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It is well recognized that many if not most children and adolescents attending paediatric rheumatology clinics will have a non-inflammatory origin for their complaints or disorder. Mechanical causes are frequently identified, and hypermobility or ligamentous laxity of joints is increasingly recognized as an aetiological factor in the presentation. Such conditions include 'growing pains', recurrent lower-limb arthralgia, anterior knee pain syndromes, and back pain. Studies of significant cohorts of such patients have now been published supporting the link of ligamentous laxity to particular symptom complexes. However, much disagreement remains as to the validity of hypermobility as an aetiogical factor. What seems clear is that not all hypermobile individuals will be symptomatic or indeed possibly have any risk for specific musculoskeletal disorders in later life. Screening tools such as the Beighton score are likely to be inadequate in many paediatric populations. Along with increasing recognition of these disorders in childhood and adolescence has been the development of a multidisciplinary management approach, which usually involves predominantly allied health professionals such as podiatrists, physiotherapists and occupational therapists. The challenge remains to interpret symptoms correctly as being related to the hypermobility and to predict why such children become symptomatic. The answer is likely to involve physiological and psychosocial factors. In addition, early identification and modification of risk factors may have major implications for subsequent prevalence of many adult medical disorders such as low back pain, chronic pain syndromes and degenerative osteoarthritis.

The management of juvenile idiopathic arthritis (JIA) has undergone dramatic changes in the last decade with undoubtedly great benefit for many patients. In particular, more effective use of available drugs and the application of newly discovered drugs have been responsible for much of this improvement. Methotrexate is the gold standard for management of moderate to severe polyarthritis. Other disease-modifying antirheumatic drugs (DMARDs) such as sulphasalazine and cyclosporine are finding a specific role for resistant disease where they may be used in combination with methotrexate, for example. The introduction of anti-TNF agents, such as etanercept, is likely to herald a major shift to the use of biological agents in those intolerant to, or unresponsive to, standard DMARD therapy. DMARDs provide major steroid spring effect in many children with severe JIA with the hope that osteoporosis and growth failure will be reduced. More judicious use of corticosteroids and techniques such as intravenous 'pulse therapy' rather than long-term high-dose use of oral corticosteroids are also major changes. Intra-articular corticosteroids are commonly used in children with oligoarticular JIA and as a useful adjunct to DMARD therapy in children with other forms of JIA. Autologous stem cell transplantation is an exciting new development currently restricted to use in patients with very severe, resistant disease. Modifications of technique, experience and increased safety may make this a more widely applicable technique, in particular for patients with a poor prognosis, such as those with systemic JIA. Although the focus of this chapter is on drug therapy, multidisciplinary team management for children with chronic arthritis focusing on the physical, nutritional, intellectual and psychosocial wellbeing of the child will continue to be important.