When should parents visit a pediatric rheumatologist?

Contrary to common belief, children can also be affected by autoimmune diseases. They are often misdiagnosed and/or slow to be diagnosed and treated. These diseases can cause much suffering and disability, especially when not properly diagnosed and treated. Pediatric rheumatologists are specialists who help treat children with conditions that affect the immune system. Pediatric rheumatology is gradually emerging in India and at present, these quaternary services are available only at a few centers across the country. Knowing when and how to consult a pediatric rheumatologist can be a challenge for most parents. They may have to make multiple hospital or doctor visits before they are finally referred to a pediatric rheumatologist. 

 

As opposed to popular perception, rheumatologists don't just deal with joint problems. Rheumatologists help in conditions where people have an abnormal immune response. A normal immune response is very important to fight infections, but when the immune system starts fighting its own body, it leads to what we call auto-immune diseases. The challenge in identifying these diseases is that these conditions present very much like infections. So, when you encounter a situation where a child is repeatedly having fever or long-standing fever, then it might not be due to an infection, it could be due to an auto-immune condition. There are certain soft pointers we look for in such cases, like red eyes, recurrent ulcers in the mouth, recurrent unexplained rashes, joint pain and involvement of multiple organs at one go, like liver, kidney and heart. The risk of fatalities in such cases is from wrong treatment due to a wrong diagnosis, or lack of treatment due to no diagnosis at all.  

 

Depending on the organ affected, other symptoms children affected with rheumatological diseases may include weakness of limbs, recurrent or persistent abdominal pain, blood in stools or urine, fits, mouth ulcers, blurring of vision or redness of eyes due to inflammation of the eyes (also called uveitis). In untreated and long-standing diseases, growth and development of children can also be affected. Some of the conditions routinely seen by rheumatologists include Juvenile arthritis, myositis, vasculitis (such as Takayasu arteritis, Kawasaki disease, Henoch Schonlein Purpura), systemic lupus erythematosus etc. This is only a suggestive but not an exhaustive list. 

 

During the visit, a pediatric rheumatologist may take a detailed history from the parents or caretaker to help narrow down on the probable differentials. Based on the history and examination further evaluation may be ordered. These may include blood tests to ascertain the presence and degree of inflammation, imaging in the form of radiographs, ultrasound scans, CT or MRI scans and specialized autoimmune blood tests to confirm the diagnosis. Children may also be screened for other conditions that may mimic an autoimmune disorder. At times, arriving at the diagnosis can be quite challenging considering the vast range of clinical symptoms. Once the diagnosis is made, treatment is usually guided by the severity of symptoms, component of immune system affected, and the number of organs involved. Largely, treatment involves a group of drugs called immunomodulatory agents which are administered in a controlled manner and may need to be continued for a prolonged period depending on the severity of disease. Whilst children are on such medications, they will be frequently monitored with blood tests apart from constant growth and development monitoring that will be done at frequent intervals. 

As access to a pediatric rheumatologist is not homogenous across the country, parents can opt for teleconsultation in liaison with their primary pediatrician. This will help parents save significant amount of travel time and will also increase the probability of offering timely intervention. 

 

At Rainbow Children’s Hospital we have managed approximately 3000 children with complex rheumatological diseases since the inception of the pediatric rheumatology department in 2019. The services are offered to patients from across the country and even the South-East Asian region especially with the help of telemedicine. Early diagnosis means better outcome and this has been our motto while catering to these little children.