Osteoarthritis in children: what parents need to remember

Juvenile arthritis in children (JRA) is a general name for a group of joint diseases in patients under the age of 16 years. Often this term refers to childhood rheumatoid arthritis, the main cause of disability in children and adolescents with musculoskeletal disorders.

In Russia, juvenile arthritis in children is quite common. According to statistics, every thousand child is affected by it. The disease does not spare even infants. Children's juvenile arthritis is more common among girls (about 2 times).

After the first episode, the disease progresses rapidly, so early diagnosis in juvenile arthritis is critical.

Causes of juvenile arthritis in children

Children's juvenile arthritis (also rheumatoid, idiopathic) is a multifactorial disease. Scientists associate its occurrence with environmental conditions, genetic characteristics and even infections. It has not yet been possible to unambiguously establish the causes of juvenile arthritis in children, but a certain connection with heredity and the patient’s medical history has been identified. Arthritis occurs more often in children whose families have a history of rheumatoid diseases.

Juvenile arthritis in children is classified as an autoimmune disease because it has a systemic effect on the child’s body. The patient's immune cells mistakenly perceive his own cells as “enemy”, pathogenic agents, and attack them. In this case, the integrity of the connective tissue is disrupted. The joints are most often affected, but the disease actively affects the eyes, heart, lungs, kidneys, digestive and other systems of the body.

Juvenile arthritis in adolescents and children can “sleep” for years, waiting for an immune surge, so it is important to distinguish it from reactive and other types of arthritis that can worsen in childhood and adolescence due to illness.

Why does reactive arthritis occur?

The main reason is pathogens that have entered the body. But if you examine the joint fluid in the acute period, you will not be able to detect bacteria or antibodies in it. This fact is explained by the following phenomenon: blood leukocytes, aimed at fighting bacteria, begin to combine with them, forming immune complexes that mistake joint cells for foreign bodies that need to be destroyed. Thus, a malfunction in the immune system leads to inflammation of the joints.

The causative agents of the disease are transmitted by airborne droplets and airborne dust, during birth from the mother. Domestic animals are also carriers.

Symptoms of juvenile arthritis in children

A distinctive symptom of juvenile arthritis in children is the presence of constant pain (aching, shooting, bursting) in the elbow, shoulder or knee joints. Less commonly, juvenile arthritis begins in the ankle and metatarsal joints, lumbosacral spine, wrist and other joints of the hands. In juvenile chronic arthritis in children, the lesions are almost always symmetrical.

Symptoms differ depending on which lesions predominate - articular or articular-visceral. The articular-visceral form means that the child has pathological changes in the internal organs. In both cases, the inflammatory process lasts in children for a long time - at least 6 months.

In the articular form (about 3-4 out of 5 cases), the following symptoms of juvenile arthritis in children are observed:

• change in gait;
• pain in the joints (especially in the morning) - sometimes acute, in which even wearing clothes causes pain;
• noticeable stiffness and limitation of mobility in the joint, caution of the child in movements, various disorders of motor activity;
• deformation of the joint, sometimes its spherical or spindle-shaped shape;
• swelling in the area of ​​the affected joints;
• crunching in joints;
• weakness and dystrophic changes in muscles (affected limb or whole body);
• local temperature increase.

The articular-visceral (systemic) form of childhood juvenile arthritis can manifest itself:

• pallor of the skin (with redness of the skin over the sore joint);
• the appearance of ulcers or unhealthy pigmentation on the skin;
• general swelling of the body;
• fever and chills;
• heart rhythm disturbances;
• enlarged lymph nodes;
• breathing problems;
• abdominal pain;
• redness of the eyes and conjunctiva, blurred vision, uneven pupils;
• cough (including with sputum);
• a pinkish rash without itching on the body or in the area of ​​the affected joint - may resemble stripes or stains, spots.

Older children are already able to tell adults what and where it hurts. Juvenile arthritis is the easiest to diagnose in teenagers.

In children from 1 to 3 years old, the presence of an inflammatory process is usually determined not by the child’s words, but by observing his behavior. Therefore, it is important to know the symptoms, causes and treatment of juvenile arthritis in children. A child suffering from JRA becomes inactive. If he needs to carry out some tasks related to movement, he may become capricious or irritated. Often the child tries to press, “rock”, warm, cover, hide the affected joint, noticeably worries even when accidentally touching it, and takes forced poses. On the side, lameness and swelling of the joints are also observed.

