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← Paediatrics and child health indexChapter sections
OverviewAetiologyPathophysiologyClinical features and red flagsInvestigationsDifferential diagnosisManagementComplicationsMonitoring and follow-upSpecial situationsCommon pitfallsQuestionsSources
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Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.

Inflammatory bowel disease in children

Paediatrics and child health · UK scope · Sources checked 27 Aug 2026 · Clinical review pending

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Acute severe colitis or abdominal complication

Frequent bloody stool with fever, tachycardia, anaemia, hypoalbuminaemia, severe pain, distension or toxicity may represent acute severe colitis, toxic megacolon, perforation or sepsis.

Action: Admit urgently under paediatric gastroenterology with early paediatric surgical involvement, obtain stool infection testing and imaging as indicated, start protocol-led intravenous treatment and assess rescue therapy or surgery daily.

Overview

Recognise paediatric Crohn disease and ulcerative colitis before growth failure advances, stage intestinal and extra-intestinal disease and coordinate nutrition, medicines, surgery and developmental monitoring through specialist care.

History covers stool frequency, blood, urgency, nocturnal waking, pain, vomiting, mouth ulcers, perianal symptoms, fever, joints, eyes and skin. Plot weight, height and growth velocity and assess puberty. Examine pallor, mouth, clubbing, abdomen, liver, spleen and perianal region with consent and chaperoning. In younger children, poor growth and anaemia may dominate while bowel symptoms are understated.

Request FBC, CRP or ESR, albumin, renal and liver profiles, ferritin and stool pathogen testing. Faecal calprotectin helps demonstrate intestinal inflammation but rises during infection and is age sensitive. Normal CRP does not exclude limited disease. Urgent referral is appropriate when blood, growth failure, anaemia, hypoalbuminaemia or perianal disease persists; primary care should not delay for repeated empirical diets.

Specialist diagnosis maps distribution and behaviour. Ileocolonoscopy with terminal ileal and segmental biopsies plus upper endoscopy is the reference mucosal assessment. MR enterography or intestinal ultrasound evaluates small bowel and transmural complications without routine ionising radiation. Histology separates chronic IBD from infection and other enteropathy. Very-early-onset or atypical disease may need immunology and genomic investigation.

Aetiology

01

Genetic susceptibility

Polygenic epithelial and immune variants raise risk, with very-early-onset disease sometimes reflecting an identifiable monogenic immune dysfunction.

02

Dysregulated mucosal immunity

An inappropriate sustained response to intestinal microbes drives tissue injury in a genetically susceptible child through persistent cytokine signalling.

03

Environmental interaction

Antibiotic exposure, diet, smoking exposure and geography influence risk, but no single behaviour explains an individual child's disease.

04

Very early onset immune disease

Presentation under six years, severe perianal disease or unusual infection can signal an underlying primary immune disorder requiring genomic assessment.

Pathophysiology

  1. 1
    Crohn transmural inflammation

    Patchy full-thickness inflammation may affect mouth to anus, producing strictures, fistulas, abscesses and impaired nutrient absorption.

  2. 2
    Ulcerative mucosal inflammation

    Continuous colonic inflammation begins at the rectum and causes friable bleeding mucosa, urgency and high stool frequency.

  3. 3
    Systemic inflammatory burden

    Cytokines suppress appetite and growth pathways, increase energy demand and drive anaemia, bone loss and extra-intestinal disease.

  4. 4
    Growth and puberty disruption

    Malnutrition, inflammation and corticosteroid exposure impair linear growth and pubertal progression, sometimes preceding dramatic bowel symptoms.

Clinical features and red flags

Crohn phenotype

Patchy mouth-to-anus disease, weight loss, right-sided pain, perianal lesions and stricturing or fistulation support Crohn disease.

Ulcerative phenotype

Continuous rectal and colonic inflammation produces bloody diarrhoea, urgency and tenesmus without small-bowel transmural complications.

Growth-first presentation

Falling height velocity or delayed puberty can precede obvious diarrhoea and is a central paediatric severity marker.

Extra-intestinal inflammation

Arthritis, erythema nodosum, pyoderma gangrenosum, uveitis and hepatobiliary disease may track or diverge from gut activity.

Acute severe colitis

Frequent bloody stool plus systemic upset, anaemia, low albumin or colonic dilatation requires inpatient rescue planning.

Red flags requiring action

  • Persistent blood in stool, nocturnal diarrhoea, weight loss, falling height velocity or delayed puberty requires urgent paediatric assessment.
  • Severe abdominal pain, guarding, distension, bilious vomiting or absent bowel sounds raises obstruction, abscess, toxic megacolon or perforation.
  • Perianal fistula, abscess, skin tags or poor wound healing strongly suggests Crohn disease and needs expert examination.
  • Fever, tachycardia, more than eight stools daily, low haemoglobin or albumin and CRP above 45 mg/L increases likelihood of surgery in acute severe colitis.

