Ask the Expert: Dr. Thomas Lehman, Rheumatologist, Answers Questions About Juvenile Arthritis

Little girl playing with blocks

July is Juvenile Arthritis Awareness Month.

Q1. What kind of tests do you run to confirm if a child has juvenile arthritis?

Arthritis is diagnosed on the basis of pain, swelling and limitation of motion. There is no single blood test that will make the diagnosis.

Q2. Can juvenile arthritis stunt a child’s growth?

Yes. Untreated arthritis will almost always stunt the child’s growth.

Q3. Is it safe for a child with juvenile arthritis to get a flu shot since some juvenile arthritis medications suppress their immune system?

Flu shots are recommended. Talk with your physician.

Q4. My 2-year-old daughter has JRA. I read that it can cause uveitis – what are the symptoms and how is it treated?

Uveitis is an inflammation of the front of the inside of the eye (anterior chamber).  Most often it begins without any symptoms and that is why routine eye examinations by an ophthalmologist are so important. If left undetected until the child complains of difficulty seeing, it can lead to permanent blindness. Most children respond to steroid eye drops. Some require stronger medications like methotrexate, adalimumab (Humira) or infliximab. Consult with your physician about treatment.

Q5. My daughter is on her third medication. She was diagnosed in December with spondyloarthropathy. She took Relafen 500 twice a day worked for a little bit, Diclofenac 50mg twice a day and it didn’t work. Now she is on Lodine 600mg and it has helped her greatly. She is not stiff in the mornings and since school ended we have been home not doing much, just her stretches. Since she started summer day camp on Monday, when she came home, she was in pain in her heels. When she did PT her right knee was hurting and with OT her back. Is this normal? Or is she ever not going to have any pain at all? ?

Children with spondyloarthropathy often have highly varied responses to medication so it’s not unusual to try two or three before finding the right one for a particular child. Once you’ve found one that works, stick with it. Aches and pains are frequent but with the right medication, it is usually easily managed. This disease is best thought of as a chronic and recurrent inconvenience. There will usually be mostly pain-free days, but always an occasional ache. Talk with your physician about finding the right medication.

Also her knees give out on her and she has fallen but no injuries. Her knees are locking on her, so if it’s not one it is the other. Is this normal?

Some children get muscle spasms that cause this, but that can usually be controlled with physical therapy. Speak with your physician to see if physical therapy is right for your daughter.

In reading all the side effects of Enbrel, I know it’s rare but some children have developed cancer. On her father’s side of the family, there have been many aunts and cousins who have breast cancer. Should I be concerned? Also it lowers her immune system. Do kids on this medicine go to school and summer day camps even though it lowers their immune system and puts them at a greater risk of infection?

Enbrel has been very carefully studied. The incidence of cancer in children with arthritis on Enbrel does not differ from the incidence in children with arthritis taking other drugs. The link to cancer is almost entirely in children with inflammatory bowel disease. If there is a family history of breast cancer, you need to be concerned but not because of the Enbrel. Infections are always something to watch out for. They are more frequent in children on Enbrel, but not more frequently enough to make up for the dramatic improvement in the arthritis we usually see. Consult with your physician about the medication.

Q6. Does the sun affect the arthritis? If kids with JIA go to the pool and beach, how long should their exposure to the sun be?  Even with sun block and sun protection shirts? 

The other day we were at the pool and after awhile my daughter looked flushed and her head was hurting her, meanwhile the other kids were ok.

Some of the medicines children take for arthritis can cause sun sensitivity, but the arthritis itself doesn’t. If it happens again you should be sure to discuss it with your doctor.


Topics: Pediatrics
The information provided in this blog by HSS and our affiliated physicians is for general informational and educational purposes, and should not be considered medical advice for any individual problem you may have. This information is not a substitute for the professional judgment of a qualified health care provider who is familiar with the unique facts about your condition and medical history. You should always consult your health care provider prior to starting any new treatment, or terminating or changing any ongoing treatment. Every post on this blog is the opinion of the author and may not reflect the official position of HSS. Please contact us if we can be helpful in answering any questions or to arrange for a visit or consult.


  1. My daughter got white finger then blue then redness back on both hands today; we were in about 50 F damp weather. She is known said to have Raynaud’s; but can Kawasaki or other underlying diseases cause this too.

    1. “What you describe is Raynaud’s, which can occur alone or in combination with another rheumatic disease, like lupus rheumatoid arthritis, or scleroderma. However, Raynaud’s would be an unusual finding in someone with Kawaski.” – Dr. Michael Lockshin, Rheumatologist

    1. Hi Lisa, thank you for asking. Dr. Thomas Lehman is a pediatric rheumatologist at HSS, and is not affiliated with CUMC.

