Juvenile idiopathic arthritis (JIA) is an umbrella term that refers to several subtypes of chronic arthritis that occur in children and adolescents. There are six different forms of arthritis that fall under the category of JIA, each with its own unique presentation.
This nonspecific type of arthritis appears before the age of 16 years old and lasts at least six weeks. It can impact any part of the body but most commonly causes joint pain and inflammation in the knees, ankles, hands, elbows, and/or wrists. While the exact cause(s) of JIA remains unknown ("idiopathic"), it is thought to involve an autoimmune process where the body attacks its own tissues.
JIA is the most common chronic rheumatic disease of childhood and occurs in around 2 to 20 to 16 to 150 per 100,000 children. Most types of JIA, with the exception of the enthesitis-related subtype, are more common in females.
Treatment of JIA encompasses medications, dietary and lifestyle approaches, and supplements. This article will focus on a functional medicine approach to JIA that can help control inflammation to manage pain and prevent complications.
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What is Juvenile Idiopathic Arthritis?
Juvenile idiopathic arthritis occurs when there is inflammation in the joints in children or adolescents that leads to pain and damage to the joint structure. To be classified as JIA, a child must experience arthritis symptoms that last at least six weeks before the age of 16. It is the most common type of arthritis in children of this age group.
The term “idiopathic” in the name refers to the fact that the exact causes are not fully understood, but it seems to involve the body's immune system attacking its own tissues, which creates inflammation in an autoimmune process. This leads to chronic, long-lasting joint pain, stiffness, loss of motion and function, and swelling. These symptoms can occur in any joint of the body, and the pattern of symptoms varies depending on the specific type of JIA.
There are multiple types of juvenile idiopathic arthritis that all present with arthritic symptoms of joint pain, swelling, warmth, and stiffness that last at least six weeks, but each type has some unique characteristic features.
The six main subtypes of JIA include the following, noted by their characteristic symptoms.
Oligoarthritis affects four or fewer joints, typically the larger ones (knees, ankles, elbows). This is the most common subtype.
Polyarthritis impacts five or more large and/or small joints, usually on both sides of the body (both knees, both wrists, etc.). This type affects about 25% of children with JIA.
Systemic JIA impacts the entire body with inflammation in the joints, skin, and internal organs. It can cause high spiking fevers (103°F or higher) that last at least two weeks, as well as rashes. The systemic type affects about 10% of children with JIA.
Psoriatic arthritis (PsA) causes joint pain and swelling of one or more joints (often the wrists, knees, ankles, fingers, or toes) along with a scaly rash behind the ears and/or the eyelids, elbows, knees, belly button, and/or scalp. The skin symptoms may occur before or after joint symptoms appear.
Enthesitis-related or spondyloarthritis affects the ligaments or tendons (entheses) where the muscles attach to the bone, most commonly causing inflammation around the hips, knees, and feet. It may also affect the elbows, fingers, chest, pelvis, digestive tract (Crohn’s disease or ulcerative colitis), and lower back (ankylosing spondylitis). Unlike most of the other subtypes, this subtype of JIA is more common in boys and typically appears in children between the ages of eight and fifteen.
Undifferentiated JIA refers to arthritis that occurs in children or adolescents when the inflammation is present in one or more joints but does not fit within one of the other subtypes.
Symptoms of Juvenile Idiopathic Arthritis
JIA usually causes flare-ups of disease that may come and go. This results in times of elevated inflammation and worsening symptoms that can last for days or months.
The specific pattern of symptoms can vary depending on the subtype, but the most common symptoms of JIA include:
- Joint pain or stiffness that is often worse after waking up or staying in one position too long
- Red, swollen, tender, and/or warm joints
- Chronic bone inflammation that can result in growth issues and weakened bones over time
- High fevers
- Fatigue and feeling very tired or rundown
- Blurry vision, dry, gritty eyes, and sensitivity to light due to uveitis (chronic eye inflammation)
- Rashes such as a faint salmon-colored rash or a red, scaly rash (psoriatic arthritis)
- Loss of appetite
- Inflammation and scarring that can lead to shortness of breath and lung issues
What Causes Juvenile Idiopathic Arthritis?