Investigations

  1. 01
    First-line inflammatory and nutritional profileFirst stepFirst line
    Why
    Detect anaemia, inflammation, hypoalbuminaemia, organ involvement and treatment baseline abnormalities.
    Interpretation and limitations
    Normal individual markers do not exclude IBD; combine trends with growth, stool and examination.
  2. 02
    Stool pathogen testing
    Why
    Exclude bacterial, C difficile and selected parasitic mimics before immunosuppressive escalation.
    Interpretation and limitations
    Positive results need clinical correlation because infection can coexist with established IBD.
  3. 03
    Faecal calprotectin
    Why
    Support the presence and follow-up of intestinal neutrophilic inflammation in an age-appropriate context.
    Interpretation and limitations
    It is not disease specific and cannot replace endoscopy for initial classification.
  4. 04
    Ileocolonoscopy and upper endoscopy with biopsies
    Why
    Provide reference diagnosis, histology and extent across the gastrointestinal tract.
    Interpretation and limitations
    Take segmental samples including apparently normal mucosa; chronicity and distribution inform Crohn versus ulcerative classification.

Differential diagnosis

01

Enteric infection

Campylobacter, Salmonella, Shigella, Yersinia, C difficile and parasites can mimic inflammatory diarrhoea and must be excluded appropriately.

02

Coeliac disease

Growth failure, anaemia and diarrhoea overlap, but coeliac serology and small-bowel histology distinguish gluten-driven enteropathy from IBD.

03

Functional bowel disorder

Functional pain lacks bleeding, nocturnal stool, growth failure, objective inflammation and destructive perianal disease on careful assessment.

04

Polyps or Meckel diverticulum

Painless lower gastrointestinal bleeding with less inflammatory illness may arise from a juvenile polyp or ectopic gastric mucosa.

05

Immune deficiency or allergy

Infantile colitis, unusual infection and severe eczema broaden assessment beyond conventional adolescent IBD toward immune deficiency or allergy.

Management

01SuspectProtect growth and referFirst stepBlood, nocturnal stool, growth failure, anaemia or perianal disease persists.+
  1. 1Assess severity, hydration and abdominal or perianal complication and admit if unstable.
  2. 2Obtain inflammatory, nutritional and stool tests without delaying specialist referral.
  3. 3Continue adequate nutrition and avoid empirical restrictive diets that impair growth.
02Confirm and induceClassify before treatment escalationEscalationSpecialist assessment clinically supports newly diagnosed IBD.+
  1. 1Complete endoscopy, histology and small-bowel assessment appropriate to phenotype.
  2. 2Use enteral nutrition or corticosteroid induction for Crohn disease with paediatric growth considerations.
  3. 3

Complications

01

Stricture fistula and abscess

Transmural Crohn disease can obstruct bowel, connect organs and form septic collections requiring drainage or surgery.

02

Toxic megacolon and perforation

Fulminant colitis can dilate and thin the colon, causing systemic toxicity, perforation and a possible need for emergency colectomy.

03

Malnutrition and bone disease

Reduced intake, malabsorption, inflammation and steroids impair growth, puberty, vitamin D status and peak bone mass.

04

Treatment toxicity

Infection, cytopenia, liver or pancreatic injury and infusion reactions require structured screening, laboratory monitoring and named clinical ownership.

05

Psychosocial and educational harm

Urgency, fatigue, admissions and treatment burden affect school, body image, independence and transition to adult services.

Monitoring and follow-up

  • Plot weight, height velocity, BMI and puberty at every meaningful review.
  • Track stool frequency, blood, nocturnal symptoms, pain, school and validated activity index.
  • Monitor FBC, liver, renal and inflammatory markers according to disease and exact medicine.
  • Review infection exposure, vaccines and live-vaccine restrictions before and during immunosuppression.
  • Assess iron, vitamin D, nutrition and bone health during chronic activity or after systemic steroids.
  • Maintain rapid contact routes for fever, severe pain, distension, bleeding and medication toxicity.

Special situations

Growth is an inflammatory marker

A falling height velocity may reveal active Crohn disease even when stool frequency appears modest.

Calprotectin has context

Infection and young age can elevate it, while a value cannot distinguish Crohn disease from ulcerative colitis.

Nutrition can induce remission

Exclusive enteral nutrition treats intestinal inflammation while supporting growth and avoiding corticosteroid toxicity.

Surgery is not treatment failure

Timely drainage, resection or colectomy can control complications and restore health when medicine cannot do so safely.

Common pitfalls

  1. 01

    Reassuring from a normal CRP despite blood, growth failure or perianal disease.

  2. 02

    Starting immunosuppression before relevant stool infection testing.

  3. 03

    Using corticosteroids as maintenance treatment.

  4. 04

    Ignoring height and puberty while recording weight only.

  5. 05

    Delaying surgical involvement in acute severe colitis.

  6. 06

    Allowing restrictive diets to worsen energy and micronutrient intake.