    1. Hi Annie, thank you for your question. Treatment for this condition includes steroid and vitamin D creams, light (UVA1 or UVB therapy), and immunosuppressive medications (i.e., corticosteroids, methotrexate, etc.). More information can be viewed at the following link: It’s recommended to schedule a consultation with your child’s treating physician so that they can determine the best course of treatment. If you would like to schedule an appointment at Hospital for Special Surgery, please contact our Physician Referral Service at 800-796-0482 for further assistance.

  2. My 18 yr old daughter Patyon, has had painful tearful, growing pains her whole life in the knees. She has surgery to remove plica in both knees as well as several rounds of physical therapy, has been checked for RA by her primary care Dr. That’s says test are Negative. RhA runs in the family. She has taken many meds, seen orthopedic and pediatric rheumatologist that did no blood work and this Dr said she need tonstretch her muscles more??? She uses a TENS unit…. And all with NO RELIEF. Now that she is 19
    All her joints are aching, hip pain, stiff joints. We need to see u but can you come here to help her. No one here can figure it out. She pops and cracks in her joints.

  3. I was diagnosed with Juvenile Rheumatoid Arthritis when I was 3 years old and have been seeing a pediatric rheumatologist ever since. I’m now 20 years old and am looking for a new doctor. Should I be looking for a regular rheumatologist now or continue seeing a pediatric rheumatologist?

    1. Hi Kiana, thank you for reaching out. Dr. Nancy Pan, Pediatric Rheumatologist, says: ?Between the ages of 18 and 21, you can see either an adult or pediatric rheumatologist. After the age of 21, it would be best to follow with an adult rheumatologist. There are some rheumatologists who are trained and board-certified in both pediatric and adult rheumatology as well. Just check with your pediatric rheumatologist to see what they recommend for you.? It is best to consult with your treating physician. If you wish to receive care at HSS, please contact our Physician Referral Service at 877-606-1555 for further assistance.

  4. Sometimes called charley horses — particularly when they are in the calf muscles — cramps are caused by muscle spasms, involuntary contractions of one or more muscles. In addition to the foot and calf muscles, other muscles prone to spasms include the front and back of the thigh, the hands, arms, abdomen, and muscles along the rib cage.

  5. For Dr. Lehman: Our son who is not quite 3 has been on Naproxen for 7 weeks at the full dose (4ml/2x’s day). His Dr cut his medication down to 3ml/1x day at night and 4 days later he could not walk. She increased the meds to 3ml 2x/day but he was still limping after a week. So we are back up to 4ml at night and 3ml in the morning. The second opinion also wants us to decrease him back down to 3ml/2x day and then to 2ml/2x day (or 2ml & 3 at night). But this isn’t working…is there some reason in your opinion why we can’t just stay at 3ml in the am and 4ml at night for the next 4-6 months with blood tests once/month? His weight is 35 1/2 pounds, he is a very tall kid and was diagnosed w/olig arthritis in both knees. He did get toxic synovitis about 4-5 months prior to waking up one morning and not being able to walk. Thank you for your opinion and also for writing such a helpful book.

    1. I forgot to add that all of his bloodwork came back negative, see rate was low at 6, a mild case. And if fine for a full dose (4ml/2x”s day) for 6months is it ok long-term (like 2 years)? vs doing a sedated steroid injection into the knee? Thank you in advance, your opinion is appreciated more than you know.

      1. I thought I”d add that we have just switched him to diclofenac (full dose 1ml/2x”s day), sometimes given w/an antacid. How long do you recommend staying on an NSAID like this for before going to steroid injections, same question as above. Thanks

        1. Dr. Nancy Pan, Assistant Attending in Pediatrics, says: “It is reasonable to consider non-steroidal anti-inflammatory medicine, such as diclofenac, for a longer duration if there is active inflammation (joint pain, swelling, limping etc). A steroid injection into the joint is also an option if there is still arthritis in the knee, but that is a decision you will make together with your doctor. Regardless of what type of medicine is used, it is important to control the inflammation promptly to decrease any potential damage to the joint or growing bones. Every child is different, so together with your doctor, you can decide on the best course of treatment for your son”s arthritis.” If you”d like to make an appointment with one of our doctors, please contact Physician Referral Service at 877-606-1555 or visit them online at

  6. Dr. Lehman – How long do you recommend that a child with oligoarticular JRA stay on NSAID”s after the affected joint(s) have been “cleared” of arthritic symptoms? In this case, the condition is mild in the left knee, moderate in the right knee, and blood work is all normal including immunoglobulin and ESR with no obvious genetic markers or risk factors present. 100 mg of Naprosen 2x daily worked very well to eliminate symptoms of arthritis in both knees after initial identification of pauci JRA over the course of 2-3 weeks.

