The past 25 years have witnessed remarkable advances in treating inflammatory bowel disease (IBD), from the introduction of monoclonal antibodies to the recent advances in small molecule therapy. Unfortunately, these life-altering therapies have been almost exclusively approved for adult patients and because of excessive delays in pediatric drug approval, children continue to be therapeutic orphans. Two anti-TNF biologics, infliximab, and adalimumab received pediatric approval for Crohn’s disease 8 (2006) and 6 years (2012), respectively, after adult approval. Subsequently, these 2 drugs received approval for ulcerative colitis 6 (2011) and 9 (2021) years, respectively, after adult approval. No other advanced therapies have been approved for children. It is now 10 years since the adult approval of vedolizumab and eight years since the approval of ustekinumab, and neither is close to being approved for pediatric use. Both agents are considered safe and effective in adults with ulcerative colitis. Yet, children with corticosteroid-dependent ulcerative colitis are invariably denied these medications by payers unless they have failed anti-TNF therapy. None of the recently approved or emerging biological and small molecule therapies currently used to treat adults are within a decade of approval in children. These ongoing delays significantly compromise the care of children with IBD as off-label use occurs without the benefit of adequate dosing and safety data. Pediatric gastroenterology experts configure extrapolation of efficacy and dosing based on knowledge and experience in the use of drugs. Still, it is far from optimal management or the expected standard for any adult patient, let alone a vulnerable child. Third-party payers refuse or delay the approval of effective medications. Children with poorly controlled IBD, often complicated by growth failure, have no approved therapeutic options beyond anti-TNF agents. Over the past two decades, the pediatric IBD community has repeatedly engaged with regulatory agencies as well as pharmaceutical and biotechnology companies to remedy this situation with minimal success.