Little patients with childhood juvenile arthritis refuse to stand on their feet for a long time. They have a hard time with educational games and sitting on the potty.

Other symptoms include:

• rapid fatigue unusual for a child;
• weight loss and poor appetite;
• low-grade or high temperature (up to 40°C).

As juvenile arthritis progresses in children, deformities in the joints and growth retardation become noticeable. Exacerbation of JRA with greater or less intensity occurs against the background of almost any infection.

Arthropathy - symptoms and treatment

The diagnosis of arthropathy is made when all possible joint diseases are excluded.

Analysis of complaints and medical history collection

Diagnosis of arthropathy begins with an analysis of complaints and anamnesis. The doctor’s task at this stage:

1. To clarify the nature of joint pain:

• is there a connection with the time of day, with the load and its nature, with the position of the joint;
• Is the pain accompanied by symptoms of inflammation: swelling of the joints and surrounding tissues, a change in shape due to the accumulation of exudate (fluid in the joint cavity), a change in skin color, an increase in the temperature of the joint.

2. Find out the number of joints involved in the process, the presence of deformities, and limitations of mobility [1][3][9].

3. To clarify the nature of the debut (onset) of the disease and its subsequent course. In rheumatoid arthritis, for example, joint damage occurs in childhood or adolescence against the background of streptococcal tonsillitis. In this case, the inflammation moves from one joint to another, but subsequently disappears without a trace [9]. With gout, arthritis of the first toe may recur periodically. Then exacerbations occur more often, and other joints become involved in the inflammation, and the arthritis no longer goes away, but becomes wave-like [4]. With rheumatoid arthritis, the process steadily progresses, affecting more and more new joints and destroying previously affected ones. The inflammatory process worsens.

Risk factors for debut:

• infections: tonsillitis, enterocolitis, genital and acute respiratory infections (ARI);
• cooling, stress, climate change;
• pregnancy, lactation and the postpartum period [7][9].

Physical examination

During an objective physical examination, the doctor examines the patient in standing, sitting, and lying positions on a couch. Changes in posture, gait, joint shape and position sometimes indicate arthropathy.

When examining the skin, you need to pay attention to the presence of rashes. The rash can be a sign of psoriasis, which in 70% of cases is accompanied by psoriatic arthritis. In rheumatoid arthritis, rheumatoid nodules appear.

Examination of the scalp is necessary to identify alopecia. Hair loss characteristic of diffuse connective tissue diseases, such as systemic lupus erythematosus.

To diagnose damage to the tendon-ligamentous apparatus, joints are examined. It includes inspection, palpation, study of the volume of active, passive and resistive movements:

• the patient performs active movements himself, for example, squats, bending his arms at the elbow, raising his arms above his head, etc.;
• passive ones are performed by the doctor when the patient’s muscles are completely relaxed;
• active resistive movements are performed against resistance, i.e. the doctor tries to make a movement in the joint, and the patient resists this movement by tensing the corresponding muscles.

Changes in the shape and volume of the joints may be associated with exudate (liquid) in the joint cavity. In the knee joints, for example, effusion can be seen as a horseshoe sign over the patella [9][11].

Instrumental and laboratory diagnostics

Instrumental research methods have different information content and have their own indications.

Ultrasound of joints helps to identify degenerative changes in tendons, ligaments and articular cartilage, and the presence of fluid in the joint cavity.

X-ray examination allows you to visualize bone structures and identify erosions of articular surfaces or osteophytes.

Using MRI of joints, it is possible to evaluate the internal environment of the joints, soft tissue and bone structures. The study must be carried out in case of injuries and for the purpose of differential diagnosis. MRI makes it possible to differentiate arthritis in the early stages, especially of deep-lying joints (sacroileal joints, for example), internal tears of the meniscus and ligaments. Due to the high cost, it is not always prescribed.

Laboratory diagnostics help identify signs of systemic rheumatic diseases. To do this, rheumatoid tests are performed: the level of rheumatoid factor, antinuclear antibodies, antistreptolysin O and C-reactive protein in the blood is determined. They also do a general blood test with a detailed leukocyte formula, an analysis for total protein, albumin, circulating immune complexes and uric acid.

