Approximately half of pediatricians and pediatric residents in Spain have wrong beliefs and misconceptions about the incidence and manifestation of juvenile idiopathic arthritis, a national survey showed.
The findings were described in the study, “Pediatrician Beliefs about Juvenile Idiopathic Arthritis May Result in Referral Delays: A Spanish National Survey,” published in The Journal of Pediatrics.
Juvenile idiopathic arthritis (JIA) is the most common form of chronic rheumatic disease among children. The disease can have an unpredictable relapsing-remitting course, with more than 40% of patients experiencing active disease into adulthood.
Although it can affect a significant number of children — approximately 1–2 in 2,000 children younger than 16 years — it is frequently considered an extremely uncommon disease by many pediatricians, with “certain myths, such as that children with JIA present with significant joint pain, have positive antinuclear antibodies (ANAs), or elevated acute phase reactants (an increase in the concentration of serum proteins), [resulting] in referral delays,” researchers stated.
Spanish researchers conducted a national survey to gain a detailed perspective on the knowledge and views of pediatricians and pediatric residents regarding the cause, incidence, clinical and laboratory manifestations, and therapy of JIA.
The survey was performed online between January and May 2014 and included 13 questions planned to cover the main clinical features of JIA and general disease management.
A total of 699 pediatricians and 132 pediatric trainees responded to the survey. Two-thirds of the respondents worked in primary care. Approximately 53% of the respondents had more than 15 years of experience, while 25% had five or fewer years of clinical care experience.
Almost half the clinicians and trainees believed that JIA was 3–15 times less frequent than it is, and almost 1 in 10 of respondents considered it less frequent than some uncommon metabolic diseases (with an incidence lower than a single case per 100,000 people).
“Their considering JIA as such a rare event may interfere with its diagnosis, especially younger children who usually present [the disease with few symptoms],” researchers stated.
About 45% were aware that oligoarticular JIA more commonly affects girls with ages ages 2–4. However, there was still a high percentage of respondents who thought that oligoarticular JIA was more common in adolescent girls (24%) and those who thought it was more frequent among boys regardless of their age (14%).
Despite these discrepancies on gender-related presentation of oligoarticular JIA, the majority of clinicians (82%) were aware that this is the most common form of JIA and that uveitis (inflammation of the eye) is more frequent among patients positive for antinuclear antibodies (72%).
For the diagnosis of oligoarticular JIA, approximately 52% of the respondents indicated joint pain as the most common symptom, while only 39% chose the correct option, joint swelling.
“The belief that joint pain is the most common presenting symptom of inflammatory articular disease is one of the major myths in pediatric rheumatology, despite multiple studies,” researchers said. “Pediatricians, therefore, have to consider JIA in the differential diagnosis of painless joint swelling or limping.”
Most respondents were familiar with the concept of enthesitis (98%), the clinical characteristics of inflammatory back pain (83%), and the recommendation of conducting frequent screenings for uveitis (89%) in follow-up of these patients. Enthesitis is the inflammation of the entheses, or the connective tissue joining tendons and ligaments to bone.
Clinicians’ answers also showed that a high percentage had incorrect beliefs about the role of some complementary blood examinations, such as erythrocyte sedimentation rate, C-reactive protein, or ANAs in the diagnosis of oligoarticular and polyarticular disease.
“These myths may result in referral delays given the common belief that “normal concentration of acute phase reactants or negative ANA rules out JIA,’” researchers stated.
Regarding treatment for JIA, the survey showed that 61% of the clinicians knew that the use of nonsteroidal anti-inflammatory drugs (NSAIDs) does not change the course of the disease. Still, 17% considered that only pediatric rheumatologists should prescribe NSAIDs to avoid masking disease symptoms and delaying diagnosis.
Most of the respondents were aware of the indications and main side effects of therapy used in the treatment of these children. However, 20-30% of them believed they had insufficient information on additional preventive measures, especially those to be applied in the treatment of children receiving methotrexate or biological therapies.
Based on the survey’s results, researchers developed new educational material specifically designed for primary care and emergency department pediatricians addressing the main issues detected regarding JIA.
“One of the principal aims of the study was to share the results and increase pediatricians’ awareness of this issue,” researchers said. “This national survey identified some common misconceptions in Spanish pediatricians about JIA, which are probably common among pediatricians trained elsewhere and that can result in delayed referral of patients.”