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Appendicitis in children, the signs, the scan and the surgery, in plain English.

The most common surgical emergency in children aged 5 to 15. Younger children present atypically and are much more likely to reach hospital after the appendix has burst, so early recognition really matters.

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A radiographer guides a patient onto the bed of an advanced 3 Tesla MRI scanner in a London imaging suite

Why trust this guide

  • 01

    Editorial team

    Written by our editorial team from the UK sources listed on each page.

  • 02

    Sourced from guidance

    Checked against NICE, RCS, BAPS and peer-reviewed paediatric surgical sources listed at the end.

  • 03

    Current for 2026

    Reflects modern UK practice including ultrasound-first imaging, PAS scoring and the growing evidence for antibiotics-only pathways.

Key facts

Paediatric appendicitis at a glance.

The essentials for parents and carers, what it is, how it presents differently across age groups and how UK paediatric surgical teams approach it today.

  • What it is

    Inflammation of the vermiform appendix, the most common surgical emergency in children aged 5 to 15 years.

  • Age distribution

    Peak between 5 and 15 years. Rare under 5 but far more serious when it does occur.

  • Perforation risk

    Around 80 percent of children under 5 present with perforation, versus 20 to 30 percent in older children.

  • Younger children

    Atypical picture with irritability, poor feeding, vomiting, fever, lethargy and sometimes diarrhoea.

  • Older children

    More classic pattern with central abdominal pain migrating to the right iliac fossa, then nausea and low-grade fever.

  • First-line imaging

    Ultrasound is preferred in children because it avoids ionising radiation. MRI or CT are used selectively.

Why this guide matters

Recognise it early, treat it decisively.

Paediatric appendicitis rewards early recognition. The three points below shape everything else on this page and are what UK paediatric surgeons consistently focus on.

  • Age changes the picture

    Older children show classic migratory right iliac fossa pain. Younger children look non-specifically unwell, so keep a low threshold for review.

  • Ultrasound first, then MRI

    UK paediatric practice favours ultrasound as first-line imaging to avoid radiation, with MRI reserved for equivocal cases.

  • Surgery works, and antibiotics may too

    Laparoscopic appendicectomy remains the standard, but antibiotics-only care is a reasonable option in selected uncomplicated cases with informed parental choice.

How the diagnosis is made

From first tummy ache to a confirmed plan.

A typical NHS or private paediatric pathway, from clinical assessment through scoring and imaging to surgical review.

  1. 01

    Assessing

    Focused history and serial examination

    A careful history and repeated abdominal examination over a few hours, essential when the picture is equivocal.

  2. 02

    Assessing

    Paediatric Appendicitis Score

    PAS and Alvarado scores help stratify risk and guide whether imaging or admission is needed.

  3. 03

    Assessing

    Baseline bloods

    FBC for white cell count and neutrophils, CRP, U and E, plus a beta-hCG in post-menarchal girls.

  4. 04

    Confirming

    Urinalysis

    A dipstick and microscopy to exclude a urinary tract infection or pyelonephritis masquerading as abdominal pain.

  5. 05

    Confirming

    Ultrasound first

    Target sign, non-compressible tubular structure over 6 mm and pericaecal fluid. No radiation, safe to repeat.

  6. 06

    Confirming

    MRI or CT if needed

    MRI when ultrasound is inconclusive. CT is reserved for complex adolescents or suspected complications.

  7. 07

    Deciding

    Surgical review and laparoscopy

    Paediatric surgical assessment. Diagnostic laparoscopy is both confirmatory and therapeutic in a single anaesthetic.

Typical timeline: first assessment to a confirmed surgical plan within hours, not days.

Differential diagnosis

What else it might be.

Many childhood conditions cause abdominal pain. These are the diagnoses paediatric surgical teams routinely consider and exclude.

  • Mesenteric adenitis

    A viral illness with enlarged mesenteric lymph nodes that closely mimics appendicitis, often self-limiting.

  • Gastroenteritis

    Diarrhoea and vomiting usually precede the pain, and tenderness is generalised rather than focal.

