OBJECTIVES: Despite advances in the management of ambulatory paediatric ulcerative colitis (UC), challenges remain as many patients are refractory to therapy and some require colectomy. The aim of these guidelines is to provide an update on optimal care for UC through detailed recommendations and practice points. METHODS: These guidelines are an update to those published in 2018 and are a joint effort of the Paediatric IBD Porto group of European Society of Paediatric Gastroenterology, Hepatology and Nutrition and the European Crohn's and Colitis Organisation. An extensive literature search with subsequent evidence appraisal using the Oxford methodology was performed, followed by three online voting sessions and a consensus face-to-face meeting. Thirty-nine recommendations and 77 practice points were endorsed by the 25 experts with at least an 84% consensus rate. RESULTS: Robust evidence-based recommendations and detailed practice points are provided. In addition to reemphasising and updating the role of more 'traditional' UC therapies, these guidelines outline optimising the use of antitumour necrosis factor therapies and integrating newer biologics and small molecules, as well as supportive therapy, to improve outcomes and provide an updated management algorithm. Measurement and monitoring tools and decision aids are provided, and additional aspects, including nutritional support, extraintestinal manifestations, pouchitis, inflammatory bowel disease-unclassified and patient support, are discussed. Some aspects, including surgery and thromboprophylaxis, are covered in the acute severe UC guidelines. CONCLUSIONS: These guidelines serve as an aid in managing children with UC through a combination of evidence-based recommendations and more practical practice points in the ambulatory setting.

Child Life and Health Centre for Inflammation Research University of Edinburgh Scotland UK

Colorectal Surgery Vall d'Hebron University Hospital Universitat Autònoma de Barcelona UAB Barcelona Spain

Department of Advanced Medical and Surgical Sciences Universitá degli Studi della Campania Luigi Vanvitelli Naples Italy

Department of Medicine Solna Division of Clinical Epidemiology Karolinska Institutet Stockholm Sweden

Department of Paediatric Gastroenterology Erasmus MC Sophia Children's Hospital Rotterdam The Netherlands

Department of Paediatric Gastroenterology Hepatology and Nutrition University Medical Center Groningen University of Groningen Groningen the Netherlands

Department of Paediatric Gastroenterology Jenny Lind Children's Hospital Norfolk and Norwich University Hospitals Faculty of Medicine and Health Science University of East Anglia Norwich UK

Department of Paediatric Gastroenterology Royal Hospital for Children and Young People Edinburgh Scotland UK

Department of Paediatrics University Hospital Motol Prague Czech Republic

Department of Paediatrics Vittore Buzzi Children's Hospital University of Milan Milan Italy

Department of Pediatric Gastroenterology Hepatology and Nutrition Hospital Sant Joan de Déu Barcelona Spain

Department of Pediatrics Children's Hospital Zagreb University of Zagreb Medical School Referral Center for Pediatric Gastroenterology and Nutrition Zagreb Croatia

Department of Pediatrics Division of Pediatric Gastroenterology University of Alberta Edmonton Alberta Canada

Division of Gastroenterology Hepatology and Nutrition The Hospital for Sick Children Toronto Ontario Canada

Division of Paediatric Gastroenterology and Nutrition Emma Children's Hospital Amsterdam UMC Amsterdam The Netherlands

DOCHAS Group Children's Health Ireland University College Dublin Dublin Ireland

Faculty of Medical and Health Sciences Tel Aviv University Tel Aviv Israel

Faculty of Medicine Tel Aviv University Tel Aviv Israel

Pediatric Gastroenterology and Nutrition Unit Centro Hospitalar Universitário São João Porto Portugal

Pediatric Gastroenterology Ghent University hospital Ghent Belgium

Pediatric Gastroenterology Hepatology and Cystic Fibrosis Unit Department of Pathophysiology and Transplantation University of Milan Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico di Milano Milan Italy

Pediatric Gastroenterology Institute Dana Dwek Children's Hospital Tel Aviv Sourasky Medical Center Tel Aviv Israel

Schneider Children's Medical Center of Israel Institute of Gastroenterology Nutrition and Liver Diseases Petah Tikva Israel

Section of Paediatrics Department of Translational Medical Science University of Naples Federico 2 Naples Italy

Shaare Zedek Medical Centre The Juliet Keidan Institute of Paediatric Gastroenterology and Nutrition Eisenberg R and D Authority The Hebrew University Jerusalem Israel

Translational Gastroenterology Unit John Radcliffe Hospital Oxford University Hospitals NHS Trust Oxford UK

University of Toronto Toronto Ontario Canada

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