Management of early appendicitis in children

This algorithm applies to children with a diagnosis of acute appendicitis. Appendectomy remains the treatment of choice for most children with acute, uncomplicated appendicitis. When performed by a pediatric surgeon or surgeon with pediatric expertise, NOM may be an option for selected children who can verbally describe their symptoms, can be reliably examined, meet strict criteria, and after shared decision-making between the managing surgeon and the parent/primary caregiver.

WBC: white blood cell count; US: ultrasound; IV: intravenous.

* Nonoperative management should only be performed by a surgeon with pediatric expertise.

¶ Antibiotic choices are not standardized. Refer to Inset 2 for sample choices. Refer to UpToDate content on the management of appendicitis in children for other appropriate antibiotic regimens.

Δ Lower rates of initial failure or recurrence are associated with using strict criteria for nonoperative management.

◊ These are sample choices for low- to moderate-risk community-acquired infections. For the full complement of suitable regimens, refer to the appropriate UpToDate content on management of appendicitis in children. Doses shown are for patients with normal kidney function; some agents require adjustment for kidney impairment; refer to Lexicomp pediatric drug monograph(s).

§ Amoxicillin-clavulanate is a reasonable option if the community rate of Escherichia coli resistance to the agent is <10%.

Adapted from:

Minneci PC, Hade EM, Lawrence AE, et al. Association of nonoperative management using antibiotic therapy vs laparoscopic appendectomy with treatment success and disability days in children with uncomplicated appendicitis. JAMA 2020; 324:581.
Salminen P, Tuominen R, Paajanen H, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA 2018; 320:1259.
Steiner Z, Buklan G, Stackievicz R, et al. Conservative treatment in uncomplicated acute appendicitis: Reassessment of practice safety. Eur J Pediatr 2017; 176:521.

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Management of early appendicitis in children