Children and adolescents
Juvenile idiopathic arthritis (JIA)
Joint swelling for 6 weeks or more in a child under 16, often with morning stiffness or a limp and few complaints of pain.
What to look for
- Persistent joint swelling or effusion, morning stiffness, limp, or reluctance to use a limb
- Symptoms for 6 weeks or more, starting before age 16
- Enthesitis or back pain suggests enthesitis-related arthritis or juvenile spondyloarthritis
- ANA-positive young girls with oligoarthritis have the highest uveitis risk
What to do
- Refer within 2–4 weeks. Send CBC with differential, ESR, CRP, metabolic panel and ANA (for uveitis risk). Add HLA-B27 if enthesitis or back pain is present.
- Exclude infection, malignancy (night pain, cytopenias, high LDH) and trauma.
- Arrange an ophthalmology screening exam now. Don't wait for the rheumatology visit.
- The 2026 ACR guidelines recommend DMARDs first-line for polyarthritis and intra-articular glucocorticoids first-line for oligoarthritis. Methotrexate is the preferred first csDMARD and a TNF inhibitor the preferred first biologic. For suspected juvenile spondyloarthritis, SI joint MRI (without contrast) is the preferred imaging.
About this urgency level
Early specialist assessment changes outcomes. Send the usual workup with the referral, but don't hold the referral while waiting for results.
Timeframes are typical targets. Local pathways, capacity and clinical judgment come first.