Juvenile idiopathic arthritis in relation to perinatal and maternal characteristics: a case control study

Infant gut microbiota and environment associate with juvenile idiopathic arthritis many years prior to disease onset, especially in genetically vulnerable children

BACKGROUND

The etiology of juvenile idiopathic arthritis (JIA) is poorly understood. This study investigated genetic and environmental factors and infant gut microbiota in a prospective birth cohort to assess disease risk.

METHODS

Data was collected from the All Babies in Southeast Sweden (ABIS) population-based cohort (n = 17,055), 111 of whom later acquired JIA (ABIS_JIA). Stool samples were collected at one year of age for 10.4%. To determine disease association, 16S rRNA gene sequences were analyzed, with and without confound adjustment. Genetic and environmental risks were assessed.

FINDINGS

ABIS_JIA had higher abundance of Acidaminococcales, Prevotella 9, and Veillonella parvula and lower abundance of Coprococcus, Subdoligranulum, Phascolarctobacterium, Dialister spp., Bifidobacterium breve, Fusicatenibacter saccharivorans, Roseburia intestinalis, and Akkermansia muciniphila (q's < 0.05). Parabacteroides distasonis greatly increased the odds of later contracting JIA (OR = 6.7; 1.81-24.84, p = 0.0045). Shorter breastfeeding duration and increased antibiotic exposure compounded risk in a dose-dependent manner, especially in those with genetic predisposition.

INTERPRETATION

Microbial dysregulation in infancy may trigger or accelerate JIA development. Environmental risk factors have a stronger impact on genetically predisposed children. This study is the first to implicate microbial dysregulation in JIA at such an early age, with many bacterial taxa associated with risk factors. These findings provide opportunities for intervention or early screening and offer new insights into JIA pathogenesis.

FUNDING

Barndiabetesfonden; Swedish Council for Working Life and Social Research; Swedish Research Council; Östgöta Brandstodsbolag; Medical Research Council of Southeast Sweden; JDRF-Wallenberg Foundation; Linköping.

Pre- and perinatal exposures associated with developing pediatric-onset immune-mediated inflammatory disease: A Danish nation-wide cohort study

OBJECTIVES

We aimed to identify pre- and perinatal risk factors for developing pediatric-onset immune-mediated inflammatory (pIMID).

METHODS

This nation-wide, cohort study included all children born in Denmark from 1994 to 2014 identified from the Danish Medical Birth registry. Individuals were followed through 2014 and cross-linked to the continuously updated national socioeconomic and healthcare registers to obtain data on pre- and perinatal exposures (maternal age, educational level, smoking, maternal IMID, parity, mode of conception and delivery, plurality, child's sex, and birth season). The primary outcome was a pIMID diagnosis (inflammatory bowel disease, autoimmune hepatitis, primary sclerosing cholangitis, juvenile idiopathic arthritis, or systemic lupus erythematosus) before 18 years of age. Risk estimates were calculated using Cox proportional hazards model and presented by hazard ratios (HR) with 95% confidence intervals (95%CI).

RESULTS

We included 1,350,353 children with a follow-up time of 14,158,433 person-years. Among these, 2,728 were diagnosed with a pIMID. We found a higher risk of pIMID in children born to women with a preconception IMID diagnosis (HR: 3.5 [95%CI: 2.7-4.6]), children born by Caesarean section (HR: 1.2 [95%CI: 1.0-1.3]), and among females (1.5 [95%CI: 1.4-1.6]) than among children without these characteristics. Plural pregnancies were associated with a lower risk of pIMID than single pregnancies (HR: 0.7 [95%CI: 0.6-0.9]).

CONCLUSIONS

Our results indicate a high genetic burden in pIMID but also identifies intervenable risk factors, such as Cesarean section. Physicians should, keep this in mind when caring for high-risk populations and pregnant women previously diagnosed with an IMID.

An overview of the relationship between juvenile idiopathic arthritis and potential environmental risk factors: Do early childhood habits or habitat play a role in the affair?

AIM

The current study was undertaken to evaluate the influence of breastfeeding on the development and outcome measures of juvenile idiopathic arthritis (JIA). The second aim was to determine the consequences of particular sociodemographic and sociocultural characteristics and nutritional behavior of early childhood on JIA.

METHODS

The study includes the patients diagnosed with JIA and regularly followed up at the Department of Pediatric Rheumatology in Istanbul University-Cerrahpasa. The comparison group consisted of healthy subjects and patients with juvenile systemic lupus erythematosus (jSLE). A face-to-face survey method was conducted with the parents of the participants between February 1, 2021, and September 1, 2021.