    Do you recommend keeping the child on the same dosage of NSAID during this period after the joint(s) have been “cleared”, or do you start to taper the NSAID as soon as arthritic symptoms have abated?

    Thank you.

    1. Hi Chris, thank you for your question. Dr. Nancy Pan, Pediatric Rheumatologist, says: “If a child with arthritis in a single joint no longer has joint swelling, pain, stiffness or other signs of inflammation and normal laboratory parameters, it would be reasonable to discuss with your rheumatologist carefully weaning off NSAID therapy. It is important to keep in mind that there are often flares with oligoarticular JIA and uncontrolled or undetected inflammation can lead to growth and functional issues, so close ongoing follow-up with a pediatric rheumatologist is very important even once your child is no longer on medication. Your child should also keep close follow-up with an ophthalmologist for uveitis screening even if there is no active arthritis.”

  7. Would you recommend Enbrel for a child that has JIA in only one knee and it”s only a little swollen. Pain is managed and the child has no problems with any physical activities.

    1. Hi Laura, thank you for your question. Dr. Lehman says: “The use of Enbrel is a matter of clinical judgment. If the knee is warm, swollen, or stiff in the morning, then there probably still is active inflammation and using an anti-TNF drug like Enbrel may indeed be the right answer. You should consult with your physician for the best course of treatment.”

  8. Hi Dr. Lehman,

    Thank you for taking the time to answer these questions. Thank you a million times. I have had Onset Systemic JRA for 22 years and I have been on everything. I currently take MTX (not as prescribed as it has been harder and harder for my body to tolerate) Actemra 800mg (also recently reduced as I am having trouble digesting any food at all and I have a lot of stomach pain). I take a NASAID for pain or 1/2 a Vicoprofen for pain. My hormones are completely out of balance and I have not had a period since July (my other Doc believes it is all related). I would like to go on IVIG. I am at my breaking point as it is the first time my life is being dictated by my body. I cannot work. I cannot have a relationship. I am hopeful for answers that don”t involve my loosing more control over my body.

    My intention is to be as drug free as possible, to work, and have a normal social life. My intention is to have a balanced body that flows naturally. I can not spend all of my day battling this and I am, 90%. I am exhausted. I want to feel like a whole person again at the age of 35. What are your thoughts on IVIG? I want my hormones to be in balance again. Any light or intuitions you have would be received gratefully.

    Much love,

    1. Hi Allison, thank you for your question on JRA. Dr. Lehman says, “I’m sorry to hear you have had such a long and difficult course. There is no simple solution. You need to develop a good working relationship with a wise physician who can guide you through the thorough evaluation and help you develop a new plan of treatment.”

  9. Well, ive had been diagnosed with spondiloarthopathy since when i was 15 .
    now i am on Sulfasalazine 2g/day , Indomethacin 75/day . but the pain does not seem to go away.
    I have to attend school as this is my board year.
    i am suffering for 8 months
    What should i do?

  10. I”ve had JRA since I was 18 months old, I”m now 20. Dr”s have tried many different medications and after so long they just stop working. Should I always expect this as I continue to age?

    1. Hi Alexandria, thank you for your question. Dr. Lehman says:

      “Many times when caring for children and young adults with arthritis, I come across situations where a medicine seems to ‘stop working.’ There’s no simple answer. Sometimes they have been given a different generic version of the drug which doesn’t have the same effectiveness as the previous generic they were using. This can be fixed by going back to the pharmacy and asking for the previous generic or asking your doctor to ‘write for brand.’ Sometimes this makes a big difference and other times it”s not the answer. For the injectable medications some patients develop antibodies over time that inactivate the medicine. For pills and other medications and even the injectables, if antibodies aren’t the cause of the problem, there are no easy answers. The biologic systems in the body are redundant and complicated. When I hear a patient say the medicine has “stopped working,” I’m never sure if their disease has changed, they have changed, or they just aren’t feeling well and the medicine really has nothing to do with it. Fortunately new medicines are being developed and we can usually find a solution.”

  11. Oh, where was this five years ago?!?!?! Thank you so much for writing this. I have two of your books, and I have been researching JA, JDM, MCTD, SLE, Ssc & Raynaud””s for years, but I have many friends that are newly diagnosed parents. I will be passing this link around. Would you also be able to write an entry on JDM (Dermatomyositis)? It seems that more children are being diagnosed lately.

    1. Hi Danielle, thanks for your comment and interest in an entry on JDM. We’ll have a future blog post on it so please check back!

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