teachers and help the student get their accommodations in place
so they can be successful at school.
JRA, Part 2 — Treatment, restrictions, and implications for school
For more information, please contact:
Kathy Davis, MSEd, PhD
kdavis2@kumc.edu
(913) 588-6305