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Consensus guidelines of ECCO/ESPGHAN on the medical management of pediatric Crohn’s disease
Open accessAbstract
Children and adolescents with Crohn's disease (CD) present often with a more complicated disease course compared to adult patients. In addition, the potential impact of CD on growth, pubertal and emotional development of patients underlines the need for a specific management strategy of pediatric-onset CD. To develop the first evidenced based and consensus driven guidelines for pediatric-onset CD an expert panel of 33 IBD specialists was formed after an open call within the European Crohn's and Colitis Organisation and the European Society of Pediatric Gastroenterolog, Hepatology and Nutrition. The aim was to base on a thorough review of existing evidence a state of the art guidance on the medical treatment and long term management of children and adolescents with CD, with individualized treatment algorithms based on a benefit-risk analysis according to different clinical scenarios. In children and adolescents who did not have finished their growth, exclusive enteral nutrition (EEN) is the induction therapy of first choice due to its excellent safety profile, preferable over corticosteroids, which are equipotential to induce remission. The majority of patients with pediatric-onset CD require immunomodulator based maintenance therapy. The experts discuss several factors potentially predictive for poor disease outcome (such as severe perianal fistulizing disease, severe stricturing/penetrating disease, severe growth retardation, panenteric disease, persistent severe disease despite adequate induction therapy), which may incite to an anti-TNF-based top down approach. These guidelines are intended to give practical (whenever possible evidence-based) answers to (pediatric) gastroenterologists who take care of children and adolescents with CD; they are not meant to be a rule or legal standard, since many different clinical scenario exist requiring treatment strategies not covered by or different from these guidelines.
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“This interest and use of CAM is common in pediatric IBD, despite being limited evidence for the role of diet and other types of CAMs in inducing and maintaining disease remission in IBD (excluding exclusive enteral nutrition in pediatric Crohn’s disease) [22,23,24].”
From Online Acceptance and Commitment Therapy and Nutrition Workshop for Parents of Children with Inflammatory Bowel Disease: Feasibility, Acceptability, and Initial Effectiveness. (2021) · cites this paper as [22]
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“(11) ❚ FINAL COMMENTS Thalidomide appears to be an alternative option for pediatric patients with refractory IBD, as it induces disease remission.”
InfluentialCalabrese, F., Pasta, A., Formisano, E., Marabotto, E., Furnari, M., Pisciotta, L., Zentilin, P., Giannini, E. G., & Bodini, G. (2025) · Digestive Diseases and Sciences · doi:10.1007/s10620-025-09590-y · Cited by 2
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Kong, Y., Cao, P., Wu, J., & Ye, X. (2025) · Microbiology Spectrum · doi:10.1128/spectrum.01502-25 · Cited by 2
“Although EEN is recommended as first-line therapy to induce remission in children with mild to moderate CD, up to 30% patients have no clinical response, and 50% patients have no endoscopic response to EEN (10, 11).”
Boneh, R. S., Banci, E., Scarallo, L., Herrador‐López, M., Halmos, E. P., Shouval, D. S., Wierdsma, N., Shabat, C. S., Navas‐López, V. M., de Carpi, J. M., et al. (2026) · JCC Plus · doi:10.1002/jcc5.70016 · Cited by 2
Alvisi, P., Valerii, M. C., Perre, E., Barbieri, G., Rizzello, F., Congiu, M., Pranzetti, A., Dussias, N. K., Sbravati, F., Imbesi, V., et al. (2026) · Nutrients · doi:10.3390/nu18081290 · Cited by 2
“…a polymeric formula (Modulen ® , Nestlé, Vevey, Switzerland) administered as the sole source of calories for 8 weeks, in accordance with guidelines from European Crohn’s and Colitis Organisation and European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ECCO–ESPGHAN) [35–37].”
Simple Urine Test to Evaluate Adherence to Oral 5‐ASA in Teenagers With Ulcerative Colitis
Dijkstra, A., Touw, D. J., & van Rheenen, P. F. (2017) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1097/mpg.0000000000001541 · Cited by 2
“10(8) RBC are a proxy for adequate oral ingestion of thiopurine medication.(11) Patients and parents or legal guardians were pre-informed of the study before the clinic visit.”
