CLINICAL GUIDELINES Guidelines for the Management of Growth Failure in Childhood Inflammatory Bowel Disease Robert Heuschkel, MBBS, MRCPCH, Camilla Salvestrini, MD, R. Mark Beattie, MBBS, MRCPCH, Hans Hildebrand, MD, PhD, Thomas Walters, MBBS, FRACP, and Anne Griffiths, MD Summary: Around 1 in 4 patients with inflammatory bowel dis- ease (IBD) present in childhood, the majority around the time of their pubertal growth spurt. This presents challenges over and above those of managing IBD in adults as this period is a time of dramatic psychological and physical transition for a child. Growth and nutri- tion are key priorities in the management of adolescents and young adults with IBD. Growth failure in IBD is characterized by delayed skeletal maturation and a delayed onset of puberty, and is best described in terms of height-for-age standard deviation score (Z score) or by variations in growth velocity over a period of 3– 4 months. Growth failure is common at presentation in Crohn’s dis- ease (CD), but less common in ulcerative colitis (UC). The etiology of growth failure is multifactorial. Principal determinants, however, include the inflammatory process per se, with proinflammatory cytokines (e.g., IL-1, IL-6) being directly implicated. Furthermore, poor nutrition and the consequences of prolonged corticosteroid use also contribute to the significant reduction in final adult height of almost 1 in 5 children. Initially a prompt, where possible steroid- free, induction of remission is indicated. The ideal is then to sustain a relapse-free remission until growth is complete, which is often not until early adulthood. These goals can often be achieved with a combination of exclusive enteral nutrition (EEN) and early use of immunosuppressants. The advent of potent and efficacious biolog- ical agents considerably improves the range of growth-sparing in- terventions available to children around puberty, although well- timed surgery remains another highly effective means of achieving remission and significant catch-up growth. We carried out a system- atic review of publications to identify the best available evidence for managing growth failure in children with IBD. Despite the paucity of high-quality publications, sufficient data were available in the literature to allow practical, evidence-based where possible, man- agement guidelines to be formulated. Although there is clear evi- dence that exclusive enteral nutrition achieves mucosal healing, its effect on growth has only been assessed at 6 months. In contrast to corticosteroids, EEN has no negative effect on growth. Corticoste- roids remain the key therapy responsible for medication-induced growth impairment, although the use of budesonide in selected patients may minimize the steroid effect on dividing growth plates. Immunosuppressants have become a mainstay of treatment in chil- dren with IBD, and are being used earlier in the disease course than ever before. However, there are currently no long-term data report- ing better growth outcome if these agents are introduced very soon after diagnosis. In comparison, recent data from a large prospective trial of infliximab in children with moderate to severe CD suggested significant catch-up growth during the first year of regular infusions. The only other intervention that has documented clear catch-up growth has been surgical resection. Resection of localized CD, in otherwise treatment-resistant children, early in the disease process achieves clear catch-up growth within the next 6 months. There are no data available that growth hormone improves final adult height in children with CD. In conjunction with expert endocrinological sup- port, pubertal delay, more common in boys, may be treated with parenteral testosterone if causing significant psychological prob- lems. The optimal management of children and adolescents requires a multidisciplinary approach frequently available within the pediat- ric healthcare setting. Dedicated dietetic support, along with nurse- specialist, child psychologist, and with closely linked medical and surgical care will likely achieve the best possible start for children facing a lifetime of chronic gut disease. (Inflamm Bowel Dis 2008;14:839 – 849) Key Words: pediatrics, growth retardation in IBD, Crohn’s disease, ulcerative colitis A bout 25% of patients with Crohn’s disease (CD) or ulcer- ative colitis (UC) present before the age of 18. 1 As a result, the diagnosis of their inflammatory bowel disease (IBD) falls at a critical time in the life of a young person. It is a period of immense emotional and physical change, and hence a period that provides real challenges for those managing these patients. Stud- ies have demonstrated that up to 46% of children will have a reduced height velocity before the onset of any symptoms, while only 12% had a normal height velocity at the time of diagnosis. 2 In contrast only 3%–10% of children with UC may present with reduced height velocities at diagnosis. 3 Growth and nutrition are key priorities in the management of any adolescent and young adult with a chronic disease, as only with effective disease control can growth potential and pubertal development be opti- mized. Received for publication November 30, 2007; Accepted December 3, 2007. From the Royal Free Hampstead NHS Trust, Centre for Paediatric Gas- troenterology, Hampstead, London, UK. Reprints: Dr. Robert Heuschkel, Royal Free Hampstead NHS Trust, Cen- tre for Paediatric Gastroenterology, Pond Street, Hampstead, London, NW3 2QG, UK (e-mail: Robert.Heuschkel@royalfree.nhs.uk). Copyright © 2008 Crohn’s & Colitis Foundation of America, Inc. DOI 10.1002/ibd.20378 Published online 11 February 2008 in Wiley InterScience (www.interscience. wiley.com). Inflamm Bowel Dis ● Volume 14, Number 6, June 2008 839