Diet plus biologics eased symptoms faster in children with Crohn’s disease, but inflammation lagged

Adding a structured exclusion diet to first-line biologic therapy helped children with Crohn’s disease feel better sooner, but it did not speed up the resolution of objective markers of inflammation, according to a retrospective cohort study from a single pediatric center in Argentina.

Researchers at Hospital Italiano de Buenos Aires followed 40 children and adolescents with Crohn’s disease who started anti-TNF-alpha biologic therapy between January 2020 and December 2024. Twenty-seven of the patients also received the Crohn’s disease exclusion diet combined with partial enteral nutrition, delivered using a Modulen-IBD formula and supported by a multidisciplinary team. The remaining 13 received biologics alone. The study included children diagnosed under the revised Porto criteria and excluded those with significant comorbidities, inconsistent follow-up, or a change in biologic target.

The research team, led by Jhoanna Valery Adauto and Katia Anabel Kulay, framed the analysis around the STRIDE-II treatment targets, which emphasize both clinical remission and measurable healing of the gut lining. They tracked how long it took patients to reach clinical response and clinical remission on the weighted Pediatric Crohn’s Disease Activity Index, to normalize their erythrocyte sedimentation rate, C-reactive protein, and fecal calprotectin, and to achieve mucosal healing on endoscopy.

Times to clinical response, clinical remission, and normalization of ESR and CRP were consistently shorter in the diet-plus-biologic group, although none of these differences reached statistical significance. The study was small, with 27 patients in the combined-therapy group and 13 in the biologic-only group, which limits the statistical power to detect differences in time-to-event outcomes.

Overall, fecal calprotectin normalization was achieved in 72.5 percent of patients and mucosal healing in 55.0 percent. Kaplan-Meier analysis showed no significant difference between the two groups in the cumulative incidence of either outcome, with a log-rank p-value of 0.82 for calprotectin normalization and 0.54 for mucosal healing. At four months, the cumulative incidence of calprotectin normalization was 23.7 percent in the diet group versus 30.8 percent in the biologic-only group, and at twelve months the cumulative incidence of mucosal healing was 16.0 percent versus 18.2 percent.

One measure did separate the groups clearly. When the researchers compared absolute changes from baseline, the reduction in the weighted Pediatric Crohn’s Disease Activity Index was significantly greater in the combined-therapy group, with a p-value of 0.029. Changes in fecal calprotectin, the Simple Endoscopic Score for Crohn’s Disease, ESR, CRP, albumin, and body mass index did not differ between the groups.

The investigators also tested whether the location of disease within the bowel modified the effect of the diet, using median regression models with a diet-by-location interaction term. No effect modification was detected for any outcome, with all interaction p-values above 0.10. However, the authors caution that this analysis was exploratory because of the small number of patients with isolated colonic disease.

The study’s design carries important limitations. It was retrospective and single-center, meaning patients were not randomly assigned to receive the diet, and unmeasured differences between the groups could have influenced the results. The modest sample size means that the consistently shorter times to clinical response and remission in the diet group may reflect real effects that the study lacked the power to confirm statistically.

The authors conclude that in this real-world pediatric cohort, the incremental value of adding the Crohn’s disease exclusion diet with partial enteral nutrition to first-line biologic therapy may lie in earlier symptomatic control rather than in faster resolution of objective inflammation. They note that exclusive enteral nutrition and the exclusion diet with partial enteral nutrition are known to induce remission in pediatric Crohn’s disease, but that evidence on their use as adjuncts to biologic therapy has remained limited.

For clinicians managing children with Crohn’s disease, the findings suggest that dietary therapy added to a biologic may help children feel better more quickly, even while laboratory and endoscopic measures of inflammation follow a similar course with or without the diet. The authors call for further research to clarify whether these symptomatic benefits translate into durable advantages over longer follow-up.

Subject of Research: Adjunctive dietary therapy combined with first-line biologic treatment in pediatric Crohn's disease

Article Title: Diet meets biologics: accelerating remission in pediatric Crohn’s disease – a real-world experience

Article References: Adauto Luizaga, J. V., Arcucci, M. S., Kulay, K. A., Vollweiler, F., Gallo, J., Pagotto, V., Busoni, V., & Orsi, M. (2026). Diet meets biologics: accelerating remission in pediatric Crohn’s disease – a real-world experience. Frontiers in Gastroenterology, 5, Article 1951489. https://doi.org/10.3389/fgstr.2026.1951489

Image Credits: AI Generated

DOI: 10.3389/fgstr.2026.1951489

Keywords: pediatric Crohn's disease, Crohn's disease exclusion diet, partial enteral nutrition, anti-TNF-alpha therapy, biologics, mucosal healing, fecal calprotectin, wPCDAI, STRIDE-II targets, retrospective cohort study, clinical remission, gastroenterology