BackgroundManagement Challenges in Adolescents with Crohn?s Disease-Current Practice
Kasirer, Y. M., Birimberg‐Schwartz, L., Negari, S. B. H., & Turner, D. (2017) · Journal of Inflammatory Bowel Diseases & Disorders · doi:10.4172/2476-1958.1000117 · Cited by 2
“Exclusive Enteral Nutrition (EEN) improves growth by mediating mucosal healing and down-regulating proinflammatory cytokines such as IL-6 and TNF, potent inhibitors of IGF-1 [21].”
BackgroundInfectious Complications of Pediatric Inflammatory Bowel Disease
Ardura, M. I., & Kim, S. C. (2017) · Springer eBooks · doi:10.1007/978-3-319-49215-5_49 · Cited by 2
Wang, B., Wang, W., Tian, Z., Wei, C., & Zhao, Y. J. (2019) · Terra Nova · doi:10.1111/ter.12447 · Cited by 2
Appleton, L., Watt, E., Jagger, F., Hansen, R., Gearry, R. B., & Day, A. S. (2020) · Gastrointestinal Disorders · doi:10.3390/gidisord2020017 · Cited by 2
“Treatment regimens typically also differ from those utilised in adults with CD: for example, international guidelines promote the use of exclusive enteral nutrition as the first-line therapy to induce remission after diagnosis of CD in children [8].”
BackgroundThe Use of Elimination Diets in Gastrointestinal Disease: a Review
Memel, Z. N., Berschback, M. A., & Palchaudhuri, S. (2022) · Current Treatment Options in Gastroenterology · doi:10.1007/s11938-022-00387-w · Cited by 2
“Initially studied in the pediatric population, exclusive enteral nutrition (EEN) has been found to achieve high remission rates in patients with Crohn’s disease [31, 32, 33].”
BackgroundInflammatory bowel disease in patients with systemic juvenile arthritis: Case report
Zholobova, E. S., Yusupova, V., Afonina, E. Y., Анатольевна, С. В., Nikolaeva, M. N., Dzis, M., Sukhovjova, O. G., Kurbanova, S. K., & Valieva, S. I. (2023) · Consilium Medicum · doi:10.26442/20751753.2023.8.202357 · Cited by 2
Infliximab biosimilar GP1111: a review of 5 years’ post-approval experience
Huizinga, T. W. J., Dipasquale, V., Zabransky, M., Heyn, J., & Romano, C. (2024) · Expert Opinion on Biological Therapy · doi:10.1080/14712598.2024.2377298 · Cited by 2
“…d b y t r e a t m e n t o f i n t e s t i n a l d i s e a s e w i t h T N F i ( n o g r a d i n g o f r e c o mm e n d a t i o n g i v e n ) E U : [ 13 ] U S : [ 14 ] A d u l t U C T N F i ( e . g . i n f l i x i m a b ) i s r e c o mm e n d e d f o r : ● I n d u c i n g r e m i ss i o n i n p a t…”
Jaakkola, T., Merras‐Salmio, L., Nikkonen, A., & Kolho, K. (2024) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1002/jpn3.12397 · Cited by 2
“23 This all could propose that our relatively positive outcomes are related to the active treatment escalation rather than the L4b phenotype being less aggressive.”