Practice

Two practice questions

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Paediatrics and child healthOriginal SBA

Crohn induction with growth concern

A child with newly diagnosed active Crohn disease has poor linear growth and the family wishes to avoid corticosteroid toxicity. Which induction option does NICE specifically support?

Choose one answer, then submit
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Sources and review status4 sources · checked 27 Aug 2026 · clinical review pending+
Sources

Sources and review status

National guidance is shown before implementation-dependent detail. Apply principles in context and verify current guidance when a decision affects care. Source check completed 27 Aug 2026; clinical approval remains outstanding.

  • NICE NG129 Crohn Disease RecommendationsInduction, enteral nutrition, maintenance, surgery and monitoring.
  • NICE NG130 Ulcerative Colitis RecommendationsExtent-based treatment, acute severe colitis and paediatric monitoring.
  • BSPGHAN Paediatric Ulcerative Colitis GuidelinePaediatric activity assessment, severe-colitis rescue and specialist management.
  • NICE DG11 Faecal Calprotectin DiagnosticsUse of faecal calprotectin to support inflammatory assessment.

Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes

Authoring stateComplete draftClinical stateAwaiting reviewJurisdictionUnited Kingdom

Treatment targets steroid-free remission, mucosal control, growth and quality of life. Crohn induction uses exclusive enteral nutrition or corticosteroids according to disease, growth and preference; abscess and obstruction need surgical collaboration. Ulcerative colitis uses topical and oral aminosalicylates for mild disease by extent, corticosteroids when needed and biologic or other advanced therapy for moderate to severe disease. Maintenance is specialist selected from risk and response; thiopurines are not monotherapy for induction.

Acute severe colitis is a time-defined emergency. Admit, exclude infection, provide IV corticosteroid and thrombosis, fluid and nutrition assessment, and involve surgeon at the outset. Use paediatric activity indices and daily trajectory. NICE recommends rescue ciclosporin or surgery if there is little or no improvement by seventy-two hours, with infliximab in defined circumstances. Delay in surgical discussion increases risk.

Long-term care monitors stool and pain alongside growth, puberty, blood counts, liver tests, drug levels or antibodies when indicated and bone health after chronic activity or systemic steroids. Update non-live vaccines before substantial immunosuppression where possible and avoid live vaccines under defined therapy. Screen mood, school and treatment burden and teach adolescents independent medicine and emergency skills before transition.

Key points

  • Suspect IBD with persistent blood or nocturnal stool, abdominal pain, weight or height faltering, pubertal delay, perianal disease, mouth ulcers or extra-intestinal inflammation.
  • First-line tests include FBC, CRP or ESR, albumin, renal and liver profiles, ferritin and stool microbiology; faecal calprotectin supports intestinal inflammation but does not establish diagnosis.
  • Refer suspected paediatric IBD urgently to specialist gastroenterology; diagnosis and classification use ileocolonoscopy and upper endoscopy with biopsies plus small-bowel imaging where appropriate.
  • Assess growth, puberty and nutrition at diagnosis and every review; paediatric disease cannot be monitored by stool symptoms alone.
  • For Crohn disease, NICE allows enteral nutrition as an alternative to systemic corticosteroid induction when growth or steroid effects are concerning; specialist paediatric practice often uses exclusive formula for 6 to 8 weeks.
  • For mild to moderate ulcerative colitis, aminosalicylate treatment is selected by extent; topical treatment is first line for proctitis and left-sided disease, with oral therapy added or used for extensive disease.
  • Acute severe ulcerative colitis requires admission, intravenous corticosteroids and gastroenterology-surgical collaboration; little improvement within 72 hours prompts rescue therapy or surgery decisions.
  • Immunomodulators and biologics require pre-treatment infection and vaccine review, exact laboratory monitoring and a named clinician to act on abnormalities.
  • Support school access, mental health, adherence, fertility discussion and planned transition to adult care.
  • Immunosuppressed children with fever, breathlessness, vesicular rash or exposure to serious infection need urgent treatment review.
  • Medication planning must include vaccination, tuberculosis and viral screening where relevant, fertility, malignancy and laboratory safety.
    • 05
    MR enterography or specialist intestinal ultrasound
    Why
    Assess small-bowel inflammation, stricture, fistula and abscess beyond mucosal endoscopic reach.
    Interpretation and limitations
    Cross-sectional findings guide medical versus surgical care and avoid repeated CT radiation where possible.
    Use extent-based aminosalicylate and corticosteroid therapy for ulcerative colitis.
  • 4Plan maintenance and monitoring before induction ends.
    • 03Severe colitisDecide rescue by day threeA child presents with acute severe ulcerative colitis.+
    1. 1Admit under paediatric gastroenterology with early surgical collaboration and exclude infection.
    2. 2Start protocol-led IV corticosteroid and supportive care and assess colectomy likelihood daily.
    3. 3At seventy-two hours, use trajectory to choose rescue therapy or surgery rather than extending ineffective steroids.