Recurrent pericarditis in children: evidence, controversies, and emerging perspectives

Recurrent pericarditis complicates approximately one-third of initial pericarditis episodes in children. Once considered a postinfectious sequel, it is now understood as an autoinflammatory disorder sustained by dysregulated interleukin-1 signaling and inflammasome hyperactivation. This review evaluates therapeutic strategies for idiopathic recurrent pericarditis in patients younger than 18 years using the PICO framework. First-line management with nonsteroidal anti-inflammatory drugs and colchicine remains the therapeutic backbone, with colchicine conferring a roughly 50% reduction in relapse risk. Glucocorticoids, although acutely effective, predispose to steroid-dependence and rebound flares, and should be reserved for refractory disease at low doses. IL-1 receptor antagonism, principally anakinra, has emerged as a transformative steroid-sparing option for colchicine-resistant or steroid-dependent cases, achieving rapid symptom control and durable remission in most treated children. Nonetheless, pediatric evidence remains limited to retrospective cohorts and small case series, highlighting the need for prospective controlled trials, standardized outcome definitions, and long-term safety surveillance of biologic agents.