Childhood Cystic Fibrosis in the Era of Highly Effective Modulator Therapy: A Critical Narrative Review of Diagnosis, Multisystem Disease and Evolving Management
Cystic fibrosis (CF) is the most common life-limiting autosomal recessive disorder among populations of European ancestry, and the childhood years determine much of its long-term trajectory. The therapeutic landscape has been reshaped by cystic fibrosis transmembrane conductance regulator (CFTR) modulators, yet the paediatric evidence base has matured unevenly across the domains that matter most to affected children. This critical narrative review evaluates the strength, consistency and limitations of the literature on CF in childhood, spanning pathophysiology, newborn screening and diagnosis, early airway infection and structural lung disease, nutrition and gastrointestinal involvement, CF-related diabetes, CFTR modulator therapy, and mental health. Peer-reviewed studies, professional consensus guidelines and authoritative institutional sources were appraised for methodological quality and translated into a thematic synthesis rather than a study-by-study catalogue. The evidence most strongly supports early diagnosis through newborn screening, the predictive value of early neutrophilic inflammation and infection for structural lung disease, and the short-to-medium-term efficacy and tolerability of triple CFTR modulator therapy in children as young as two years. Confidence is weaker for long-term safety, for outcomes in children ineligible for or unable to access modulators, and for the neuropsychiatric effects attributed to these drugs, where observational signals and case reports remain difficult to disentangle from the psychological burden of chronic illness. Persistent gaps include the management of inconclusive screening results, the durability of modulator benefit initiated in early life, the evolving natural history of CF-related diabetes and pancreatic disease under modulator therapy, and equity of access across health systems. The review concludes that childhood CF is being transformed rather than solved, and that surveillance, nutritional and psychosocial frameworks developed in the pre-modulator era require deliberate re-evaluation rather than uncritical continuation.