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Children With Arthritis
17 September 2010
Arthritis affects children and can do so seriously and with devastating effects in some children. However, many do get better.
Malaysia is plagued by various types of treatment, traditional and non-traditional which have not been proven, irresponsible and often harmful. Diagnosis is delayed and thus treatment is also delayed with consequent irreversible joint damage. Inappropriate treatment may do more harm than good.
Symptoms and signs of children with arthritis which should NOT be ignored include swollen joints, fever, the child that is not growing, uninterested in playing or eating.
There are many forms of arthritis in children. The most common is Juvenile Chronic Arthritis (JCA) of which there are several types. The most common type is pauciarticular JCA in which 4 or fewer joints are involved. Other types of JCA include polyarticular JCA, in which 5 or more joints are involved and it resembles adult RA, systemic JCA where there is fever and rashes, and juvenile ankylosing spondylitis which involves the spine. Children can also suffer from all the connective tissue diseases that afflict adults such as systemic lupus erythematosus, dermatomyositis and vasculitis but these are rarer in the paediatric population. The features and treatment are similar to that in adult practice and below are short notes on the more common diseases.
Rheumatoid Arthritis (RA)
RA is a chronic inflammatory autoimmune disease affecting predominantly the joints but can involve many other parts of the body. The prevalence of RA in adults is I % of the population. In children, it is estimated around 10- 1 5/1 00,000 children are affected. Patients with RA commonly present with painful, swollen joints, especially in the hands, wrists and feet. Other parts of the body can also be involved and patients may have dry eyes, dry mouth or skin rashes or cold, white hands and feet.
RA (and JCA) occurs because patients with RA produce antibodies against structures in their own bodies (autoantibodies). Antibodies are proteins that are normally produced by our own bodies in response to infection. These antibodies are usually responsible for eliminating the bacteria/germs from our bodies. However, in autoimmune diseases, these antibodies are formed against structures found in our bodies and there is no strong evidence that bacteria or germs are involved. In RA, the main target of the autoantibodies is the synovium, a membrane lining the inside of our joints. In normal life, the synovium is responsible for producing a small amount of synovial fluid which lubricates our joints so they can move smoothly. When the synovium is attacked by antibodies in RA, it becomes inflamed, swollen and overactive with increased production of synovial fluid. Thus the affected joints become hot and swollen. Unchecked, the joint inflammation can lead to bone destruction and eventually joint failure and disability.
Treatment for RA involves both short term symptomatic relief of painful joints and long term treatment to stop the inflammatory process from continuing. Drugs used for symptomatic relief of joint pains are pain-killers such as paracetamol (Panadol) and non-steroidal anti-inflammatory drugs (NSAIDS) such as Voltaren and Oruvail. However, to actually stop the inflammatory process, more powerful drugs such as sulphasalazine and methotrexate are given. These agents have been shown in numerous studies published in respected journals worldwide to stop or slow down the joint destruction associated with RA. As these drugs can be associated with potentially serious side-effects, they should only be prescribed by experienced doctors, usually rheumatologists. Other equally important therapeutic modalities, especially in children, include physiotherapy and occupational therapy. With early and appropriate use of these various treatment modalities, RA and JCA can be very well-controlled with relief of most symptoms and can slow down or halt the joint destruction.
THERE IS NO STRONG EVIDENCE THAT OTHER FORMS OF TREATMENT, INCLUDING THOSE THAT CAN BE BOUGHT OVER THE COUNTER OR WITHOUT PRESCRIPTION, CAN ALTER THE PROGRESSION OF RA OR JCA.
Systemic Lupus Erythematosus (SLE)
SLE is a chronic inflammatory autoimmune disease that can affect practically any part of the body. As in RA, SLE patients produce autoantibodies against a variety of structures in our bodies. More specifically in SLE, the autoantibodies are directed against parts of our DNA in our cells. Because all our cells have DNA, SLE can affect any part of our bodies. The prevalence of SLE in adults is 0.05% and it is more common in Chinese and Blacks. The prevalence in children is not known but thought to be less.
The most common symptoms of SLE are joint pains, hair loss, skin rashes and mouth ulcers. However, other parts of the body such as the brain and kidneys can be involved with serious consequences.
Treatment of SLE involves judicious use of steroids and other drugs to suppress the inflammation. These drugs, especially steroids have many side effects and should only be prescribed by doctors experienced in treating SLE. This is especially important in children where steroids can retard growth. So a fine balance is required between suppressing inflammation (which can also retard growth) and overuse of steroids. Uncontrolled inflammation in SLE is very dangerous especially if the SLE is affecting a major organ. For example, uncontrolled inflammation in the kidneys can lead to kidney failure and in the brain can lead to fits.
Like in RA, there is NO evidence that non-prescription medicines can halt the inflammatory process in SLE.
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