BACKGROUND: The contemporary management of ambulatory ulcerative colitis (UC) continues to be challenging with ∼20% of children needing a colectomy within childhood years. We thus aimed to standardize daily treatment of pediatric UC and inflammatory bowel diseases (IBD)-unclassified through detailed recommendations and practice points. METHODS: These guidelines are a joint effort of the European Crohn's and Colitis Organization (ECCO) and the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). An extensive literature search with subsequent evidence appraisal using robust methodology was performed before 2 face-to-face meetings. All 40 included recommendations and 86 practice points were endorsed by 43 experts in Paediatric IBD with at least an 88% consensus rate. RESULTS: These guidelines discuss how to optimize the use of mesalamine (including topical), systemic and locally active steroids, thiopurines and, for more severe disease, biologics. The use of other emerging therapies and the role of surgery are also covered. Algorithms are provided to aid therapeutic decision-making based on clinical assessment and the Paediatric UC Activity Index (PUCAI). Advice on contemporary therapeutic targets incorporating the use of calprotectin and the role of therapeutic drug monitoring are presented, as well as other management considerations around pouchitis, extraintestinal manifestations, nutrition, growth, psychology, and transition. A brief section on disease classification using the PIBD-classes criteria and IBD-unclassified is also part of these guidelines. CONCLUSIONS: These guidelines provide a guide to clinicians managing children with UC and IBD-unclassified management to provide modern management strategies while maintaining vigilance around appropriate outcomes and safety issues.

1st Department of Pediatrics Semmelweis University Budapest Hungary

Barts and the London School of Medicine Queen Mary University of London London UK

BC Children's Hospital University of British Columbia Vancouver BC Canada

Child Life and Health University of Edinburgh Edinburgh UK

Department of Paediatrics University Hospital Motol Prague Czech Republic

Department of Woman Child and General and Specialistic Surgery University of Campania Luigi Vanvitelli Napoli Italy

Erasmus MC Sophia Children's Hospital Rotterdam The Netherlands

Helsinki University Children's Hospital Department of Pediatric Surgery Helsinki Finland

Hospital Sant Joan de Déu Barcelona Spain

National Children's Research Centre Royal College of Surgeons of Ireland and University College Dublin Dublin Ireland

Pediatric Department University of Messina Messina Italy

Pediatric Gastroenterology and Liver Unit Sapienza University of Rome Rome Italy

Pediatric Gastroenterology and Nutrition Unit Hospital Materno IBIMA Málaga Spain

Schneider Children's Hospital Petach Tikva Affiliated to the Sackler Faculty of Medicine Tel Aviv University Tel Aviv Israel

School of Medical Sciences Ioannina University of Ioannina Ioannina Greece

Shaare Zedek Medical Center The Hebrew University of Jerusalem Jerusalem Israel

Southampton Children's Hospital Southampton UK

The Hospital for Sick Children University of Toronto Toronto Canada

The Royal Hospital for Children Glasgow UK

Université Paris Descartes Sorbonne Paris Cité APHP Hôpital Necker Enfants Malades Paris France

University Children's Hospital Zurich Switzerland

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