Juvenile idiopathic arthritis (JIA) is the most common chronic arthritis in children. This nonspecific type of arthritis appears before the age of 16 years and lasts at least six weeks. It can impact any part of the body but most commonly causes joint pain and inflammation in the hands, knees, ankles, elbows, and wrists. A functional medicine approach to JIA can control inflammation to manage pain and prevent damage and complications.
What is Juvenile Idiopathic Arthritis
Juvenile idiopathic arthritis is a form of inflammation in the joints in children. The term "idiopathic" in the name refers to the fact that the exact causes are not entirely understood, but it seems to involve the body's immune system attacking its tissues, which creates inflammation. This leads to chronic, long-lasting joint pain, stiffness, loss of motion and function, and swelling in any body joints.
JIA is the most common chronic rheumatic disease in childhood. It affects about 300,000 children in the United States. The onset of JIA is most common around ages 2 to 4 and around 6 to 12 years of age and is more common in Caucasian and female patients.
Six types of Juvenile Idiopathic Arthritis
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, and each have 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); the most common subtype
- Polyarthritis: affects five or more large and/or small joints, usually on both sides of the body (both knees, both wrists, etc.); affects about 25% of children with JIA.
- Systemic: impacts the entire body with inflammation in the joints, skin, and internal organs, causing high spiking fevers (103°F or higher) that last at least two weeks and rashes; 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 on the eyelids, elbows, knees, belly button, and/or scalp. 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, but may also affect the fingers, elbows, pelvis, chest, digestive tract (Crohn's disease or ulcerative colitis) and lower back (ankylosing spondylitis). This subtype is more common in boys and typically appears in children between the ages of eight and fifteen.
- Undifferentiated: inflammation is present in one or more joints but does not fit within one of the other subtypes.
Juvenile Idiopathic Arthritis Signs & Symptoms
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 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.
- 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.
- High fevers.
What Causes Juvenile Idiopathic Arthritis
JIA is believed to be an autoimmune or autoinflammatory disease where the immune system attacks the body's cells and tissues. This leads to the release of inflammatory chemicals that attack the synovium (tissue lining around a joint) that, 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.
Children with JIA have certain genes that are activated by a virus, bacteria, environmental, or other external factors, but the exact pathophysiology is still being studied.
The gut microbiome plays a critical role in regulating hormones, immunity, detoxification, and overall health. An imbalance in the gut microbiome and Increased intestinal permeability (leaky gut) is involved in several autoimmune and inflammatory conditions, including JIA.
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
- Delivery by cesarean section
Tissue samples of the gut lining of JIA patients commonly show inflammation. Ongoing stressors, diet, toxins, and environmental factors can lead to dysbiosis, where the gut bacteria become imbalanced and damage the gut lining contributing to inflammation. Once the gut lining is damaged, the barrier becomes ineffective, and substances can migrate across the gut lining to joints, which can subsequently promote inflammation (synovitis).
Complications of Juvenile Idiopathic Arthritis
In many patients with JIA, arthritis and inflammation persist into adulthood. If the inflammation in JIA is not addressed, it can damage the lining that covers the ends of bones in a joint (cartilage) and the bones themselves. This can contribute to issues with growth and development.
Depending on the severity of the disease and the joints involved, the bones near inflamed joints may grow too quickly or slowly. This can result in a small underdeveloped chin or mismatched lengths of the arms or legs, for example. Growth overall may be slowed with severe disease.
Since the inflammation of JIA often causes pressure and pain in and around a joint, a child may attempt to keep the inflamed joint in the most comfortable position, which is usually bent. When a joint is bent for too long, the muscles and the tendons that attach muscles to bones can shorten, tighten, and not grow properly. This leads to joint contracture.
A loss of bone density, or osteopenia and osteoporosis, can develop in children with JIA. This may be due to prolonged joint inflammation and immobility and taking anti-inflammatory medications like corticosteroids for an extended period. In these circumstances, the bones can become thin and weak, which makes them easier to fracture.
Inflammation from JIA can also impact the eyes. This can lead to a condition called uveitis due to inflammation of the front and middle parts of the eye. In some types of JIA, like enthesitis-related JIA and psoriatic JIA, episodes of acute anterior uveitis can occur, which cause sudden onset eye pain and redness along with sensitivity to light.
Functional Medicine Labs to Test for Root Cause of Juvenile Idiopathic Arthritis
Gut Health Tests
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 measures amounts of healthy and unbalanced gut bacteria (dysbiosis), inflammatory markers, leaky gut, parasites, and yeast to assess the state of the gut and guide treatment aimed at restoring balance.
Food sensitivities can further contribute to increased intestinal permeability, inflammation, and autoimmunity. Foods to which an individual is sensitive can be identified with ELISA testing.
Other tests that can indicate intestinal permeability (leaky gut) that may be underlying the autoimmunity and inflammation in JIA are the lactose/mannitol test and fecal calprotectin.
