Biologics in pediatric chronic rhinosinusitis with nasal polyps: A systematic review of efficacy and safety.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is uncommon in pediatric populations but may significantly impair quality of life. Adult data support biologics targeting type 2 inflammatory pathways, whereas pediatric evidence remains sparse and largely indirect. This systematic review aimed to summarize the available evidence on both efficacy and safety, rather than to estimate a precise treatment effect. A systematic review was conducted in accordance with the PRISMA 2020 guidelines. PubMed, Scopus, and Cochrane Library databases were searched from inception to March 2026 for studies investigating biologics in pediatric CRSwNP or pediatric type 2 airway disease with CRSwNP-related sinonasal outcomes. Studies focused on cystic fibrosis-associated nasal polyposis or allergic fungal rhinosinusitis (AFRS) were excluded from the primary synthesis and retained only for sensitivity/contextual analyses. Risk of bias was assessed using design-appropriate tools. Of 404 identified records, six studies were eligible for qualitative review. Four studies (three case series and one retrospective observational study) were retained in the primary synthesis after exclusion of cystic fibrosis-associated nasal polyposis and AFRS; two studies were considered in sensitivity analyses. The available evidence was predominantly low-level, heterogeneous, and based on small samples. Dupilumab, omalizumab, and mepolizumab showed signals of potential benefit in selected type 2 inflammatory phenotypes, but sinonasal outcomes were inconsistently reported. No major treatment-related safety issues were reported, although adverse-event reporting was inconsistent, and follow-up duration was limited and variable. For dupilumab, pediatric CRSwNP-specific safety data remain sparse, and known adverse events described in broader prescribing information, including injection-site reactions, eosinophilia, conjunctivitis, skin reactions, and arthralgia, require active monitoring. Biologics may represent a promising steroid-sparing option for selected pediatric patients with refractory type 2 inflammatory CRSwNP. However, current evidence is predominantly based on case series and indirect cohorts; therefore, conclusions should be considered cautious and hypothesis-generating. Prospective pediatric studies with standardized sinonasal outcomes and longer follow-up are required.