Yeung, A. W. K. (2024) · Frontiers in Pharmacology · doi:10.3389/fphar.2024.1498464 · Cited by 2
Liu, W.-H., Xiong, M., Chen, G., Long, Z., Xu, C., Zhu, L., & Wu, J. (2024) · World Journal of Gastrointestinal Surgery · doi:10.4240/wjgs.v17.i1.98269 · Cited by 2
Sandrine, C., Emmanuelle, D., Viala, J., & Martinez‐Vinson, C. (2024) · JPGN Reports · doi:10.1002/jpr3.12163 · Cited by 2
Bibliometric analysis of Crohn's disease in children, 2014–2024
Zhu, Y., Ma, Y., Cui, Z., Pan, Y., & Diao, J. (2025) · Frontiers in Pediatrics · doi:10.3389/fped.2025.1515251 · Cited by 2
Nutritional Therapy for Inflammatory Bowel Disease
Orel, R., Benedik, E., Erzen, J., Orel, A., & Urlep, D. (2018) · InTech eBooks · doi:10.5772/intechopen.73259 · Cited by 2
“With the exception of the ECCO/ESPGHAN recommendations to use exclusive enteral nutrition as a first-line therapeutic approach in children with active CD [58], the strict guidelines for nutritional New Concepts in Inflammatory Bowel Disease 54”
MethodInfluentialBody height in paediatric inflammatory bowel diseases: A structural equation model analysis
Chouliaras, G. L., Mantzou, A., Margoni, D., Tsilifis, N., Pervanidou, P., Panayotou, I., Kanaka‐Gantenbein, C., Chrousos, G. P., & Roma‐Giannikou, E. (2018) · European Journal of Clinical Investigation · doi:10.1111/eci.12969 · Cited by 2
“The importance of linear growth during puberty is underlined in the latest joined guidelines from the European Crohn's and Colitis Organisation (ECCO) and the European Society of Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN), according to which severe stunting is an indication for early anti‐TNFa trea…”
BackgroundP41 Pharmacists input in managing paediatric patients on the ketogenic diet
Deane, L. (2023) · Archives of Disease in Childhood · doi:10.1136/archdischild-2023-nppg.39 · Cited by 2
Difficult-to-treat-pediatric Crohn's disease: focus on adalimumab
Hyams, J. S., & Zeisler, B. (2015) · Pediatric Health Medicine and Therapeutics · doi:10.2147/phmt.s40948 · Cited by 2
“osteopenia, penetrating or stricturing disease at diagnosis, and severe perianal disease.(70) In adults, predictors of disabling”
Muncunill, G. P., & de Carpi, J. M. (2015) · Enfermedad Inflamatoria Intestinal al Día · doi:10.1016/j.eii.2015.06.003 · Cited by 2
Profile of infliximab in the treatment of pediatric Crohn’s disease
Kierkuś, J., Szymańska, E., Oracz, G., Wiernicka, A., & Dądalski, M. (2015) · Pediatric Health Medicine and Therapeutics · doi:10.2147/phmt.s64943 · Cited by 2
“infliximab is recommended as a primary induction and maintenance therapy for children with active perianal fistulizing disease.(27) However, the criteria for use of biologic agents for pediatrics in clinical trials vary depending on the research protocol.”
Shi, J., Huang, Z., Wang, Y., & Huang, Y. (2015) · Digestive Diseases and Sciences · doi:10.1007/s10620-015-3582-3 · Cited by 2
“Children with IBD who show delayed puberty are also more likely to have low serum levels of IGF-I and IGFBP3 [12, 30].”
BackgroundGenital Involvement In Pre-Pubertal Pediatric Population: A Rare Aspect of Crohn’s Disease
Warsi, Q. A., Kunduru, M., Karjoo, M., & Beg, M. (2016) · DOAJ (DOAJ: Directory of Open Access Journals) · doi:10.22038/ijp.2016.7334 · Cited by 2
Gabrusskaya, T. V., Ulanova, N., Philippov, D., Shcherbakova, O. V., & Vepreva, E. G. (2016) · Вопросы современной педиатрии · doi:10.15690/vsp.v15i4.1592 · Cited by 2
“Согласно последнему консенсусу ECCO по ведению болезни Крона у детей, при перианальном поражении анти-TNF терапия может рассматриваться в качестве терапии первой линии (индукция и поддержание ремиссии) и должна осуществляться совместно с хирургическим лечением [20].”
Assessing the feasibility of injectable growth-promoting therapy in Crohn’s disease
Altowati, M. A., Jones, A. P., Hickey, H., Williamson, P. R., Barakat, F. M., Plaatjies, N., Hardwick, B., Russell, R. K., Jaki, T., Ahmed, S. F., et al. (2016) · Pilot and Feasibility Studies · doi:10.1186/s40814-016-0112-9 · Cited by 2
“Current treatment is to improve growth using steroid-sparing anti-inflammatory medication [11].”