RESULTS

The mean age of the JIA cohort (n = 324) was 12.2 ± 4.7 years, with a female ratio of 64.8%. The breastfeeding rate differed from the control groups (253 healthy subjects and 88 patients with jSLE) but was higher with a value of 94.8%. There was no difference between the groups (P = .097, P = .064) or within the subgroups of JIA (P = .12) regarding breastfeeding duration. Cow's milk introduction time (P = .02, P = .0001), household pet-keeping (P = .001), income level (P = .0001), maternal literacy (P = 0.013) made a statistical difference vs the control groups.

CONCLUSION

No relationship was established between the rate or duration of breastfeeding and the development or severity of JIA. The early introduction of cow's milk was found to be higher in the patient cohorts. The income level and maternal literacy appeared to be relevant with the high disability and damage scores, and frequent relapse rates. Secondhand smoking, higher in JIA, may prompt the basis of primary preventable strategies in JIA.

Association of juvenile idiopathic arthritis with maternal infection: a case control study

OBJECTIVE

Maternal infection has been posited as a risk factor for childhood autoimmune disease such as type I diabetes. Given that similar studies in JIA are scant, our objective was to evaluate the association between Juvenile Idiopathic Arthritis (JIA) and maternal infection.

METHODS

This case-control study used an existing database that included 1290 JIA cases and 6072 controls matched on birth year. Maternal infection information was obtained from Washington State birth records. JIA diagnosis and categories were confirmed through chart review. Logistic regression was used to calculate adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs).

RESULTS

JIA was not associated with maternal infection (OR = 1.02, 95%CI: 0.8-1.3). There was no association between JIA and maternal infection for persistent oligoarticular, RF negative polyarticular, or enthesitis-related JIA. There was suggestive evidence of an increased association of maternal infection with JIA in females in sex-stratified analysis.

CONCLUSIONS

We did not observe an increased risk of JIA in children exposed to maternal infection. Suggestive evidence of differential sex-specific results warrants further study.

Role of Environment in Pediatric Rheumatic Diseases

Studying environmental risk factors for pediatric rheumatic diseases (PRD) is important because the identification of these factors may lead to strategies to prevent disease, and to new insights into pathogenesis and therapeutic targets. Compared with other chronic diseases, there are few environmental epidemiology studies in PRD. Although strong risk factors common to all PRDs have not been identified, some exposures including infection, smoke exposure, and ultraviolet radiation have been associated with several of them. High-technology studies, especially of microbiomics and metabolomics, are increasing and will likely lead to new understandings of the complex interplay between environment, genetics, and disease.

P037 Does perinatal history and delivery enhance the risk of hip involvement in Juvenile Idiopathic Arthritis patients? A case-control study

Background

Children are vulnerable to congenital and developmental hip disorders. One of the causes of coxitis among children is juvenile idiopathic arthritis (JIA). Existing data on associations between maternal and early childhood exposures highlighted the potential role of prematurity in JIA [1]. The aim of this study was to compare perinatal history in JIA children with coxitis compared with patients with other causes of hip involvement.

Methods

We conducted a cross-sectional study including children with JIA complicated with coxitis and patients with other causes of hip involvement. We recorded sociodemographic data and the hip disorder. The mode of delivery, the values of the neonatal birth weight as well as the delivery method (vaginal, cesarean (C) section) were retrieved from medical records. We divided the patients into two groups: G1: JIA patients with coxitis and G2: patients with other causes of hip involvement. We compared delivery mode, as well as perinatal outcomes between the two groups.

Results

The study included 81 patients. There was a male predominance (59.3% males vs 40.7% females) with a sex-ratio of 1.45. The mean age of diagnosis was 9.9 years [1–16]. The mean disease duration was 9 months [0.1–156]. Hip disorders were distributed as follows: Legg-Calvé-Perthes disease (n = 3), epiphysiolysis of the femur head (n = 30), transient synovitis of the hip n = 7, septic hip (n = 10), tumor (n = 4), hip dislocation (n = 8), hip dysplasia (n = 4), juvenile idiopathic arthritis with coxitis (n = 15). The mean birth weight of the children was 3.4 kg [1.3–9]. About half of the patients had a natural delivery (55.6%) and most of them a face presentation (71.6%). A twin pregnancy was reported only in 2.5% of cases. Childbirth complications were reported in 7.4% of cases: umbilical cord prolapse (n = 1), Meconium aspiration syndrome (n = 1), failure to descend (n = 1), acute fetal distress (n = 3). Most of them had a normal growth and psychomotor development (96% and 97% respectively). There was no statistical difference between the two groups regarding delivery mode and fetal presentation before birth (P = 0.07, P = 0.48 respectively). Similarly, weight at birth was similar between JIA children and patients with other hip involvement (P = 0.52).

Conclusion

Our study showed that maternal and perinatal history did not differ between JIA patients with coxitis and patients with other causes of hip involvement.