Juvenile idiopathic arthritis is characterized as “idiopathic” since the exact cause is not known. Children with JIA have certain genes that are activated by a virus, bacteria, environmental, or other external factors.
While the exact cause(s) and pathophysiology of JIA are still being investigated, it is believed to be an autoimmune or autoinflammatory disease in children with certain genetic susceptibilities. With this type of autoimmune process, the immune system attacks the body’s cells and tissues, leading to the release of inflammatory chemicals that attack the synovium (tissue lining around a joint) that normally produces fluid that cushions joints and helps them move smoothly. The inflamed synovium makes the joint painful or tender, red, swollen, and difficult to move.
One of the main factors involved in autoimmune and inflammatory conditions, including JIA, is an imbalance in the gut microbiome and increased intestinal permeability (leaky gut). The lining (mucosa) of the small intestine plays crucial roles in barrier function, metabolism, nutrient absorption, detoxification, and immune modulation. Since the digestive tract is the main barrier to the outside world, it is a critical mediator of the immune system. The gut microbiome or microbes that populate the digestive system play critical roles in regulating hormones, immunity, detoxification, and overall health.
Tissue samples of the gut lining of JIA patients commonly show inflammation. This inflammation can weaken the gut lining. Ongoing stressors, diet, and environmental factors can contribute to imbalances in gut bacteria (dysbiosis) and damage to the gut lining that further increases this type of inflammation. Chronic exposures to toxins, inflammatory foods such as gluten, and chronic stress all contribute to these microbial imbalances in the gut and a damaged and leaky gut lining. This causes the normal barrier formed by the gut wall to become ineffective so that substances can enter the bloodstream and trigger inflammation and autoimmune responses throughout the body. Bacteria, fragments of food, and activated immune cells can migrate across the leaky gut lining to joints, where it can subsequently promote inflammation (synovitis).
Some factors that potentially alter the gut microbiota and intestinal immunity and seem to contribute to an increased risk of JIA include the use of antibiotics at an early age, early weaning from breastfeeding, and delivery by cesarean section.
Ruling Out Differential Diagnosis
Other illnesses can also present with similar joint inflammation and arthritis-like symptoms, so it is important to rule out these differential diagnoses for JIA. These include infections like septic arthritis, other connective tissue diseases like transient synovitis and systemic lupus erythematosus, Kawasaki disease, and malignancies such as leukemia.
Septic arthritis occurs when bacteria travel in the blood to a joint and cause an infection. It is the most frequent cause of arthritis in hospitalized children and requires emergent treatment.
Transient synovitis of the hip is a self-limiting inflammation of the joint lining that usually comes on suddenly after a mild upper respiratory infection and lasts around six days. It is most common in boys between 3 to 8 years old.
In Kawasaki disease, the walls of blood vessels become inflamed. This can cause problems with the heart and blood flow, swelling in lymph nodes, inflammation of mucous membranes inside the mouth, nose, eyes, and throat, as well as arthritis, especially in the knees, ankles, wrists, and elbows.
Malignancies, such as leukemia, lymphoma, neuroblastoma, osteosarcoma, and Ewing’s sarcoma, can result in joint pain and arthritis, sometimes before the hematologic features of malignancy are obvious. In cases where joint pain is caused by malignancy, children may also have signs like pale skin, bruising, enlarged lymph nodes, a palpable liver and/or spleen, and bony tenderness.
How is Juvenile Idiopathic Arthritis Diagnosed?
To establish a diagnosis of JIA, a child must be under 16 years old, have inflammation in one or more joints that lasts for at least six weeks, and have all other conditions, such as those above, ruled out. In addition to a thorough history and physical examination looking for joint tenderness, swelling, warmth and painful or limited movement, eye redness, and skin rashes, blood tests and/or imaging can help establish the diagnosis.
Laboratory tests can help assess the degree of inflammation in the body and look for the presence of autoimmune markers like antinuclear antibody (ANA) and rheumatoid factor that can help evaluate other potential diagnoses. Blood tests can also help rule out other diseases, such as an infection or malignancy.
