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Context: Pediatric Crohn's Disease (CD) is associated with deficits in trabecular bone mineral density (BMD) and cortical structure, potentially related to TNF-α effects to decrease bone formation and promote bone resorption. Objective: This study aimed to examine changes in bone density and structure in children and adolescents with CD following initiation of anti-TNF-α therapy. Design and Participants: Participants (n = 74; age 5–21 years) with CD completed a 12-month prospective cohort study. Main Outcome Measures: Tibia peripheral quantitative computed tomography scans were obtained at initiation of anti-TNF-α therapy and 12 months later. Musculoskeletal outcomes were expressed as sex-and race-specific z scores relative to age, based on &amp;gt;650 reference participants. Results: At baseline, CD participants had lower height, trabecular BMD, cortical area (due to smaller periosteal and larger endocortical circumferences), and muscle area z scores, compared with reference participants (all P &amp;lt; .01). Pediatric CD activity index decreased during the 10-week induction (P &amp;lt; .001), in association with subsequent gains in height, trabecular BMD, cortical area (due to recovery of endocortical bone), and muscle area z scores over 12 months (height P &amp;lt; .05; others P &amp;lt; .001). Bone-specific alkaline phosphatase levels, a biomarker of bone formation, increased a median of 75% (P &amp;lt; .001) during induction with associated 12-month improvements in trabecular BMD and cortical area z scores (both P &amp;lt; .001). Younger age was associated with greater increases in trabecular BMD z scores (P &amp;lt; .001) and greater linear growth with greater recovery of cortical area (P &amp;lt; .001). Conclusions: Anti-TNF-α therapy was associated with improvements in trabecular BMD and cortical structure. Improvements were greater in younger and growing participants, suggesting a window of opportunity for treatment of bone deficits.

Improvements in Bone Density and Structure during Anti-TNF-α Therapy in Pediatric Crohn's Disease