From the Guidelines
Pediatric inflammatory bowel disease (IBD) management should prioritize a multidisciplinary approach, including exclusive enteral nutrition (EEN) for 6-8 weeks as a first-line treatment for Crohn's disease, particularly in children with growth failure, as it can induce remission 1.
Key Considerations
- For mild to moderate ulcerative colitis, 5-aminosalicylates (5-ASA) such as mesalamine at 50-75 mg/kg/day divided into 2-3 doses are recommended.
- Corticosteroids like prednisone (1-2 mg/kg/day, maximum 40-60 mg) may be used for moderate to severe flares in both conditions, but should be limited to short courses (6-8 weeks with taper) due to growth concerns, with efficacy supported by studies showing 30-day remission rates ranging from 57% to 79% in pediatric patients 1.
- Maintenance therapy often involves immunomodulators such as azathioprine (2-3 mg/kg/day) or 6-mercaptopurine (1-1.5 mg/kg/day), with regular monitoring of blood counts and liver function.
- Biologics like infliximab or adalimumab are effective options for cases not responding to conventional therapy.
Nutritional and Psychological Support
- Regular nutritional assessment is crucial due to the high risk of malnutrition and growth failure.
- A healthy, balanced Mediterranean-style diet rich in fruits, vegetables, complex carbohydrates, and monounsaturated fats, and low in added sugar, salt, red meats, and ultraprocessed foods, can be beneficial and should be introduced when patients are asymptomatic or have mild to moderate symptoms 1.
- Vitamin D, calcium, and iron supplementation may be necessary.
- Psychological support should be integrated into care due to the significant impact of pediatric IBD on quality of life and mental health.
Monitoring and Adjustments
- Regular endoscopic evaluation helps assess mucosal healing and guide therapy adjustments.
- The goal of treatment should be to achieve both clinical remission and normal growth patterns.
- Dietary advice and treatment strategies should be tailored to the individual patient's nutritional status and goals, which may vary over time, and are best achieved through collaborative interdisciplinary practice between gastroenterologists and registered dietitians 1.
From the FDA Drug Label
RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age and older with moderately to severely active Crohn's disease who have had an inadequate response to conventional therapy. RENFLEXIS is indicated for reducing signs and symptoms and inducing and maintaining clinical remission in pediatric patients 6 years of age and older with moderately to severely active ulcerative colitis who have had an inadequate response to conventional therapy. The recommended dose of RENFLEXIS for pediatric patients 6 years and older with moderately to severely active Crohn's disease is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks. The recommended dose of RENFLEXIS for pediatric patients 6 years and older with moderately to severely active ulcerative colitis is 5 mg/kg given as an intravenous induction regimen at 0,2 and 6 weeks followed by a maintenance regimen of 5 mg/kg every 8 weeks.
Pediatric IBD Management:
- Infliximab can be used to manage Crohn's disease and ulcerative colitis in pediatric patients 6 years of age and older.
- The recommended dose is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks, followed by a maintenance regimen of 5 mg/kg every 8 weeks.
- It is essential to carefully consider the risks and benefits of treatment with infliximab, especially in pediatric patients, due to the potential for serious infections and malignancies 2 2.
From the Research
Medical Management of Pediatric IBD
- Medical therapy is often successful at inducing and maintaining remission and preventing disease complications in pediatric IBD patients 3
- The mainstays of treatment are medications and other therapies that reduce inflammation and suppress the overactive immune system 3
Biologic Therapies
- Biologics have been transformative to the therapeutic goals in the pediatric population, with infliximab being well-established as a safe and efficacious therapy for Crohn's disease and ulcerative colitis 4
- Early real-world experience of vedolizumab and ustekinumab in pediatric IBD shows promising results, including clinical response rates comparable to what is seen in adults 4
- Therapeutic drug monitoring improves the likelihood of response to anti-TNFα therapies, but further studies for vedolizumab and ustekinumab are necessary 4
Health Care Maintenance
- A multidisciplinary approach that involves the general practitioner and pediatric gastroenterologist is needed to routinely monitor growth, bone health, vitamin and mineral deficiencies, vaccination status, and endoscopic surveillance in pediatric IBD patients 5
- It is also important to monitor for extraintestinal manifestations of IBD that may affect the liver, joints, skin, and eyes 5
Self-Management
- Self-management difficulties in the form of nonadherence to treatment regimens are common in pediatric IBD and are influenced by various disease-related, individual, family, and health professional relationship factors 6
- Health care providers are encouraged to adopt a long-term preventive orientation, which includes routine screening of barriers to self-management and nonadherence in the context of routine clinic appointments 6
Therapeutic Drug Monitoring
- Therapeutic drug monitoring (TDM) of thiopurine metabolites improves clinical outcomes through dose optimization and toxicity monitoring in IBD patients 7
- TDM informs clinical management in over two-thirds of patients, with significantly more changes to clinical management occurring in those with active disease than in remission 7