When children develop rheumatism

Elena elegantly lands safely on the floor mat after a jump from the box. Anyone watching the 11-year-old doing gymnastics would never guess that the schoolgirl suffers from a chronic joint disease. Elena was diagnosed with paediatric rheumatism at the age of three. When the disease is active, the fifth-grader has to rest her joints. However, when she has no symptoms, she is allowed to do everything that healthy children do.

Around one to two in 1000 children across Europe suffer from paediatric rheumatism - a collective term that covers several different rheumatic diseases. «However, when we talk about paediatric rheumatism, we primarily mean juvenile idiopathic arthritis, JIA,» explains Seraina Palmer Sarott, Senior Physician in the Department of Rheumatology at the University Children's Hospital Zurich. «It is the most common paediatric rheumatological disease that primarily affects the joints.» In Switzerland, around 1,300 children and adolescents currently suffer from the disease.

The translation of the technical term describes exactly what this disease is about. The «juvenile» stands for the onset of the disease before the age of 16, «idiopathic» for «unknown cause» and «arthritis» for one or more joint inflammations that last at least six weeks.

How does paediatric rheumatism manifest itself?

In fact, the exact cause of the disease is still not clearly understood. The only thing that is certain is that JIA, like all rheumatic diseases, is an autoimmune disease. This means that the body's own immune system is misdirected and not only fights harmful invaders such as viruses and bacteria, but also, fatally, the body's own cells.

In the case of JIA, the attack is primarily directed against the joint capsule. «This causes the synovial membrane, which forms the synovial fluid, to become inflamed,» says Palmer Sarott. "As a result, the synovial membrane swells and produces more fluid, which is recognisable externally as swelling.

Joint inflammation can lead to complete destruction of the joint.

Palmer Sarott, Senior Physician for Rheumatology at the Children's Hospital Zurich

It also causes pain, which restricts mobility, and the joint feels hot." Fatally, however, joint inflammation that persists for months and years causes lasting damage to the joint cartilage and the neighbouring bone.

«In the worst case scenario, this can lead to complete destruction of the joint,» warns the rheumatism expert. «Long-term incorrect and relieving postures can also cause restricted movement due to contractures, because the tendons shorten and the muscles involved atrophy.» There is also a risk of growth disorders such as different leg lengths or jaw anomalies, as the bone grows differently during inflammation.

«Around 15 per cent of all affected children also develop uveitis, which is an inflammation of the eye that can only be detected by an ophthalmologist and can gradually cause massive permanent visual damage,» adds Palmer Sarott.

Joint complaints in children should therefore always be taken seriously. Most cases are due to harmless causes such as strains and bruises. Previous viral infections can also lead to temporary joint inflammation, which usually heals without consequences.

Take suspicious signs of rheumatism seriously!

However, parents should be wary if joint complaints persist for several weeks without a previous injury and children show a changed movement pattern, especially after periods of rest.

«Typical symptoms include morning stiffness and initial pain after prolonged sitting or lying down,» emphasises the paediatric rheumatologist. «Unlike adults, younger children in particular don't complain about joint pain, but try to avoid using the affected joint.» Parents should therefore be suspicious if their child suddenly starts limping or begins to use their left hand instead of their right. Frequent leaning when sitting down can also indicate the onset of the disease.

The diagnosis of JIA is complex, as rheumatoid factors are rarely detectable in the blood of children.

Palmer Sarott, Senior Physician

«Other indications are when the child suddenly starts to walk down the stairs again in a postural gait, refuses to chew vigorously or avoids bending the leg when sitting on the floor,» adds Palmer Sarott. «The paediatrician should be consulted at an early stage for more detailed clarification and referral to a specialist if rheumatism is suspected.»

The diagnosis of JIA is quite complex. «As rheumatism in children, unlike rheumatism in adults, is rarely detectable in the blood, we have to work according to the principle of exclusion,» explains Palmer Sarott.

