Considerable debate exists as to whether the risk of complications and need for surgery has truly decreased in Crohn's disease (CD) over time. A recent systematic review and meta-analysis reported that after the year 2000, the surgical rates at 1, 5 and 10 years have significantly decreased. It is unclear whether this decrease can be solely attributable to the introduction of biologics, the more effective use of thiopurine dosing with monitoring or perhaps earlier disease recognition and early use of effective interventions. Uncontrolled observational studies confirmed that scheduled maintenance treatment with anti-TNF as compared to episodic or discontinued use of anti-TNF resulted in fewer surgeries. Recent population-based studies have shown similar improved disease outcomes with early immunomodulator use. There is a dearth of pediatric-specific natural history studies for both short and long term. Multiple pediatric observational cohort studies have reported that up to one third of pediatric-onset CD patients progress to surgery within 5 years. This is a slightly higher proportion than that of adult patients followed in the same time frame. This discrepancy may be explained by less early biologic use in pediatric patients. More data are needed to follow all CD patients for longer follow-up periods with an emphasis on pediatric onset to better gauge whether our proposed treatment strategies are actually altering the natural history of disease and what role biologics play in this regard.