BackgroundNavas‐López, V. M., Muncunill, G. P., Llerena, E., Navalón-Rubio, M., Gil, D., Varea-Calderón, V., Salinas, C. S., & de Carpi, J. M. (2017) · Anales de Pediatría (English Edition) · doi:10.1016/j.anpede.2017.03.001 · Cited by 2
Development of a nurse-led paediatric inflammatory bowel disease service
Crook, K. (2017) · Gastrointestinal Nursing · doi:10.12968/gasn.2017.15.8.34 · Cited by 2
Perianal Disease and Granulomas: Think Out of the Box…
Reis‐Melo, A., Espinheira, M. D. C., Pais, I. P., Vítor, A. B., Bustamante, J. C., & Trindade, E. (2019) · GE Portuguese Journal of Gastroenterology · doi:10.1159/000502358 · Cited by 2
Enfermedad perianal como primera manifestación en la enfermedad de Crohn pediátrica
Solís, A. M. S., Antuña, L. F., Cuadra, Y. R., & Castellarnau, E. (2020) · Gastroenterología y Hepatología · doi:10.1016/j.gastrohep.2019.11.013 · Cited by 2
Thalidomide for de novo Crohn’s disease after ileal pouch anal anastomosis for ulcerative colitis
Dipasquale, V., Tropeano, A., Caime, F., & Romano, C. (2020) · Journal of Clinical Pharmacy and Therapeutics · doi:10.1111/jcpt.13140 · Cited by 2
Making Decisions about Dietary Therapy in Inflammatory Bowel Disease
Solomon, S., Park, E., & Picoraro, J. A. (2020) · Gastrointestinal Disorders · doi:10.3390/gidisord2040032 · Cited by 2
Poda, O. A. (2021) · CHILD`S HEALTH · doi:10.22141/2224-0551.16.1.2021.226461 · Cited by 2
Shi, X.-Z. P. (2021) · Elsevier eBooks · doi:10.1016/b978-0-12-820472-6.00168-7 · Cited by 2
Pediatric perianal Crohn´s disease behavior in the era of biologic therapy
de la Puente, S., Góngora, R. E., Romero, H. S., Espiñeira, C. R., Huertas, A. L., Visier, C. G., Rodríguez, P. R., Hernández, D. M., Vega, M. L. E., Ruiz, J. A., et al. (2023) · Cirugía pediátrica/Cirugía pediátrica · doi:10.54847/cp.2023.01.16 · Cited by 2
Precision medicine for pediatric inflammatory bowel disease: a perspective
Choe, Y. H. (2020) · Precision and Future Medicine · doi:10.23838/pfm.2020.00058 · Cited by 2
“TPMT and 6-thioguanine nucleotide Thiopurines are recommended as an option for maintenance of steroid-free remission in children at risk for poor disease outcome, and for reducing the formation of antibodies to biologics [16,17].”
BackgroundFool me once… treatment exposure to achieve remission in pediatric IBD
Limbergen, J. V., Koot, B. G. P., & de Winter, P. (2020) · European Journal of Pediatrics · doi:10.1007/s00431-020-03862-7 · Cited by 2
“This cohort was recruited before the previous 2014 European pediatric IBD guidelines were published, and these children were therefore not routinely started during induction treatment on an immunomodulator for maintenance [4, 13].”
MethodMorbus Crohn und Colitis ulcerosa
Keller, K. (2020) · Springer Reference Medizin · doi:10.1007/978-3-662-60300-0_154 · Cited by 2
Metadata
- Authors
- Ruemmele, F. M., Veres, G., Kolho, K. L., Griffiths, A., Levine, A., Escher, J. C., Amil Dias, J., Barabino, A., Braegger, C. P., Bronsky, J., Buderus, S., Martín-de-Carpi, J., De Ridder, L., Fagerberg, U. L., Hugot, J. P., Kierkus, J., Kolacek, S., Koletzko, S., Lionetti, P., Miele, E., Navas López, V. M., Paerregaard, A., Russell, R. K., Serban, D. E., Shaoul, R., Van Rheenen, P., Veereman, G., Weiss, B., Wilson, D., Dignass, A., Eliakim, A., Winter, H., & Turner, D.