X-rays or magnetic resonance imaging (MRI) can help to exclude other conditions, such as tumors, fractures, infection, or congenital defects, and can also help to monitor joint damage and bone development over time.
Functional Medicine Labs to Test That Help Individualize Treatment for Juvenile Idiopathic Arthritis
Functional medicine laboratory testing can help assess the root causes of inflammation in children with arthritis and monitor treatment to individualize the management of JIA. An integrative medicine approach works to uncover factors that contribute to overall inflammation that impacts JIA and can help to monitor inflammation over time as well as rule out conditions that cause symptoms like JIA, such as rheumatoid arthritis and lupus.
Inflammation
C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) assess inflammation levels throughout the body and can be measured with a blood test.
Gut Health
Since dysbiosis and leaky gut are key factors in the development of the autoimmunity that occurs in JIA, a thorough assessment of gut health can help provide targeted interventions to improve the balance of the microbiome and reduce inflammation.
A Comprehensive Stool Test like the GI Effects assesses the balance of healthy and unbalanced gut bacteria to evaluate if dysbiosis is present. It also measures markers of inflammation, leaky gut, parasites, and yeast to give an overall view of the state of the gut and guide treatment that can help restore balance.
Food sensitivities can worsen leaky gut, inflammation, and autoimmunity. ELISA testing is one way to evaluate which foods you are sensitive to in order to individualize a healing dietary approach.
Intestinal Hyperpermeability
Other tests to assess gut health can indicate intestinal permeability (leaky gut) that may be underlying the autoimmunity and inflammation in JIA. These include the lactose/mannitol test and fecal calprotectin.
The Intestinal permeability assessment gives a picture of how much lactulose and mannitol are crossing through the intestinal mucosa. Looking at these two non-metabolized sugar molecules can help assess if the gut lining is leaky and/or malabsorption is occurring.
When fecal calprotectin is elevated, it can indicate that immune cells (neutrophils) are migrating into the intestinal lining. This commonly occurs with intestinal inflammation, including inflammation caused by inflammatory bowel disease and JIA.
Nutritional Status
Some children with JIA experience significant inflammation in the gastrointestinal tract that can contribute to malnutrition and poor dietary intake. Deficiencies in B vitamins, vitamin D, magnesium, and omega-3 fatty acids may occur due to malnutrition and ongoing inflammation and are associated with increased autoimmunity. The functional status of nutrients within the cell can be assessed with a micronutrient panel to uncover and target any deficiencies and imbalances.
Any Other Lab Test to Check
Certain antibodies can be measured in the blood that reflect inflammation and can help assess autoimmunity in JIA as well as rule out other causes of arthritis.
Antinuclear antibodies (ANA) react against normal components of cell nuclei and are commonly produced by the immune systems of people with certain autoimmune diseases like systemic lupus erythematosus. Elevated levels of ANA can indicate an increased chance of eye inflammation in children with JIA.
Rheumatoid factor (RF) is occasionally found in the blood of children who have juvenile idiopathic arthritis and may indicate a higher risk of damage from arthritis. It is also a marker that can suggest other autoimmune arthritis, like rheumatoid arthritis.
The rheumatoid arthritis panel includes RF, as well as anti-CCP3, IgG, and IgA. Cyclic citrullinated peptide (CCP) is another antibody in the blood of some children with JIA. When present, it may suggest a greater risk of joint damage.
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Conventional Treatment for Juvenile Idiopathic Arthritis
The most common conventional approach to treating JIA involves a combination of medications that are used to try to reduce inflammation, modulate the immune system, and reduce pain. These include non-steroidal anti-inflammatory drugs (NSAIDs), systemic glucocorticoids, steroid injections into affected joints, and medications to modulate the immune system, such as methotrexate (MTX), sulfasalazine, tumor necrosis factor-alpha (TNF-α) inhibitors (i.e., etanercept [Enbrel] and adalimumab [Humira]), leflunomide, abatacept (Orencia), anakinra (Kineret).
