Inflammatory bowel disease in infants: the other "end of the beginning"?

In the last several years, inflammatory bowel disease (IBD) has been extensively characterized, resulting in efficient (but not harmless) therapies such as with anticytokine biologicals. In spite of this remarkable progress, the pathogenesis is still confusing, but on a higher level, and a therapy to control or, better, to cure this chronic inflammation is still a long way off. The complexity of IBD is especially challenging in children—is the pathogenesis, genetics (CARD15, tumor necrosis factor-a 308 A) (1,2), immunology, diagnosis and therapy of IBD not heterogeneous enough? Even in its clinical presentation, IBD heterogeneity is broader than previously known. Although children with IBD have been studied more systematically, with the establishment of registries, it has become obvious that younger children seem to present with special features (3,4). In this issue of the Journal of Pediatric Gastroenterology and Nutrition, Ruemmele et al. (5) analyse the data of 10 infants with onset of IBD in the first year of life, adding a small but important stone to the mosaic of IBD. Compared with older IBD patients, there was a predominance of colonic involvement (with rectal bleeding) in all patients. Furthermore, but not surprisingly, this patient group required (1) more aggressive therapeutic efforts to achieve remission, (2) parenteral nutrition, (3) the application of steroids, azathioprine and cyclosporine medication, (4) more surgical interventions, and (5) had more relapses. The authors carefully looked for pathogenetic factors such as bacterial infections, use of antibiotics before disease onset and breastfeeding among others, but the study group was too small to find any significant data about them. The average duration of breastfeeding was 2 months in the patients in the Ruemmele et al. study. These factors need to be readdressed in larger cohorts. Because of the progression of the clinical manifestations