Antinuclear antibodies are specific for various systemic diseases: rheumatoid arthritis, systemic lupus erythematosus, systemic scleroderma, ankylosing spondylitis, Sjogren's disease, etc.).

In the diagnosis of infectious arthropathy, microbiological studies (cultures) and PCR are needed to diagnose chlamydia, ureaplasmosis and other infections. Studying the level of calcium, vitamin D and markers of osteoporosis can detect additional risk factors for arthropathy [5][9].

Invasive methods are used in both diagnosis and treatment. Using joint puncture, it is possible to examine the synovial fluid and inject drugs into the joint cavity.

Arthroscopy is a surgical procedure that uses optical equipment to examine the joint cavity and perform interventions on articular cartilage and ligaments.

Differential diagnosis

The differential diagnosis of arthropathy is aimed at clarifying the nature of joint damage, location and cause.

Diagnosis of juvenile chronic arthritis in children

A rheumatologist can help diagnose juvenile arthritis in children by examining the patient, interviewing him and his parents, as well as laboratory and instrumental studies.

Among the first tests carried out are the following:

• general and biochemical blood test;
• immunological analysis;
• analysis for rheumatoid factor;
• analysis for the presence of antinuclear factor.

For differential diagnosis and identification of visceral complications of juvenile arthritis in children (systemic lesions), computed tomography, magnetic resonance imaging, electrocardiography, ultrasound, x-ray of joints and chest, and tuberculin test may be prescribed. All children undergo a mandatory examination by an ophthalmologist using a slit lamp.

Clinically and laboratory-wise, pediatric rheumatoid arthritis differs from adults and is diagnosed mainly before the age of 4 years.

Treatment of juvenile arthritis in children

Treatment of juvenile arthritis in children includes drug therapy, therapeutic exercises, orthopedic regimen, healthy daily routine and a nutritious diet.

It is aimed at stopping the inflammatory process, combating systemic manifestations and organ damage, destructive changes in joints, as well as maintaining normal mobility in the joints

Depending on the form and rate of progression of the disease, juvenile arthritis in children is treated on an outpatient or inpatient basis.

Treatment of juvenile arthritis in children with drugs

The main tool in the treatment of juvenile arthritis in children is immunosuppressive therapy. Parents are often frightened by this name, because immune suppression is perceived as an a priori bad effect. However, in conditions where high immunity becomes the cause of a child’s disability, it is important not to delay or interrupt the use of immunosuppressants. Otherwise, the disease may worsen and develop into a series of almost continuous relapses.

The following immunosuppressants are used as basic therapy:

• methotrexate;
• adalimumab;
• infliximab;
• cyclophosphamide.

Non-steroidal anti-inflammatory drugs (NSAIDs) are also used to relieve inflammation, pain and fever in juvenile arthritis in children:

• meloxicam;
• indomethacin;
• diclofenac;
• piroxicam;
• ibuprofen;
• etoricoxib;
• ketoprofen.

In especially severe cases, the doctor prescribes hormonal glucocorticoid drugs (GC):

• prednisolone;
• methylprednisolone;
• hydrocortisone;
• betamethasone.

Uncontrolled use of both of these medications without a doctor’s prescription can lead to stomach ulcers and severe endocrine disorders in a child.

In the vast majority of cases, drugs are taken for life (immunosuppressants) and in regular courses (NSAIDs, GCs) - in tablets, in the form of ointments, creams, intramuscular and intra-articular injections. If they are also ineffective, genetic engineering biological therapy is prescribed for the treatment of juvenile arthritis in children.

Non-drug therapy for juvenile arthritis

To relieve symptoms and preserve joint function in children, the following is used:

• mud therapy (usually in a sanatorium);
• ultra-high frequency therapy;
• magnetic therapy;
• ultrasound therapy;
• paraffin therapy and more.

In the acute phase of juvenile arthritis in adolescents and children, joint immobilization using splints and other orthoses, as well as bed rest, are indicated. Orthopedic insoles and other devices are widely used.

During remission, exercise therapy and therapeutic massage have a positive effect on the child’s musculoskeletal system.