Integrative Medicine Treatment Protocol for Juvenile Idiopathic Arthritis
Integrative medicine can be used to help balance the inflammation involved in JIA, manage pain, and improve the child’s quality of life. Diet and lifestyle approaches like an anti-inflammatory diet and balanced exercise can help improve the quality of life and function in children with JIA. An individualized treatment approach guided by clinical symptoms and functional laboratory testing can tailor a dietary and lifestyle approach that works for each child.
Therapeutic Diet and Nutrition Considerations for Juvenile Idiopathic Arthritis
An essential step in managing JIA in children and adolescents is to eliminate contributing factors to the increased chronic inflammation involved in this condition. This includes addressing an imbalanced diet, nutrient deficiencies, and chronic stress from a poor diet that contribute to an imbalanced microbiome, leaky gut, and increased inflammation.
Diet has a significant impact on the levels of inflammation and pain in the body. Inflammation can increase the chance of an autoimmune reaction that can attack the joints, so a nutrient-rich, anti-inflammatory diet tailored to an individual child's needs can help balance inflammation and tame autoimmunity. Dietary patterns high in ultra-processed foods and low in nutrient-dense foods like fruits, vegetables, whole grains, legumes, and olive oil help to balance inflammation. On the other hand, an anti-inflammatory diet like the Mediterranean diet eliminates foods that can promote inflammation and focus on foods that can prevent, reduce, or resolve it.
Eliminating unique trigger foods, such as gluten and other grains, dairy, processed sugars, and other foods that an individual child is sensitive to also helps to calm systemic inflammation. Since gluten is a common trigger of autoimmunity, removing gluten can help heal the gut and improve chronic inflammation. Reducing processed and added sugar intake is also important for balancing inflammation. In addition, some children with JIA can benefit from reducing nightshades such as potatoes, tomatoes, peppers, and eggplant during an elimination trial to see if this improves overall inflammation.
Since the gut microbiome plays such a significant role in the immune system, maintaining diverse and balanced bacteria can help tame autoimmunity and the increased inflammation that occurs in JIA. Feeding children a wide variety of whole foods while incorporating probiotic-rich foods like kimchi and sauerkraut that contain naturally-occurring probiotics and prebiotic-rich foods like artichokes, garlic, and beans can help to restore balance to the microbes in the gut. Once the microbiome is rebalanced, the mucosal barrier has a better chance to repair, while excess inflammation and autoimmunity that can contribute to joint inflammation can be tamed.
Supplements Protocol for Juvenile Idiopathic Arthritis
In addition to making dietary modifications, some supplements can help manage inflammation and pain in children with JIA. Vitamin D, fish oil, glutamine, and turmeric show promise for managing joint pain and inflammation. Individual regimens and dosing for children should be specified by a qualified practitioner to individualize the approach.
Vitamin D
Vitamin D is a steroid hormone and fat-soluble vitamin with important roles in bone metabolism and immune system regulation. Vitamin D has been shown to help regulate the immune system, with vitamin D receptors found on many types of immune cells and synovial cells in the joint. Studies suggest that many children with JIA have low levels of vitamin D.
Dose: Specific dosing in JIA is still under study, but initial research suggests a 400 IU daily regimen as the minimum dosing supplementation or 1–2 μg/kg/day for supplementation in children with JIA.
Duration: 6-24 months
Curcumin/Turmeric
Turmeric contains curcumin which has antioxidant, anti-inflammatory, antibacterial, antifungal, and antiviral properties. It shows promise in reducing inflammation and intestinal permeability found in autoimmune diseases, including JIA. Studies show that curcumin has an anti-inflammatory effect and inhibits inflammatory cytokines and enzymes, including cyclooxygenase-2 (COX-2). Curcumin has also been studied as an adjunctive therapy for patients affected by juvenile idiopathic arthritis-associated uveitis with a good safety profile.
Curcumin combined with piperine (black pepper extract) is more easily absorbed. This combination is available in formulations like Curcumin-Bioperine ®, which has over 2000% increased bioavailability.