The lactulose: mannitol (LM) test measures the ability of two non-metabolized sugar molecules—lactulose and mannitol—to permeate the intestinal mucosa, indicating that the gut lining is leaky and/or malabsorption is occurring.
Fecal Calprotectin measures a protein that, when elevated, indicates the migration of immune cells (neutrophils) to the intestinal lining. This commonly occurs with intestinal inflammation, including inflammation caused by inflammatory bowel disease and JIA.
Inflammation markers such as high-sensitivity hs-C-reactive protein (hsCRP) and erythrocyte sedimentation rate (ESR) assess inflammation levels throughout the body.
High-sensitivity CRP is a predictive marker of long-term outcomes in JIA. Baseline CRP concentrations over ten mg/l have been shown to predict greater disease severity after several years of follow-up.
While normal levels of these inflammatory markers do not necessarily indicate no disease activity, elevated ESR seems to help predict the occurrence of uveitis in patients with JIA.
Specific antibodies can be measured in the blood, reflecting inflammation and autoimmunity that may occur in some children with JIA.
- Antinuclear antibodies (ANA) react against normal components of cell nuclei and are commonly produced by the immune systems of people with certain autoimmune diseases, including arthritis; they can indicate an increased chance of eye inflammation in children with JIA.
- Rheumatoid factor is occasionally found in the blood of children who have juvenile idiopathic arthritis and may indicate a higher risk of damage from arthritis.
- Cyclic citrullinated peptide (CCP) is another antibody that may be found in the blood of children with juvenile idiopathic arthritis and may indicate a higher risk of joint damage.
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.
Conventional Treatment for Juvenile Idiopathic Arthritis
The most common conventional approach to treating JIA involves a combination of medications used 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
- 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)
7 Natural Treatments for Juvenile Idiopathic Arthritis (JIA)
Studies show that an anti-inflammatory diet can help balance inflammation, reduce pain, and prevent autoimmunity. This involves a personalized diet rich in fruits and vegetables, whole grains, lean protein, healthy fats like avocado and olive oil, and foods rich in omega-3 fatty acids. Omega-3 fatty acids, such as walnuts, salmon, and flaxseeds, are converted into mediators that resolve inflammation and reduce pain.
Conversely, an anti-inflammatory diet reduces or excludes processed foods and sugars, conventionally-raised red meats, and inflammatory vegetable or seed oils that contain mostly n-6 linoleic acid. Some omega-6 fatty acids tend to promote inflammation. There is evidence that a high omega-6 fatty acid diet inhibits the anti-inflammatory and inflammation-resolving effect of omega-3 fatty acids. Therefore it's important to balance the intake of omega 3 to omega 6 ratios.
Elimination of Reactive Foods
Based on food sensitivity results most practitioners will remove highly reactive foods for at least 3 months and reintroduce one by one to see if they are still causing a inflammatory response once the body has had a chance to heal.
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 essential 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.
Specific Carbohydrate Diet (SCD)
The specific carbohydrate diet (SCD) removes certain complex carbohydrates, including grains, rice, corn, potatoes, lactose, and refined sugars. Instead, it focuses on meat, poultry, fish, eggs, nuts, fruits, beans, peas, honey, fully fermented yogurt, and hard cheese. This approach is based on the concept that the digestion of complex carbohydrates relies on enzymes produced by the microbiome, with large amounts of carbohydrates altering the microbiota. In contrast, simple carbohydrates (monosaccharides) can be more easily absorbed and therefore have a lesser impact on the gut microbiome. It has been used to improve inflammatory bowel disease in children and has been suggested for treatment in JIA patients.
Balancing the Microbiome
Research involving several autoimmune conditions like rheumatoid arthritis show promise for utilizing prebiotics and probiotic supplementation to improve symptoms and laboratory markers of disease. Restoring equilibrium in the gut microbiota is critical for repairing the mucosal barrier and stopping autoimmunity and excess inflammation, which can help improve symptoms of JIA.
This may be accomplished through an individualized balanced whole foods diet incorporating pre- and probiotic-rich foods as tolerated. Fermented foods like kimchi and sauerkraut contain naturally-occurring probiotics that enhance the microbiome, while prebiotic-rich foods like artichokes, garlic, and beans can provide nourishment for healthy bacteria.
- Vitamin D has been shown to help regulate the immune system, with low levels of vitamin D found in many children with JIA.
- Glutamine is an amino acid that helps to protect and heal the intestinal lining and reduce inflammation.
- 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. Curcumin combined with piperine (black pepper extract) is more easily absorbed.
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.
Fifteen minutes of daily massage by a parent has been shown to improve anxiety, serum cortisol, pain, and morning stiffness in children with JIA.
Juvenile idiopathic arthritis refers to a group of autoimmune conditions that result in inflammation and pain in the joints of children before the age of 16 years. The cause of the disease is multifactorial, involving 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 joint pain flares 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.