In case of severe destruction of the joint, surgery to replace it is indicated.

Prevention

All preventive measures can be divided into primary and secondary.
Primary measures include measures that reduce the risk of developing arthropathy: avoiding injuries, wearing comfortable shoes, timely diagnosis and treatment of disorders that can cause the development of pathology, proper nutrition, sufficient but not excessive physical activity, etc. Secondary prevention is carried out when a diagnosis has already been made and is aimed at preventing relapses. This is, first of all, massage, gymnastics, swimming. In this case, the program is compiled on an individual basis.

Arthropathy can be either a relatively harmless consequence of an injury or a serious problem indicating a malfunction in the body. Only timely diagnosis and treatment will help restore joint mobility to full extent and without pain. Experienced doctors at the SM-Doctor clinic will help you identify the pathology in time and take the necessary measures.

Prognosis for juvenile chronic arthritis in children

Juvenile rheumatoid arthritis is a disease that tends to progress rapidly. The activity of the disease depends on the form of onset of the disease - in one joint, in 2 or 3 or in multiple joints at the same time. If the disease begins in the form of polyarthritis (symptoms are observed in 4 or more joints), the number of affected joints increases over time.

The number of children requiring mobility and/or self-care assistance has decreased significantly over the past decade. In 95% of cases, treatment avoids disability. Among the remaining 5% there are still children with early onset of the disease, positive rheumatic factor. Juvenile arthritis in adolescents has fewer consequences than in early childhood. Every 7-10 patients suffering from inflammation of the uvea are at risk of losing their vision.

The following features indicate an unfavorable prognosis for juvenile chronic arthritis in children:

• acute course with fever and active progression of the disease within six months;
• the need for rapid re-administration of systemic GCs;
• inflammation of the serous membranes;
• localization of the disease in the hip joints;
• erosive destruction of joints and narrowing of the lumen of the joint space.

In more than half of the cases, with timely consultation with a doctor and lifelong therapy, severe destruction of the joints can be avoided. Under favorable circumstances, the child can attend school on an equal basis with peers, dance and participate in sports games in a gentle manner, with minimal restrictions. With juvenile arthritis in children, doctors and parents are increasingly able to achieve a full life for the child. Early contact with a doctor contributes to drug-free remission - that is, the patient does not need to constantly receive therapy.

Treatment tactics in childhood

Treatment of arthrosis and osteoarthritis in children is complex: it includes medication and physiotherapeutic components. With the help of painkillers in a dosage specially selected for age, it is possible to relieve pain spasms. Sometimes it is advisable to use anti-inflammatory ointments and balms only as prescribed by the attending physician.

In some cases, intra-articular injections of a synovial fluid substitute, for example the safe synthetic drug Noltrex, help cope with the disease. As a rule, this method is used if the disease has progressed to the second or third stages and is accompanied by a severe course.

In the initial stages, physiotherapeutic measures - massage, electrophoresis and UHF, as well as a course of special exercise therapy - help cope with symptoms. During the period of remission, it will not be superfluous for a small patient to go for sanatorium treatment. In general, tactics depend on the child’s health status, physical capabilities, and lifestyle.

A child with osteoarthritis should be seen by an orthopedist at least once a year

Clinical guidelines for juvenile arthritis in children

The condition of the tissues and the nature of the lesions in juvenile arthritis can worsen and change. Therefore, clinical recommendations for juvenile arthritis in children necessarily include routine follow-up with a doctor and regular examinations to monitor the condition.

When the disease has been put into remission, it is important to follow the following rules to prevent exacerbations:

• have less contact with animals, people and surfaces on which infectious agents may be present;
• follow sanitary and hygienic recommendations in the room where the child lives, as well as in cases where one of the family members is sick;
• avoid hypothermia and prolonged exposure to the sun;
• if possible, avoid moving and traveling to regions with a different climate (to avoid acclimatization symptoms);
• Do not allow vaccination (except for the Mantoux test) and take immunostimulating drugs without consulting your treating rheumatologist.

Parents should ensure that the child does not attend educational institutions “undertreated” until all symptoms of infectious diseases disappear. Clinical guidelines for juvenile arthritis in children should be followed throughout life.

Be vigilant and let your children stay healthy!