  • Intussusception

    Classically in children under 2, with intermittent colicky pain, drawing up of the knees and redcurrant-jelly stool.

  • Meckel diverticulum

    Can inflame or bleed and can mimic appendicitis. Usually found intra-operatively.

  • Urinary tract infection

    Dysuria, frequency and fever with a positive urinalysis, though pelvic appendicitis can also inflame the bladder.

  • Torsion of testis or ovary

    Always examine the groin and testes. Ovarian torsion in adolescent girls can present with lower abdominal pain.

  • Pyelonephritis

    Loin pain, high fever and systemic upset, confirmed by urinalysis and culture.

  • Pelvic inflammatory disease

    A consideration in sexually active adolescents, with adnexal tenderness and cervical excitation.

  • Ovarian cyst rupture or functional pain

    Cyclical, positional or non-progressive pain without systemic upset in older girls.

Symptoms

What appendicitis looks like in children.

A different picture at different ages. The features to look for, and the ones that mean it is time to be seen urgently.

  • Right iliac fossa pain

    Classic migration from the umbilicus to the right iliac fossa in older children, worsened by movement and coughing.

  • Fever and tachycardia

    Low-grade fever early, higher temperatures with perforation or abscess. Persistent tachycardia is a warning sign.

  • Nausea, vomiting and anorexia

    Loss of appetite is almost universal. Vomiting usually follows the pain, not the other way round.

  • Guarding and rebound

    Localised tenderness with voluntary or involuntary guarding suggests peritoneal irritation.

  • Atypical younger children

    Under 5s often show only irritability, poor feeding, lethargy or diarrhoea. A low threshold for review is vital.

  • Diarrhoea and urinary symptoms

    Pelvic appendicitis can mimic gastroenteritis or a urinary infection, delaying the diagnosis.

  • Post-menarchal presentations

    Adolescent girls need pelvic causes considered, including ovarian pathology and pelvic inflammatory disease.

  • Red flag features

    Generalised peritonism, sepsis, a palpable mass or a rapidly deteriorating child needs immediate surgical involvement.

Treatment

How paediatric appendicitis is treated in the UK.

Emergency laparoscopic appendicectomy is safe and effective across all ages, alongside IV fluids, antibiotics and analgesia. Antibiotics-only care is a genuine option in selected uncomplicated cases.

  • Emergency laparoscopic appendicectomy

    The standard of care across the paediatric age range. Small port incisions, quick recovery and low wound-infection rates.

  • Open appendicectomy

    Reserved for select cases where laparoscopy is not feasible or when the anatomy or contamination make it safer.

  • IV fluids and resuscitation

    Weight-based crystalloid resuscitation, correction of electrolytes and careful monitoring of urine output.

  • Broad-spectrum IV antibiotics

    Co-amoxiclav or piperacillin-tazobactam, tailored to local microbiology and the severity of contamination.

  • IV analgesia and antiemetics

    Paracetamol and morphine for pain, ondansetron for nausea. Nil by mouth until a surgical plan is set.

  • Antibiotics-only pathway

    A growing option for uncomplicated cases in selected children, guided by CODA-Peds, Minneola and APAC-2 evidence and informed parental choice.

  • Percutaneous drainage plus antibiotics

    For an established appendix mass or abscess, drainage and antibiotics may be preferred over emergency surgery.

  • Interval appendicectomy

    When a complicated appendicitis has been managed non-operatively, a planned appendicectomy at 6 to 12 weeks is often offered.

What this guide is based on

The sources behind every claim on this page.

UK national guidance, specialist society standards and modern paediatric surgical trials, current at the time of last review.

Key references

Guidelines, trials and standards we relied on.

A quiet reminder

This guide is for information, not medical advice.

If your child has worsening abdominal pain, fever, persistent vomiting or looks unwell, seek urgent medical review through NHS 111, your GP or your local emergency department.

  • NICE. Suspected acute appendicitis in children and young people, quality standards and interim guidance.

  • Royal College of Surgeons of England. Commissioning guide for emergency general surgery.

  • British Association of Paediatric Surgeons (BAPS). Paediatric appendicitis position statements.

