Management of Pediatric Patients with Suspected Inflammatory Bowel Disease
Initial Diagnostic Workup
Complete ileocolonoscopy with biopsies AND esophagogastroduodenoscopy (EGD) should be performed in all children with suspected IBD to establish the diagnosis and assess disease extent. 1, 2
Essential Diagnostic Components:
Endoscopic evaluation: Perform both ileocolonoscopy and EGD routinely—this dual approach improves diagnostic accuracy and identifies upper GI involvement, which occurs more frequently in pediatric patients than adults 1, 3
Biopsy protocol: Obtain multiple biopsies from the ileum and each colonic segment including the rectum, sampling both abnormal AND normal-appearing mucosa to assess disease distribution 1
Small bowel imaging: MR enterography should be performed to evaluate small bowel disease extent, as pediatric CD often involves more extensive disease than adults 4
Laboratory screening at diagnosis (complete this BEFORE starting immunosuppression): 5
- Complete blood count with differential, CRP
- Hepatitis B, C, and HIV serologies
- Varicella zoster virus (VZV) serology if no reliable vaccination history
- Epstein-Barr virus serology
- Tuberculosis screening (chest X-ray, tuberculin skin test or interferon-gamma release assay)
- Stool examination for infectious causes
- Fecal calprotectin for baseline disease activity 5, 1
Critical Age-Specific Consideration:
Children presenting under age 5-6 years require evaluation for underlying primary immunodeficiency disorders before initiating standard IBD therapy. 5, 1 This very early onset IBD (VEOIBD) may represent monogenic disorders requiring genomic testing rather than standard immunosuppression 1.
Treatment Algorithm Based on Disease Severity
Mild to Moderate Crohn's Disease:
For induction therapy, use either exclusive enteral nutrition (EEN) OR budesonide, NOT oral 5-aminosalicylates. 5
- Exclusive enteral nutrition is suggested as first-line induction therapy and provides a critical window to update vaccination status before immunosuppression 5
- Budesonide is suggested for mild-moderate disease with appropriate anatomic distribution 5
- Avoid oral 5-ASA: The Canadian Association of Gastroenterology recommends AGAINST using 5-aminosalicylates for induction or maintenance in moderate pediatric CD 5
Severe Disease or High-Risk Features at Diagnosis:
Initiate biologic TNF antagonist therapy early in patients with severe disease at presentation or poor prognostic factors. 5
Poor prognostic indicators requiring early aggressive therapy include: 5
- Deep colonic ulcerations on endoscopy
- Perianal disease
- Extensive disease involvement
- Persistent severe symptoms despite initial therapy
Maintenance Therapy:
- TNF antagonists are suggested for maintenance after successful induction 5
- Thiopurines alone are recommended AGAINST for induction therapy 5
- Corticosteroids are recommended AGAINST for maintenance therapy 5
- Thiopurine combinations with biologics are NOT recommended for male patients due to hepatosplenic T-cell lymphoma risk 5
Vaccination Strategy
Update all vaccinations BEFORE starting immunosuppressive therapy, ideally during the EEN induction window. 5
Critical vaccination considerations: 5
- Complete all routine childhood vaccinations before immunosuppression
- Administer inactivated vaccines (influenza, pneumococcal, HPV) as indicated
- Withhold live vaccines once immunosuppression begins
- For infants whose mothers received biologics during pregnancy, withhold live vaccines until at least 6 months of age 5
Monitoring and Treatment Targets
Assess for mucosal healing within 1 year of treatment initiation in patients achieving clinical remission on immunomodulators. 5
Monitoring Strategy:
- Fecal calprotectin is the preferred non-invasive biomarker for monitoring disease activity and mucosal inflammation 5, 1, 6
- MR enterography for surveillance of small bowel disease, with 71-86% sensitivity for detecting recurrence 4
- Growth parameters: Monitor height, weight, and pubertal development at every visit—growth failure is a unique pediatric concern requiring aggressive disease control 5, 6
- Bone health: Monitor vitamin D, calcium, and consider bone density assessment in patients with chronic disease or prolonged steroid exposure 5, 6
Treatment Goals:
The primary outcomes to achieve are: 5
- Mucosal healing (deep remission)
- Restoration of linear growth and achievement of genetic growth potential
- Optimization of bone health before peak bone mass is reached
- Quality of life improvement
Common Pitfalls to Avoid
Do not dismiss very early onset IBD (under age 5-6) as typical IBD—these children require immunodeficiency evaluation before standard immunosuppression. 5, 1 Starting biologics or thiopurines without ruling out primary immunodeficiency can be catastrophic.
Do not use 5-aminosalicylates as primary therapy for moderate Crohn's disease—the evidence shows they are ineffective for induction or maintenance in this population 5
Do not start immunosuppression without completing the infection screening checklist—tuberculosis reactivation and other opportunistic infections are preventable with proper screening 5
Do not neglect growth monitoring—failure to achieve genetic height potential is irreversible after epiphyseal closure, making aggressive early disease control essential 5, 6
Do not assume clinical remission equals mucosal healing—particularly in PSC-IBD, symptoms underrepresent mucosal inflammation; use objective markers like fecal calprotectin 5