Managing Infection Risk for Kids with Arthritis

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

Updated April 29, 2022

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. Knowing the factors that can increase infection risk can help you keep your child safe.  

Risk Factors for Infection 

When JA is active and not well controlled, the disease itself can increase the risk of infection, says Melissa Mannion, MD, assistant professor in the Division of Pediatric Rheumatology at the University of Alabama at Birmingham. And, she says, “disease activity may also increase the need for more medication, which can also increase infection risk.”

That’s because some medications to treat JA can also hamper the immune system’s ability to fight off bacteria, viruses and fungi. 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 City. Studies show that children taking methotrexate or biologics, such as TNF inhibitors — 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, Dr. 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, Dr. Onel says.

Doctors should test children for tuberculosis before starting TNF inhibitors (i.e., adalimumab, etanercept or golimumab). 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.”

Cough is a key symptom of 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 one 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.

Kids and COVID

When children with arthritis get infections, such as chickenpox or the flu, the illness may be more serious than in kids without arthritis. But recent research suggests that children with JA have a relatively low risk of severe coronavirus infection. Data from three international rheumatology databases found that only 7% of children with juvenile idiopathic arthritis (JIA) were hospitalized with COVID-19 and most weren’t seriously ill. Treatment with biologics, including TNF inhibitors, didn’t appear to put kids at higher risk of severe COVID-19, either. Researchers who studied the data say parents should be reassured by these findings.

That’s echoed by Michael George, MD, rheumatologist and epidemiologist at the University of Pennsylvania. “The chances of kids having a severe disease or severe lung issues [from the coronavirus] seem to be very low,” he says. (Listen to Dr. George on an early episode of the Live Yes! With Arthritis Podcast discuss the SARS-CoV2 coronavirus at the time.)


Although most kids with arthritis don’t seem at special risk of COVID-19, any child — even those with mild cases — can develop a rare, potentially fatal complication called multisystem inflammatory syndrome in children (MIS-C). It can cause severe inflammation in organs and tissues throughout the body, including the heart, kidneys, blood vessels, digestive system, skin and eyes. The most common symptoms seem to involve the digestive tract and heart, but may also include:

  • A fever that lasts 24 hours or longer
  • Vomiting
  • Skin rash
  • Fatigue
  • Fast breathing or heartbeat
  • Red eyes
  • Headache, dizziness, or lightheadedness

If your child develops severe stomach pain, trouble breathing or, depending on skin tone, pale or bluish skin, lips or nails, get emergency care right away.

No one is sure what causes MIS-C or why some kids get it and others don’t, but it seems to be an extreme immune response to COVID-19. Some of the first cases were diagnosed as Kawasaki disease, a rare type of vasculitis with many symptoms similar to MIS-C. Subsequent research has shown that while the two have some features in common, they’re separate conditions.

Most kids recover from MIS-C with treatment — usually a combination of intravenous (IV) immunoglobulin, and corticosteroids — but a few who get sick very rapidly don’t survive.

Limiting Your Child's Risk 

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 the human papillomavirus vaccine, 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 might 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. It’s also important to warn your child about the risks of sharing drinks, food and lip balm, Dr. Mannion says.

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