Dose: up to 1000 mg per day for adults, adjusted by weight for children
Duration: up to 48 weeks
Fish Oil
Fish oil supplementation shows promise in reducing inflammation and joint pain in many arthritic conditions, including JIA. Children with JIA showed significant improvement in the number of swollen joints and inflammatory cytokine levels when taking two grams per day of oral omega-3 fatty acid supplements for 12 weeks. Those children who took the omega-3 fatty acid supplements were also able to reduce their intake of NSAID and related side effects.
Dose: 2 g/day
Duration: 12 weeks
L-Glutamine
Glutamine is an amino acid that helps to protect and heal the intestinal lining and reduce inflammation. It acts as the primary fuel source for the cells that line the GI tract and plays a key role in repairing the gut lining, which is often damaged and leaky in children with autoimmunity like JIA. Glutamine can help tighten the junctions between cells in the gut lining, which can help to prevent a "leaky gut" where particles from the gut can leak into the bloodstream, causing inflammation and triggering autoimmunity.
Dose: Dosages for children should be determined based on weight with a qualified practitioner and taken two times a day; some studies suggest 0.25 g/kg/day to 0.7 g/kg/day, or one small study found 0.65 g/kg is safe and tolerated well in children.
Duration: 16 weeks in adults, adjusted based on the child’s age with a practitioner
Acupuncture and Acupressure for Juvenile Idiopathic Arthritis
In traditional Chinese medicine (TCM), conditions associated with JIA, like autoimmune disease, leaky gut, and intestinal dysbiosis, are referred to as a "knotty" disease that arises from complex imbalances of qi, or "life force." This can include spleen qi vacuity, damp heat, liver qi stagnation, and other conditions. Research shows significant improvement in neck, back, and shoulder pain with acupuncture in adults with arthritis, although further studies are needed in children.
Physical Therapy for Juvenile Idiopathic Arthritis
Children may also benefit from physical and occupational therapy to stay active and perform daily tasks with greater ease. Research suggests that exercising in a fun, positive way for three weeks with free weights, core exercises, and jumping rope can improve leg strength, bone health, and mental health without increasing pain scores in JIA patients. Regular physical activity can also help regulate sleep patterns and promote an overall sense of well-being to help cope with and reduce chronic pain from JIA.
Hydrotherapy for Juvenile Idiopathic Arthritis
Hydrotherapy is a type of physical therapy that employs aquatic exercises. Exercises in a warm pool can provide gentle resistance and buoyancy to relieve pressure on joints while improving strength and flexibility. Studies suggest hydrotherapy can also help children with JIA improve the distribution of weight and plantar pressure, as well as provide social and psychological benefits.
Mind-Body Techniques for Juvenile Idiopathic Arthritis
Various mind-body techniques are used to help manage stress and cope with pain. Self-regulatory mind-body techniques like progressive muscle relaxation, guided imagery, and meditative breathing may reduce pain intensity and improve function for patients with JIA. Studies show that these strategies led to a substantial reduction of pain intensity when practiced by children with JIA over six to 12 months.
Another practice that may help children with JIA cope with pain is massage. Studies show that fifteen minutes of daily massage by a parent can improve anxiety, serum cortisol, pain, and morning stiffness in children with JIA.
When to Retest Labs
Depending on the individual child, overall symptoms, and treatment approach, reviewing clinical symptoms and repeating laboratory testing after 6-8 weeks can determine how to modify or continue the treatment approach.
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Summary
Juvenile idiopathic arthritis encompasses a group of autoimmune conditions that result in inflammation and pain in the joints of children before the age of 16 years. This condition is caused by several factors, including environmental factors that trigger immune system imbalance and inflammation in children with genetic susceptibility and gut microbiome dysfunction.
A functional medicine approach to JIA looks at underlying contributors to inflammation and autoimmunity that can cause flares of joint pain and strives to restore balance. An individualized treatment approach can help to reduce inflammation, rebalance the gut, and prevent ongoing damage from joint disease by utilizing dietary modification, supplementation, balanced nutrients, massage, and enjoyable exercise.
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