Managing Infection Risk for Kids with Arthritis

Learn about the risk factors for infection and severe disease and ways to keep your child healthy.

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. This is especially true during virus outbreaks, like the coronavirus. Children with arthritis may have an increased risk of infection, but there are ways to help keep your child healthy and protected.

Risk Factors for Infection 

Particularly when JA is active and not well controlled, the disease itself can increase the risk of infection.

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

That’s because some medications to treat JA can also hamper the immune system’s ability to fight off bacteria, viruses and fungi. But fortunately, the risk is still low for most treatments, says Karen Onel, MD, chief of pediatric rheumatology at the Hospital for Special Surgery in New York.  Studies show that children taking methotrexate, TNF inhibitors or other biologics – the most common treatments for JA – have a much lower infection risk than for adults taking these same medications.

“What’s more, globally the infection risk for children with JA taking these drugs is not much greater than for children with JA not taking them,” says Dr. Onel. “This should be reassuring for parents.”

At the same time, doctors say there are medication risk factors that parents should be aware of. For example, systemic corticosteroids can increase the risk of infection when taken long term and at high doses, says Dr. Onel. This does not apply to corticosteroids applied topically or injected directly into the joint.

In a 2016 study using Medicaid data, Mannion and her colleagues found that kids with juvenile idiopathic arthritis (JIA) who were on high dose corticosteroids were more likely to be hospitalized for infection.

For that reason, doctors always give the lowest doses possible for the shortest amount of time possible, says Dr. Onel.

Doctors should also test children for tuberculosis before starting TNF inhibitors (i.e. etanercept, infliximab or adalimumab). Children who take TNF inhibitors also have a greater risk of fungal infections, though the risk is low, says Dr. Onel. “However, fungal infections in children who take TNF inhibitors may look very different than in children not taking those medications and may be missed,” she says. That means people who encounter infected children may be exposed and not even know it.

Cough is a key symptom in fungal infections. So, if a child on a TNF inhibitor develops a bad cough that doesn’t go away, doctors should consider the possibility of a fungal infection, as well as other common childhood infections, says Dr. Onel.   

Cough is also a symptom of the coronavirus, along with fever and shortness of breath, so tell your child's doctor right away if you notice any of these symptoms.

When children with arthritis do get infections, such as chickenpox or the flu, the illness may be more serious. It’s unclear whether the same may be true for the coronavirus.

“The chances of kids having a severe disease or severe lungs issues [from the coronavirus] seem to be very low, in general,” , said Michael George, MD, MSCE, rheumatologist and epidemiologist at the University of Pennsylvania, on the Coronavirus and Arthritis Live Yes! with Arthritis Podcast.  Listen to the podcast and read our Coronavirus FAQ to get more information about the virus and how it may affect children with arthritis.

Whether or not kids with JIA or other autoimmune conditions are at a higher risk for getting seriously ill from the virus is hard know, he said. “But at least we know that [as children], they’re starting at a lower spot in terms of serious illness, which I think is quite reassuring,” he said. Still, parents and children with JA need to take the standard precautions to avoid infections as much as possible.

Limiting Your Child's Risk 

In the same Medicaid study, Mannion and her colleagues found that children were more likely to be hospitalized for infection if they were recently sick with something else.

Parents can help protect their children by making sure they receive age-appropriate immunizations, including an annual flu shot, with one important exception: Children taking corticosteroids 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. 

Regularly disinfecting frequently touched household surfaces such doorknobs and faucets can also help. 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.

Never stop medications without first consulting your child’s doctor. 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.

If your child starts to show symptoms of the coronavirus, let your child’s doctor know right away. In some special circumstances, some medications might need to be increased or decreased, says Richard Vehe, MD, director of the Division of Pediatric Rheumatology at University of Minnesota Medical School in Minneapolis. Doctors may also suggest stopping certain medications for a short time to make sure they don’t contribute to more severe illness, says Dr. George.

Talking to Your Child 

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.  

Right now, it’s important to practice the social distancing guidelines from the CDC – which means putting a halt on playdates, extracurricular activities, and of course, avoiding contact with sick people. But once life returns to normal, it’s important to warn your child about the risks of sharing drinks, food and lip balm, says Dr. Mannion.

While it’s important to stay aware, kids with arthritis can’t live in a bubble. “But fortunately, most children with arthritis 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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