Managing Infection Risk for Kids with Arthritis

 Rheumatic diseases and the medications used to treat them may increase your child’s infection risk. Here’s what you can do to protect your child.

Aside from the risks of the disease itself, one of the greatest concerns for parents of kids with juvenile arthritis (JA) is the risk of infection. Particularly when JA is active and not well controlled, the disease itself can increase infection risk, experts say.

“We think that disease activity increases the risk for infection,” says Melissa Mannion, MD, assistant professor in the Division of Pediatric Rheumatology at the University of Alabama at Birmingham. Disease activity also increases the need for more medication, which can increase infection risk, she says. 

Drugs that suppress the immune system to control arthritis can hamper its ability to fight off bacteria, viruses and fungi. But studies show that children taking methotrexate, TNF inhibitors or other biologics – the most common treatments for JA – are at much less risk for infection than for older adults taking these same medications. “Globally the infection risk is not much greater than for children with JA not taking these drugs,” says Karen Onel, MD, chief of pediatric rheumatology at the Hospital for Special Surgery in New York. “This news should be reassuring for parents.” 

At the same time, doctors say there are risks parents should be aware of. For example, systemic corticosteroids can increase infection risk when taken long term. Also, children taking TNF inhibitors are at greater risk of fungal infections. The risk is still low, says Dr. Onel. “However, fungal infections in children who are receiving TNF inhibitors may look very different than in children not receiving those medications and so may be missed,” she says. That means people who encounter infected children may be exposed and not even know it. Lastly, when children with arthritis do get common infections, such as chickenpox or the flu, the illness may be more serious.  

Here’s what doctors, parents and kids can do to help reduce the risk.


In a study using Medicaid data, Mannion and her colleagues found that kids with juvenile idiopathic arthritis (JIA) were more likely to be hospitalized for infection if they had a recent infection or were on high-dose corticosteroids. 

While systemic corticosteroids [i.e., oral or intravenous corticosteroids] quickly control inflammation to prevent or reduce damage from active arthritis, if given long term and/or at high doses, they increase infection risk, says Dr. Onel. However, corticosteroids applied topically or injected directly into the joint do not increase the risk. 

“It always our goal to give the lowest doses possible for the shortest time possible,” says Dr. Onel. Likewise, doctors often limit the use of stronger immunosuppressive drugs (i.e., cyclosporine) for arthritis that’s difficult to manage by using other medicines. 

Doctors should also test children for tuberculosis before starting TNF inhibitors (i.e. etanercept, infliximab or adalimumab) and be mindful of regional fungal infections, including blastomycosis (common in the midwest, south-central and southeast) and histoplasmosis (common in Mississippi and Ohio river valleys). Cough is a key symptom in both infections. So, if a child on a TNF inhibitor develops a bad cough that doesn’t go away, [the doctor] should consider the possibility of a fungal infection, as well as other common childhood infections, says Dr. Onel.   


Parents can help protect their children from infection by making sure they receive age-appropriate immunizations, including an annual flu shot, with an important exception: If your child is taking corticosteroids, he should avoid live vaccines (including the chickenpox vaccine, MMR vaccines or the nasal flu vaccine) because they increase your child’s risk of illness. Other immunizations, such as the hepatitis A, hepatitis B, meningitis and Gardasil® vaccines, are all safe.  Additionally, parents should ensure that all members of the household, including themselves, get immunized to reduce the exposure risk for their children with arthritis. 

Parents should also regularly disinfect frequently touched household surfaces such door knobs and faucets. Dr. Onel recommends requesting that other shared surfaces– the barre in your daughter’s ballet class, the wrestling mats in the school gym, for example –be cleaned as well.  

“It’s also important for parents to discuss frequent colds or infections with their child’s rheumatologist so they can decide if medication needs to be changed or if further immunologic evaluation would be helpful,” says Dr. Mannion.

One of the worst things a parent can do when a child gets sick is to withhold medication, says Dr. Onel. Doing so could reactivate the disease and have longer-lasting consequences than most infections, she says. Always to talk to your child’s doctor before stopping any medication. 


Practicing good hygiene and frequent hand washing are the most important things kids can do to prevent infection. Dr. Onel recommends giving kids a portable hand sanitizer for times it’s not possible to use a faucet and soap.  

Also, caution your children against hanging out with friends who are sick and from sharing drinks, food and Chapstick with other people, says Dr. Mannion.

“We want kids with arthritis to live a normal life, so they can't live in a bubble,” says Dr. Mannion. “Fortunately, most children with JA do very well as long as parents and doctors are surveillant, protective and keep everyone in good shape around them,” says Dr. Onel.

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