Pediatric Rheumatologist Shortage Spurs Need for Adult Specialists to Treat Children with Rheumatic Conditions

Brocreative/shutterstock.com

WASHINGTON, D.C.—Addressing a gathering of healthcare providers at the 2016 ACR/ARHP Annual Meeting concurrent session titled, Pediatric Rheumatology for the Adult Rheumatologist, part of the ACR Review Course, expert Sangeeta Sule, MD, PhD, associate professor of pediatrics specializing in rheumatology at Johns Hopkins Hospital in Baltimore, displayed a color-coded map of the U.S. on which purple-shaded states represented regions without pediatric rheumatologists. There were several purple states.

“There’s a national shortage of pediatric rheumatologists,” Dr. Sule said, using the visual aid to make clear the need for more physicians in the specialty.

It stands to reason, then, that adult rheumatologists either already are treating children or will need to do so as this shortage worsens. With this in mind, she gave an overview of rheumatologic issues faced by children and pointed out how they differ from those that affect adults.

Pediatric Inflammatory Conditions

Inflammatory conditions in children include Henoch-Schönlein purpura, which most commonly presents as a purpuric rash, starting in the leg and proceeding up to the trunk. It accounts for 49% of all pediatric vasculitis, has a peak onset at 4–6 years old, is seen more often in boys and is more common in winter and spring. Treatment includes supportive care, hospitalization in severe cases, and urinalysis and blood pressure monitoring every week or two for the first couple of months.

“Our goal as pediatricians and pediatric rheumatologists is [to] support these children while minimizing complications,” Dr. Sule said.

In Kawasaki disease, children have fever for at least five straight days, along with other factors, such as bloodshot eyes and oral mucous membrane changes, including “strawberry tongue,” Dr. Sule noted. These children typically are treated with intravenous immunoglobulin, which can reduce the incidence of coronary artery aneurysms in these patients.

In neonatal lupus, which can result in such complications as rash, heart block and hepatitis, the main goal is to prevent heart block, Dr. Sule said. Pregnant women with anti-Ro or anti-La antibodies should have a Doppler fetal echocardiogram every week from weeks 18 to 26, then every other week through 32 weeks. If second-degree heart block is found, fluorinated glucocorticoids are called for, she said. Pre-emptive treatment with hydroxychloroquine has been shown to be safe and effective, she added. Prevention is the goal, since third-degree heart block can’t be corrected medically and will require a pacemaker.

Non-Inflammatory Pediatric Conditions

Dr. Sule also identified several non-inflammatory pediatric rheumatic conditions, such as:

• Hypermobility, which is characterized by intermittent muscular pain not related to the joints;
• Legg-Calve-Perthes disease, or idiopathic osteonecrosis of the hip, which requires an X-ray to determine whether it’s bilateral;
• Slipped capital femoral epiphysis, which is a hip condition in which the femur head slips off the body of the femur. It is most commonly seen in overweight boys and is often bilateral; and
• Osgood-Schlatter disease, which involves pain and swelling at the tibial tuberosity that is worsened by activity and mostly treated with supportive care.

JIA

Speaking on the topic of arthritis in children, Dr. Sule noted that most cases of juvenile idiopathic arthritis (JIA) are oligoarticular, affecting up to four joints in the first six months. It tends to involve the large joints—knees, ankles, wrists and elbows—and can be seen nearly throughout childhood. Girls are affected more frequently than boys.