«All other possible causes such as infections, bone dysplasia or cancer must first be ruled out with the help of a medical history, physical examinations, but also blood tests and imaging procedures such as X-rays or magnetic resonance imaging (MRI).» Once the diagnosis of JIA has been confirmed, the subtype of JIA still needs to be clarified. Depending on how many joints are affected and which additional symptoms occur, a total of seven subtypes are differentiated.

Paediatric rheumatism has many faces

«The main differentiation is based on the number of joints affected,» explains Palmer Sarott. «Around half of all young patients suffer from so-called oligoarticular juvenile idiopathic arthritis, in which fewer than five joints are affected.»

All forms of JIA cannot be completely cured to this day. However, the disease can often be well controlled with the help of modern medication. Oligoarticular juvenile idiopathic arthritis in particular can be brought to a complete standstill in around half of those affected.

We want to achieve absolute freedom from symptoms so that the children can live a completely normal everyday life.

Palmer Sarott, Senior Physician

Permanent damage, as was common decades ago, is now rare. «Our primary goal is to achieve complete freedom from symptoms so that the children can lead a normal everyday life,» emphasises Palmer Sarott. "This requires long-term therapy that is gradually adapted to the child's needs.

In addition to physiotherapy and occupational therapy, medication is also used.

The treatment is usually started with a six-week course of so-called non-steroidal anti-inflammatory drugs. These are anti-inflammatory painkillers, better known to many as ibuprofen or diclofenac.

«In some children, this therapy alone is enough to stop the inflammation,» says the Zurich senior physician. If this is not the case, the next step is to inject cortisone directly into the affected joint. «Local treatment with cortisone is very effective and, unlike systematic administration as a tablet, causes hardly any side effects,» emphasises Palmer Sarott. «However, it is mainly used when only a few joints are affected.»

If more joints or the temporomandibular joint in particular are inflamed or if the inflammation persists despite this, long-term treatment is carried out with so-called basic medications, which have an effect on the entire body. Basic medications influence the immune system and thus lead to an inhibition of inflammation. They are also relatively well tolerated when used over a longer period of time.

The new drugs in the fight against paediatric rheumatism

«In children, methotrexate is usually injected under the skin once a week,» says the paediatric rheumatologist. «However, the full effect only sets in after three to six months.» Biologics are faster-acting and in some cases better tolerated. They are the latest group of drugs in the fight against JIA and are produced using genetic engineering.

I advise rheumatism patients to eat as little lectins as possible.

Sybille Binder, qualified nutritionist

«Biologics have revolutionised the treatment options for JIA and will probably be used even earlier in treatment in the future,» reveals the rheumatologist. «So far, however, there is less data available on the long-term effects of biologics compared to the classic basic drugs, so that biologics are generally only used today when classic basic drugs are no longer sufficient.»

Complementary medical support

In addition to conventional medicine, complementary medical therapies can also positively support the success of treatment, especially in the case of systemic diseases such as JIA.

«Phytotherapeutically, for example, anti-inflammatory plant substances such as frankincense, curcuma or fenugreek can be taken in the form of capsules or powder to alleviate the symptoms,» says Sybille Binder, qualified nutritionist, lecturer and therapist for nutrition, metabolism, phyto- and respiratory therapy at the Zurich Institute for Integrative Naturopathy, NHK.

«Blood-purifying medicinal teas made from birch, nettle or yarrow as well as manual forms of elimination therapy that help to rid the body of toxins are also beneficial,» emphasises Binder. «Because from a holistic perspective, rheumatic inflammation is caused by a disorder of the excretory system.»

Special attention should therefore also be paid to diet. «I advise rheumatism patients to eat as few lectins as possible,» explains the nutrition expert. Lectins are natural plant defences against predators. They act like natural pesticides.

«In the human body, however, these proteins can demonstrably cause problems such as inflammation,» emphasises Binder. «Lectin-rich foods such as potatoes, aubergines, peppers, nuts and wheat should therefore be avoided.» Changing your diet to a healthy, low lectin diet helps to prevent new bouts of inflammation and prolong the symptom-free phases accordingly.