- Affiliations
- Hôpital Necker-Enfants Malades (FR)
- Semmelweis University (HU)
- Helsinki University Hospital (FI)
- University of Toronto (CA)
- Tel Aviv University (IL)
- Erasmus MC (NL)
- Unit of Paediatric Gastroenterology, Hospital S. João, A Hernani Monteiro, 4202-451, Porto, Portugal
- Istituto Giannina Gaslini (IT)
- University Children's Hospital Zurich (CH)
- Department of Pediatrics, University Hospital Motol, Uvalu 84, 150 06 Prague, Czech Republic
- St. Marien-Hospital Bonn (DE)
- Department of Paediatric Gastroenterolgoy, Hepatology and Nutrition, Hospital Sant Joan de Déu, Paseo Sant Joan de Déu 2, 08950 Barcelona, Spain
- Department of Paediatric Gastroenterology, Erasmus Medical Center, Wytemaweg 80, 3015 CN Rotterdam, Netherlands
- Karolinska Institutet (SE)
- Sorbonne Paris Cité (FR)
- Department of Gastroenterology, Hepatology and Feeding Disorders, Instytut Pomnik Centrum Zdrowia Dziecka, Ul. Dzieci Polskich 20, 04-730 Warsaw, Poland
- Department of Paediatric Gastroenterology, Children's Hospital, University of Zagreb Medical School, Klaićeva 16, 10000 Zagreb, Croatia
- Department of Paediatric Gastroenterology, Dr. von Hauner Children's Hospital, Lindwurmstr. 4, 80337 Munich, Germany
- Meyer Children's Hospital (IT)
- University of Naples Federico II (IT)
- Paediatric Gastroenterology and Nutrition Unit, Hospital Materno Infantil, Avda. Arroyo de los Ángeles s/n, 29009 Málaga, Spain
- Department of Paediatrics 460, Hvidovre University Hospital, Kettegård Allé 30, 2650 Hvidovre, Denmark
- Department of Paediatric Gastroenterology, Yorkhill Hospital, Dalnair Street, Glasgow G3 8SJ, United Kingdom
- Iuliu Hațieganu University of Medicine and Pharmacy (RO)
- Rambam Health Care Campus (IL)
- Department of Paediatric Gastroenterology, Hepatology and Nutrition, University Medical Center Groningen, P.O. Box 30001, 9700 RB Groningen, Netherlands
- Queen Fabiola Children's University Hospital (BE)
- Sheba Medical Center (IL)
- Royal Hospital for Sick Children (GB)
- Agaplesion Markus Hospital (DE)
- Massachusetts General Hospital (US)
- Hebrew University of Jerusalem (IL)
- Corresponding author
- Ruemmele, F.M.
- ORCID
- Venue
- Journal of Crohn s and Colitis
- Publisher
- Oxford University Press (OUP)
- Published
- 2014-10-01
- Volume
- 8
- Issue
- 10
- Pages
- 1179-1207
- ISSN
- 1873-9946 (ISSN-L)
- 1876-4479
- OpenAlex
- W2135936774
- Cited by
- 1,083
- References
- 293
- Citations by year
- 2026: 61 · 2025: 60 · 2024: 71 · 2023: 97 · 2022: 83 · 2021: 123 · 2020: 117 · 2019: 136 · 2018: 92 · 2017: 122 · 2016: 61 · 2015: 52 · 2014: 5
- FWCI
- 52.41
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Crohn s and Colitis (publishedVersion)
- PubMed (publishedVersion)
- Research Publications (Maastricht University) (publishedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion)
- EUR Research Repository (Erasmus University Rotterdam) (submittedVersion)
- BOA (University of Milano-Bicocca) (submittedVersion, cc-by-nc-nd)
- Archivio istituzionale della ricerca (Alma Mater Studiorum Università di Bologna) (submittedVersion)
- Open access LMU (Ludwid Maxmilian's Universitat Munchen) (submittedVersion)
- Florence Research (University of Florence) (submittedVersion)
- University of Groningen research database (University of Groningen / Centre for Information Technology) (submittedVersion)
- University of Southern Denmark Research Portal (University of Southern Denmark) (submittedVersion)
- VUBIR (Vrije Universiteit Brussel) (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion)
- Research Publications (Maastricht University) (submittedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich)
- Topics
- Health Sciences › Medicine › Gastroenterology › Inflammatory Bowel Disease
- Health Sciences › Medicine › Ophthalmology › Ocular Diseases and Behçet’s Syndrome
- Health Sciences › Medicine › Surgery › Anorectal Disease Treatments and Outcomes
- Keywords
- pediatric Crohn's disease, medical management
- MeSH terms
- Adalimumab, Infliximab, Adolescent, Adrenal Cortex Hormones, Algorithms, Aminosalicylic Acids, Anti-Inflammatory Agents, Non-Steroidal, Anti-Bacterial Agents, Antibodies, Monoclonal, Azathioprine, Child, Crohn Disease, Enteral Nutrition, Humans, Immunosuppressive Agents, Methotrexate, Remission Induction, Thalidomide, Tumor Necrosis Factor-alpha, Mercaptopurine, Maintenance Chemotherapy, Antibodies, Monoclonal, Humanized
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