Moving from nature to nurture: a systematic review and meta-analysis of environmental factors associated with juvenile idiopathic arthritis

Objectives

JIA is the most common paediatric rheumatic disease, thought to be influenced by both genetics and the environment. Identifying environmental factors associated with disease risk will improve knowledge of disease mechanism and ultimately benefit patients. This review aimed to collate and synthesize the current evidence of environmental factors associated with JIA.

Methods

Four databases (MEDLINE, Embase, Web of Science and Cumulative Index to Nursing and Allied Health Literature) were searched from inception to January 2020. Study quality was rated using the Newcastle-Ottawa Scale. Pooled estimates for each environmental factor were generated using a random-effects, inverse-variance method, where possible. The remaining environmental factors were synthesized in narrative form.

Results

This review includes 66 environmental factors from 39 studies (11 cohort and 28 case-control studies) over 45 years. Study sample sizes ranged from 41 to 1.9 million participants. Eight environmental factors from ten studies were meta-analysed. Caesarean section delivery was associated with increased JIA risk [pooled odds ratio (OR) 1.11, 95% CI: 1.01, 1.22]. Conversely, presence (vs absence) of siblings (pooled OR 0.60, 95% CI: 0.44, 0.81) and maternal prenatal smoking (pooled OR 0.70, 95% CI: 0.58, 0.84) were associated with decreased JIA risk.

Conclusion

This review identifies several environmental factors associated with JIA and demonstrates the huge breadth of environmental research undertaken over five decades. We also highlight the challenges of combining data collected over this period due to limited between study comparability, evolution in healthcare and social practices, and changing environment, which warrant consideration when planning future studies.

Adverse Childhood Experiences Are Associated with Childhood-Onset Arthritis in a National Sample of US Youth: An Analysis of the 2016 National Survey of Children's Health

OBJECTIVES

To determine whether there is an association between adverse childhood experiences (ACEs) and childhood-onset arthritis, comparing youth with arthritis to both healthy youth and youth with other acquired chronic physical diseases (OCPD); and to examine whether ACEs are associated with disease-related characteristics among children with arthritis.

STUDY DESIGN

In a cross-sectional analysis of data from the 2016 National Survey of Children's Health we examined whether ACEs were associated with having arthritis vs either being healthy or having a nonrheumatologic OCPD. ACE scores were categorized as 0, 1, 2-3, ≥4 ACEs. Multinomial logistic regression models examined associations between ACEs and health status while adjusting for age, sex, race/ethnicity, and poverty status. Among children with arthritis, associations between ACEs and disease-related characteristics were assessed by Pearson χ² analyses.

RESULTS

Compared with children with no ACEs, children with 1, 2-3, and ≥4 ACEs had an increased odds of having arthritis vs being healthy (adjusted OR for ≥4 ACEs, 9.4; 95% CI, 4.0-22.1) and vs OCPD (adjusted OR for ≥4 ACEs, 3.7; 95% CI-1.7, 8.1). Among children with arthritis, ACEs were associated with worse physical impairment.

CONCLUSIONS

Children with higher numbers of ACEs are more likely to have arthritis, when arthritis status is compared either with being healthy or with having OCPD. Further studies are needed to determine the direction of the association between ACEs and childhood arthritis, its impact on disease course, and potential intervention targets that might mitigate these effects.

Juvenile idiopathic arthritis and the gut microbiome: Where are we now?

In recent decades, because of advances in technology there has been an explosion of knowledge on how microbiome affects human health. In most chronic immune-inflammatory diseases, alterations in gut microbiome has been shown. The successful use of faecal microbial transplants for the treatment of clostridium difficile associated diarrhoea has also paved the way for novel therapies. Gut microbiome is affected by early life events like the mode of delivery, breast feeding, the use of antibiotics, etc. and that may have an indirect effect on the developing immune system as well as on the predisposition to juvenile idiopathic arthritis (JIA). Multiple studies have found altered gut microbiome in JIA though no single organism or microbial community has been found to be associated with JIA. In JIA, attempts to modify gut microbiome by using probiotics, exclusive enteral nutrition and other modalities have had variable success. The current review discusses the current data available on gut microbiome in different categories of JIA and how this knowledge can translate into new therapies.

Review of environmental factors and juvenile idiopathic arthritis

Juvenile idiopathic arthritis is a common rheumatic disease that presents as chronic childhood arthritis. JIA is considered a multifactorial disease that may result from diverse genetic and environmental risk factors. A minority of the population-attributable risk of JIA is estimated to be due to familial factors. Thus, non-genetic or environmental factors likely account for a majority of the risk of developing JIA. Yet, while substantial data have linked environmental factors to the development of rheumatoid arthritis, similar evidence regarding JIA is sparse. This narrative review provides updates on recent literature about environmental factors that might influence the risk of developing JIA, including studies about potentially beneficial and harmful influences as well as factors with unclear effects.