Risks of Undertreatment and Overtreatment in Pediatric Inflammatory Bowel Disease: Navigating the Balance

Despite major therapeutic advances in recent years, and early signs that the overall standard of care we can deliver to children with inflammatory bowel disease (IBD) is improving, the promise of precision medicine remains largely unfulfilled in daily practice. The goal is to match the right therapy to the right patient, in the right time window, so that treatment intensity reflects true disease biology and future risk rather than broad population averages. However, this approach is still an unmet need. Even when management is framed within a risk-based paradigm, clinical decisions are often guided by generalized recommendations and imperfect predictors, with limited capacity to individualize strategies at diagnosis and during follow-up. As a result, two opposite but equally relevant pitfalls remain very real. On one hand, overtreatment can lead to unnecessary exposure to immunosuppressive regimens in children and adolescents with mild, slowly progressive, or self-limited disease, increasing the burden of adverse events, monitoring, and psychosocial impact. On the other hand, undertreatment in truly high-risk patients can delay effective control of inflammation, allowing ongoing tissue damage, disease extension, growth impairment, and avoidable complications, ultimately worsening long-term outcomes. This critical review summarizes and critically appraises current recommendations and available evidence, focusing on the pitfalls of overtreatment and undertreatment in pediatric IBD.