Does a child with colitis require treatment?

Treatment of Pediatric Colitis

Yes, a child with colitis absolutely requires treatment to prevent serious long-term complications including growth failure, bone density loss, and increased risk of colorectal cancer. Untreated inflammation in children leads to irreversible consequences that cannot be recovered even with later aggressive therapy 1.

Critical Distinction: Type of Colitis Matters

The treatment approach depends fundamentally on whether the child has Crohn's colitis versus ulcerative colitis, as these require different first-line therapies 1, 2.

For Crohn's Disease with Colonic Involvement

Exclusive Enteral Nutrition (EEN) should be the first-line therapy for inducing remission in children with active luminal Crohn's disease, including those with colonic involvement 1. This approach is superior to corticosteroids because it:

• Promotes mucosal healing more effectively 1
• Restores bone mineral density 1
• Improves linear growth 1
• Provides a critical window to update vaccinations before starting immunosuppression 2

Implementation specifics:

• Duration: 6-8 weeks of exclusive formula feeding 1
• Use whole protein formulas given orally; reserve elemental formulas only for cow's milk protein allergy 1
• If no clinical response within 2 weeks, switch to alternative treatment 1
• Combined remission rate of 73% in pediatric studies 1

Important caveat: There is no firm data supporting EEN effectiveness in severe isolated Crohn's pancolitis 1. In these cases, or when EEN fails, escalate to immunomodulators or biologics.

For Ulcerative Colitis

5-aminosalicylates (5-ASA) are first-line therapy for mild to moderate pediatric ulcerative colitis 2, 3. For moderate to severe disease:

• Oral corticosteroids for patients failing 5-ASA therapy 2
• Intravenous corticosteroids for severe disease requiring hospitalization 2, 4
• At day 3 of IV steroids, use PUCAI score >45 to identify likely steroid failure 4
• At day 5, PUCAI >65-70 mandates introduction of second-line therapy 4

Second-line options when steroids fail (34% of pediatric cases):

• Infliximab: 75% short-term response rate, 64% one-year response 4
• Cyclosporine: 81% short-term success, but restrict use to 3-4 months as bridge to thiopurines 4

Why Treatment Cannot Be Delayed

Children face unique consequences of untreated inflammation that adults do not:

• Growth failure: Linear growth impairment is irreversible if inflammation persists through critical growth periods 1
• Bone health: Peak bone mass achieved by late adolescence acts as the "bone bank" for life; approximately half of children with Crohn's disease have decreased bone density 1
• Failure to control inflammation may result in children not achieving their genetic growth potential 1

Essential Pre-Treatment Workup

Before initiating immunosuppression, complete the following 2:

• Complete blood count
• Hepatitis B and C serologies
• Varicella zoster virus serology
• Epstein-Barr virus serology
• Tuberculosis screening
• Stool examination for infectious causes (including C. difficile)

Special consideration: Children presenting under age 5-6 years require evaluation for primary immunodeficiency disorders, as very early onset IBD may represent monogenic disorders requiring genomic testing rather than standard immunosuppression 2.

Treatment Escalation Criteria

Optimize therapy with immunomodulators or biologics early when these poor prognostic factors are present 1:

• Deep colonic ulcerations on endoscopy
• Persistent severe disease despite adequate induction therapy
• Extensive (pan-enteric) disease
• Marked growth retardation (height Z score < -2.5)
• Severe osteoporosis
• Stricturing or penetrating disease at onset
• Severe perianal disease

Monitoring Requirements

Assess for mucosal healing within 1 year of treatment initiation in patients achieving clinical remission 2. Use objective markers:

• Fecal calprotectin for non-invasive monitoring 1, 2
• Monitor growth parameters (height, weight, pubertal development) at every visit 2
• Assess bone health including vitamin D and calcium levels 2

Common Pitfalls to Avoid

• Do not restrict food in severe ulcerative colitis unless surgical abdomen is present – this is particularly harmful in children 4
• Do not use partial enteral nutrition for induction of remission in Crohn's disease – it is ineffective 1
• Do not delay second-line therapy in steroid-refractory ulcerative colitis – use PUCAI scores at days 3 and 5 to guide escalation 4
• Do not give live vaccines once immunosuppression begins 2