Pediatric Inflammatory Bowel Disease: Diagnosis and Management
The diagnosis and management of pediatric inflammatory bowel disease (IBD) requires a systematic approach including endoscopic evaluation with biopsies, appropriate imaging, and targeted treatment based on disease severity, with special considerations for the unique challenges in the pediatric population.
Diagnosis of Pediatric IBD
Clinical Evaluation
- Pediatric IBD often presents with more extensive colitis and less ileitis compared to adults 1
- Children under 6 years of age with IBD (very early onset IBD or VEOIBD) may have underlying immune deficiencies requiring special consideration 1
- Red flag symptoms warranting immediate endoscopic evaluation include rectal bleeding and perianal disease 2
- In patients without red flags, a combination of symptoms, blood markers (C-reactive protein, hemoglobin), and stool markers (fecal calprotectin) can help distinguish IBD from other causes of abdominal pain or diarrhea 3
Endoscopic Assessment
- Ileocolonoscopy with biopsies is essential in all children with suspected IBD 1, 4
- Esophagogastroduodenoscopy (EGD) should be routinely performed in pediatric patients to improve diagnostic accuracy 1, 4
- Multiple biopsies should be taken from the ileum and each colonic segment, including the rectum, to assess disease distribution 1
- Biopsies should be taken from both abnormal and normal-appearing areas 1
Histopathological Features
- Pediatric patients have a higher frequency of granulomas compared to adults, which can aid in diagnosis 1
- Upper GI tract involvement in pediatric IBD may include lymphocytic esophagitis, focally enhanced gastritis, and duodenal inflammation 5
- Key histological features supporting IBD diagnosis include basal plasmacytosis, architectural changes, and transmural inflammation 1
- In children, the presence of granulomas not associated with ruptured glands/crypts is diagnostic of Crohn's disease 1, 5
Imaging
- MR enterography is safe, well-tolerated, and effective for assessing disease extent in pediatric populations 1
- Intestinal ultrasound (IUS) is a non-invasive alternative for detecting postoperative recurrence 1
- CT should be reserved for emergency settings due to radiation exposure concerns 1, 6
- Balloon-assisted enteroscopy allows direct mucosal visualization and therapeutic intervention but is more invasive 1
Classification of Pediatric IBD
- Pediatric IBD is classified into ulcerative colitis (UC), atypical UC, Crohn's disease (CD), and IBD unclassified 5
- Very early onset IBD (VEOIBD), defined as onset by 6 years of age, may represent a distinct entity with more severe disease behavior 1
- Genomic testing should be considered for VEOIBD patients to identify potential monogenic disorders that may require different therapeutic approaches 1
- Children with IBD often have more extensive disease and upper GI involvement compared to adults 1
Treatment Approach
Initial Management
- Treatment should be based on disease severity, extent, and risk factors for poor outcomes, with early use of anti-TNF therapy recommended for high-risk patients 2
- For mild to moderate disease, 5-aminosalicylates (mesalamine) are recommended as first-line therapy, particularly for left-sided colitis or proctitis 4
- For moderate to severe disease, oral corticosteroids are recommended for patients who fail to respond to 5-ASA therapy 4
- Severe disease requiring hospitalization should be treated with intravenous steroids 4
Biologic Therapy
- Infliximab is indicated for reducing signs and symptoms and inducing/maintaining clinical remission in pediatric patients 6 years and older with moderately to severely active Crohn's disease or ulcerative colitis who have had inadequate response to conventional therapy 7
- Adalimumab is approved for moderately to severely active Crohn's disease in pediatric patients 6 years and older and for ulcerative colitis in pediatric patients 5 years and older 8
- The recommended infliximab dosing for pediatric patients is 5 mg/kg at weeks 0,2, and 6, followed by maintenance dosing of 5 mg/kg every 8 weeks 7
Special Considerations
- Growth failure and pubertal delay are unique challenges in pediatric IBD requiring close monitoring 4, 2
- Nutritional support is particularly important for children with growth failure and active small bowel disease 4
- Exclusive enteral nutrition at diagnosis offers a window to update patients' vaccination status 1
- In infants whose mothers received biologics during pregnancy, live vaccines should be withheld until at least 6 months of age 1
Monitoring and Follow-up
- The goal of therapy should be biochemical or endoscopic remission rather than just clinical remission 2
- Fecal calprotectin is a sensitive marker for monitoring disease activity 1, 4
- Regular assessment of disease activity and response to treatment is essential 4
- Surveillance for early detection of dysplasia is recommended using chromoendoscopy with targeted biopsies 1
Complications and Safety Considerations
- Post-marketing cases of hepatosplenic T-cell lymphoma have been reported in adolescents and young adults treated with TNF blockers, particularly when used in combination with azathioprine or 6-mercaptopurine 7, 8
- Screening for opportunistic infections, including tuberculosis, should be performed before starting immunosuppressive therapy 1
- A standardized checklist for screening opportunistic infection risk should be completed at IBD diagnosis 1
- Transfer to adult care is a recognized risk for disease relapse, highlighting the need for a structured transition program 2
Common Pitfalls to Avoid
- Delaying treatment while awaiting screening tests for infectious colitis 4
- Overlooking nutritional status assessment, especially in pediatric patients 4
- Failing to consider VEOIBD as a potential manifestation of underlying immune deficiency in children under 6 years 1
- Relying solely on clinical symptoms for disease monitoring, as intestinal inflammation often persists despite symptom resolution 2