  • CODA-Peds, Minneola and APAC-2 trials on non-operative management of paediatric appendicitis.

  • World Society of Emergency Surgery (WSES) Jerusalem guidelines for acute appendicitis.

Red flags

When to seek urgent care.

Most tummy pain in children is not appendicitis. These features mean your child needs immediate assessment in an emergency setting.

  • Perforation and generalised peritonism

    A rigid, silent abdomen with systemic upset needs immediate resuscitation, antibiotics and theatre.

  • Sepsis

    Tachycardia, prolonged capillary refill, cold peripheries or altered consciousness demand paediatric sepsis pathways without delay.

  • Rapid deterioration in a young child

    Any child under 5 with worsening abdominal signs should be assumed to have complicated appendicitis until proven otherwise.

  • Palpable right iliac fossa mass

    Suggests an appendix mass or abscess. Imaging and paediatric surgical input are essential before any manipulation.

  • Bilious vomiting

    Raises the possibility of an obstructive complication or an alternative surgical diagnosis such as intussusception or malrotation.

  • Recurrent atypical abdominal pain

    Persistent or relapsing symptoms need re-examination rather than reassurance, especially in the pre-verbal child.

  • Immunocompromised children

    Chemotherapy, immunosuppression or steroids can mask classic signs. A lower threshold for imaging is appropriate.

  • Post-operative deterioration

    Return of fever, worsening pain or ileus after appendicectomy suggests a collection needing repeat imaging.

  • Safeguarding concerns

    Delayed presentation without a clear explanation deserves a routine safeguarding assessment alongside the surgical review.

After treatment

Recovery, step by step.

Children usually bounce back quickly after uncomplicated appendicitis. Perforation or abscess formation lengthens the stay but the outlook remains excellent.

A quiet reminder

Post-operative pain that worsens is not normal.

A collection or wound infection can develop days after surgery. Return to hospital if your child develops new fever, worsening pain or persistent vomiting.

  1. 01 Recovery

    Quick return in most children

    Uncomplicated cases are usually home within 24 to 48 hours. Complicated cases typically need 3 to 5 days on the ward.

  2. 02 School

    Back to school in one to two weeks

    Most children return within a week or two, avoiding contact sports and heavy lifting for four to six weeks.

  3. 03 Activity

    Gradual, guided rebuild

    Walking straight away, gentle activity within days, sport reintroduced on surgical advice. Listen to fatigue.

  4. 04 Follow-up

    Safety-netting for recurrent pain

    Parents should have a clear plan for who to contact if abdominal pain returns, along with red-flag prompts.

Frequently asked

Parent questions we hear most.

Straight answers on presentation, imaging, surgery and modern non-operative pathways.

  • How common is appendicitis in children?

    It is the most common surgical emergency in children aged 5 to 15 years. It is rarer under 5, but the complication rate is substantially higher in that group because the diagnosis is often delayed.

  • Why is appendicitis harder to spot in younger children?

    Under-5s often cannot describe pain clearly and show non-specific features such as irritability, poor feeding, vomiting, fever, lethargy or diarrhoea. This is why up to 80 percent of children under 5 present after the appendix has already perforated.

  • What scan will my child have?

    Ultrasound is the first-line imaging test in children because it avoids ionising radiation. If the scan is inconclusive an MRI may be arranged, and CT is reserved for complex or older adolescent cases.

  • Is surgery always necessary?

    Laparoscopic appendicectomy remains the standard of care. However, there is growing evidence that antibiotics alone can treat uncomplicated appendicitis in selected children. Recent trials such as CODA-Peds, Minneola and APAC-2 support informed parental choice as part of the discussion.

  • What happens if the appendix has burst?

    A perforated appendix or an appendix abscess is managed with IV antibiotics and, sometimes, percutaneous drainage of the collection. A planned appendicectomy may then be offered 6 to 12 weeks later, known as an interval appendicectomy.

  • How long is recovery after surgery?

    Most children with uncomplicated laparoscopic appendicectomy go home within 24 to 48 hours and return to school in one to two weeks. Complicated appendicitis typically means a 3 to 5 day stay and a longer restricted-activity period, guided by the surgical team.

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