PEDIATRIC RHEUMATOLOGY UPDATE
This page is provided by Thomas J. A. Lehman MD
Delivering the
best care - with great care
Dr. Lehman is the author
of many textbook chapters and articles on the care of children and young adults
with rheumatic disease. He practices in
Frequent Sprains??? Sports
injuries?? Ankylosing Spondylitis??
Do you have a teenager
or older child in your practice who is always
spraining his/her ankles or knees? Some children are just clumsy, and others
too aggressive playing sports. However, this is often the initial story for
children with spondyloarthropathies.
Spondyloarthropathies typically present in boys or
girls from ages 10 and up. Their characteristic feature is tendon
inflammation, usually in the lower extremities. Many of these children
initially present to their pediatricians with repeated complaints of knee,
ankle, or heel pain associated with activities. It’s almost always thought
to be an injury.
There are several key
findings which help in making the proper diagnosis. The most important is that
these children tend to be tight. Often they cannot bend over and touch their
toes. This disease tends to run in families, so don’t be fooled when mom or dad
says, "Oh, Don’t worry. I can’t do that either."
The second key finding
is that these children often have low back pain or stiffness. Don’t expect them
to tell you about it unless you specifically ask. Typical responses are,
"Sure, but what’s my back got to do with my ankle pain," or, "Isn’t
everybody stiff in their back when they wake up in the morning?" If you
think the child might have a spondylo-arthropathy
look for the following findings: 1) tender SI joints, 2) heel pain on
percussion, - I thump the heel with my fist while the child is lying on their
stomach with their knee bent so the foot is up in the air, 3) swollen and/or
tender Achilles’ tendons which hurt when you squeeze them.
The final question to
ask is whether mom or dad have low back pain. Often
the answer is yes, but they have an ‘excuse.’ Few injuries cause persistent
back stiffness in the morning. It’s not a definite finding, but it should make
you more suspicious. The spondyloarthropathies are actually very common. They
have a genetic basis and tend to ‘run in families.’ However, they have highly
variable penetrance. Often one family member will have minimal symptoms while
another has significant problems.
Is this
important? Yes!!. With proper therapy we can make
these children and young adults much more comfortable. Often they can resume
full activities and go back to being successful athletes, cheerleaders, etc.
Two academic points
about spondyloarthropathies: first, many people expect these patients to be
HLA-B27 positive. Also many people “improperly” (personal opinion
see below) label these children as having juvenile ankylosing spondylitis. About half of these children are HLA-B27
positive. However, about half are not. Don’t make the diagnosis based on the
presence or absence of this HLA antigen. The second academic point; all of the
childhood rheumatic diseases are going through a period of ‘redefinition.’ The
international nomenclature committee has decided that ‘spondyloarthropathy’ is
to be replaced by ‘enthesitis associated arthritis.’
If you have a child or
young adult whom you suspect might have a spondyloarthropathy or who has been
labeled with juvenile ankylosing spondylitis, give us a call. We’ll be glad to
help you out. Most get better with NSAIDs, but some children require more
aggressive therapy including TNF blocking agents or immunosuppressives. The choice of
NSAID is very important as all NSAIDs are not equally effective for this
disease.
In many children this
tends to be a recurrent disease. Proper counseling, monitoring, and physical
therapy are important. A small percentage will go on to develop full fledged
ankylosing spondylitis. Although I
discuss this subject in much more detail in my book (below), I think it is very
important for every parent of a child diagnosed with juvenile ankylosing
spondylitis to understand that no one can predict the future with
certainty. I’ve been in practice over
twenty-five years. During that time the
answer has changed from every HLA-B27 child with joint pain will ultimately
develop ankylosing spondylitis to maybe very few to ….. No one really knows how often this happens
and no one really knows if your child will go on to develop full fledged
ankylosing spondylitis. The key is not
to lose sleep over what you call it. It
must be treated aggressively and appropriately for the problems the child or
young adult has. Labeling children with
‘juvenile ankylosing spondylitis’ unnecessarily causes them and their parents great worry about the future and impedes their
development into the young adults they should be. Yes some HLA-B27 positive boys will go on to
ankylosing spondylitis and they should be watched carefully. But, they should not be labeled prematurely
or prevented from reaching their full potential by a premature and often incorrect
diagnosis.
For a more detailed
discussion of the many forms of spondyloarthropathies and their treatment
consider my book below.
Dr. Lehman is the author of many
textbook chapters and articles on the care of children and young adults with
rheumatic diseases including SLE, JRA, dermatomyositis, scleroderma,
My
book –click here to order at a discount from Amazon.com!!
Get
the answers you need for your child today _ Only
$24.50 at Amazon.com
“Dr.
Tom Lehman’s
experience and compassion are evident on every page of this book, and they help
guide the reader—child,
parent, and healthcare professional alike – through the world of childhood arthritis. This book is an absolute gem written with a
single goal in mind: improve the lives
of kids with arthritis.” -- Jack Klippel, M.D. President and
CEO of the Arthritis Foundation
“Dr. Lehman has given
parents and families of children with arthritis the first book that speaks to
the parent and child as equals. His book
explains the illnesses, the medications, the lab tests, and the disease course
in simple, understandable lay language and givens them valuable insight into
how a pediatric rheumatologist thinks.
Bravo!”-- Charles Spencer, M.D., Professor of
Clinical Pediatrics,
It’s not just
growing pains.
A guide to childhood muscle, bone, and joint pain,
rheumatic diseases and the latest treatments
Click here to order this book and get the answers you need
for your child today.
Click here to see
the full table of contents
It
has always been a frustration trying to answer the many questions I have
received from people over the web. I can’t
take the time and give them the detail I would like to. I have to take care of my patients. This book is a distillation of my experience
answering questions for parents and health professionals over 25 years of
practice. If you want to know about the
diseases, the tests, the medications, or how to be sure you are getting the
best care– If you are the family member of a child with joint pains, this book will give you the answers. There are chapters on sports injuries, common
orthopedic conditions and of course on all the various forms of arthritis. If you are a general physician, a
pediatrician, or a nurse who cares for children with these diseases it will
answer many of the questions families ask you, and you can recommend it to
them. It will also answer many of your
questions about what shots to give, what precautions to take, and the other
questions families, pediatricians, and other health care providers have asked
me over the years.
Click here to order this
book and get the answers you need for your child today.
The Division of Pediatric
Rheumatology at HSS
continues to grow. We’re adding faculty, and we’ve received grants to expand
both our teaching programs and our research into the causes and care of
childhood rheumatic disease. Thank you for your continued support!
We’re in White Plains!
If you have patients who
don’t want to come into NYC we can see them at the Burke Rehabilitation
Center in White Plains. Call our NYC office 212-606-1151 for appointments.
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Dr. Lehman
is the author of many textbook chapters and articles on the care of children
and young adults with SLE. He practices
in
The Arthritis Foundation also works with
children with enthesitis.
Click for BOOKS dealing with
childhood arthritis.
This site provided by Thomas J. A. Lehman MD
Chief, Division of Pediatric Rheumatology
The Hospital for Special
Surgery
535 E 70 St,
212-606-1151, fax 212-606-1938, e-mail goldscout@aol.com
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