Angela Chun, MEd, MD, FAAP, highlights key red herrings in pediatric joint pain

At the 2024 American Academy of Pediatrics National Conference & Exhibition, Angela Chun, MEd, MD, FAAP, a pediatric rheumatologist at Northwestern University and Lurie Children’s Hospital, discussed key considerations for pediatric joint pain, focusing on common presentations, red herrings, and more serious underlying conditions.

Chun emphasized that many cases of joint pain in children are mechanical in nature and related to overuse or hypermobility. “We actually see a lot of kids with recurring joint pains, but it’s because they have generalized hypermobility,” she explained. “It’s important to remember that young kids are at baseline just more flexible than us adults, and the majority of kids will grow out of it to a certain degree.” Hypermobile children can often develop joint pain without actual arthritis, and Chun highlighted the role of the Beighton criteria, an objective scoring system to assess flexibility. "You need at least four out of nine to be classified as generalized hypermobility."

In addition to mechanical issues, Chun stressed the importance of ruling out other causes of joint pain, particularly gastrointestinal (GI) pathologies. She shared that children with conditions such as appendicitis or inflammatory bowel disease (IBD) may present with joint pain. "A kid who has appendicitis... might mean that they’re limping, so people think that it’s the right hip, but actually, it’s higher up." Chun also noted that IBD can cause arthritis and sacroiliitis, adding, "The things I look out for are any kind of drop-off in their growth curve, unexplained anemia, or elevated inflammatory markers."

While most cases are benign, Chun warned of more serious red flags that should raise concern, such as bone malignancies, leukemia, or infections like septic arthritis or osteomyelitis. “Those are all things that you don’t want to miss,” she advised, underscoring the need for careful history-taking and physical examination to navigate these concerns.

Finally, Chun highlighted the urgency of identifying juvenile idiopathic arthritis (JIA), particularly due to the risk of silent uveitis, a condition that can lead to permanent eye damage. She urged pediatricians to refer children suspected of having JIA to ophthalmology quickly, stating, “From a joint standpoint, it’s okay to keep those kids on scheduled NSAIDs... versus the eyes, which are a little bit more of an emergency.”