Appendicitis in children: Symptoms from infancy to adolescence
From Johanna: Pediatric nurse, health and social manager and mother
Status of source verification: September 11, 2026
"Mommy, my tummy hurts." Many parents are familiar with this phrase. Perhaps your child needs to use the toilet, or perhaps a stomach bug is starting. But if the pain intensifies and your child suddenly lies still on the sofa, the question quickly arises: Could it be appendicitis?
Abdominal pain in children often has temporary causes. Appendicitis in children is one of the illnesses that needs to be recognized and treated quickly. It presents differently in a baby than in a school-aged child. In this blog post, you'll learn more about appendicitis in childhood.
What parts of the body become inflamed in appendicitis?
The appendix is the first, sac-like section of the large intestine and is usually located in the lower right abdomen.
Attached to it is a small, tube-shaped vermiform appendix .
When we talk about appendicitis, it is usually this vermiform appendix that is inflamed.
The medical term is appendicitis .
One possible cause is that its narrow interior is closing up, for example, through hardened stool or swollen immune tissue.
Then secretions and bacteria can accumulate and worsen the inflammation.
However, this does not explain every case, the origin is not fully understood.
In uncomplicated appendicitis, there are no signs of perforation or abscess.
If the wall becomes leaky, bacteria can enter the abdominal cavity. This can lead to a local accumulation of pus, known as an abscess, or to peritonitis.
Appendicitis in children: the different age groups
Infants and children under two years of age
Appendicitis is very rare at this age . However, when it does occur, the symptoms one typically associates with it are often absent. A baby cannot yet indicate exactly where the pain is located. Sometimes the first signs are vomiting, reduced feeding, a bloated stomach, or unusual restlessness. Other children become noticeably quiet, pale, or sleepy. Fever may be present, but it is not always.
The overall picture is crucial: Is your baby reacting as usual? Is it drinking enough? Can it be soothed? Is its tummy becoming increasingly distended?
An interesting difference lies within the abdominal cavity itself: there, a sheet of tissue, the greater omentum , hangs over the loops of the intestine . This can help to contain the source of inflammation. In young children, this omentum is less developed. This can contribute to the spread of inflammation more easily after a perforation. Together with the often difficult diagnosis, this explains why very young children have a higher risk of complicated courses of the disease.
Toddlers and preschool children – approximately two to five years old
"Tummy ache" might be the only description available at this age. Some children point to their belly button, others to their whole stomach. Vomiting, loss of appetite, fever, diarrhea, or constipation are also possible. This can initially seem like a common infection.
Therefore, pay particular attention to how your child moves and how the symptoms change. Does your child suddenly walk with a stoop? Does your child want to be carried even though they usually walk everywhere on their own? Do they resist being touched on their tummy or lie unusually still?
If your child experiences increasing pain, a noticeable protective posture, or appears increasingly unwell, they should be examined the same day; in cases of severe symptoms, immediately. A follow-up appointment is also necessary if the child's condition worsens rather than improves after the initial examination.
School children – approximately six to twelve years old
Appendicitis becomes more common in school-aged children, and the typical course of the disease is often more recognizable . Many children can describe in more detail what has changed.
It often begins with a dull ache around the navel , sometimes also in the upper abdomen. The child has a reduced appetite, feels nauseous, or vomits. The pain often starts before the vomiting, but this sequence is not a reliable rule. Over the next few hours, the pain becomes more persistent and often migrates to the lower right side.
Youth
In adolescents, the course of the illness is often similar to that in adults:
Initially unclear abdominal pain,
Later, more severe pain in the lower right corner,
often accompanied by loss of appetite, nausea or vomiting.
Fever may also occur.
At this age, other causes of lower abdominal pain must also be considered. These include testicular or ovarian torsion, ovarian cysts, and, if pregnancy is possible, an ectopic pregnancy. Testicular torsion may initially only manifest as lower abdominal pain. Therefore, a prompt examination is important in cases of sudden, severe pain.
It is beneficial for young people to be able to conduct part of the medical consultation confidentially. Questions about menstruation, sexuality, or a possible pregnancy help to identify important underlying causes.
Why does the pain start at the navel?
This is because, during the course of appendicitis, the tissue that sends pain signals and the nerve pathways through which these signals are transmitted change.
Initially, the pain originates in the appendix itself.
If the appendix becomes inflamed, its wall can swell and stretch.
This activates pain-conducting nerve fibers.
This pain originating from an internal organ is called visceral pain .
It is often perceived as dull or oppressive and is difficult to pinpoint to a specific location.
Why specifically around the navel? Pain signals from the appendix travel to sections of the spinal cord that also process information from the area around the navel. The brain cannot clearly distinguish the origin of these signals. That's why your child can feel the pain there, even though the inflammation is located on the lower right side. This imprecise localization is due to processing within the nervous system and also occurs in adults.
Later, the peritoneum on the abdominal wall can also become irritated.
The peritoneum is a thin layer of tissue that, among other things, lines the inside of the abdominal cavity.
If the inflammation of the appendix irritates this adjacent layer, further pain signals are added.
The peritoneum on the abdominal wall has a different nerve supply, which allows the brain to pinpoint the location of the pain much more accurately.
This often makes the pain more pronounced, persistent, and intense.
Your child may now be pointing to a specific spot in the bottom right corner.
To you, it may seem as if the pain has moved from your belly button to that area. In reality, additional tissue is now involved in the sensation of pain.
This also explains why movement can hurt.
Walking, coughing, or sudden movements cause the abdominal wall and its contents to shift. This can further irritate the inflamed peritoneum. This might explain why your child walks cautiously or with a stoop, pulls their legs up when lying down, or is reluctant to turn over.
This pattern is typical, but not present in every child. The appendix, for example, can be located behind the cecum or deeper in the pelvis. In such cases, other adjacent structures become irritated, and the symptoms can manifest on the side, in the back, or deep in the lower abdomen. If it is located close to the bladder, frequent urination or pain during urination is also possible.
Appendicitis can therefore also be present if the pain does not move or is not located exactly in the lower right.
Is fever a typical sign of appendicitis?
Fever can be a symptom, but it's not a reliable indicator. Especially at the beginning, the temperature can be normal. Conversely, many children with a milder infection have fever and abdominal pain. The symptoms, their progression, and the examination are crucial. Therefore, don't wait for a fever to develop if the pain is worsening or your child seems clearly ill.
What other diseases can look similar?
Especially in the beginning, many symptoms overlap. The following differences provide clues, but do not allow for a reliable diagnosis at home.
Possible cause | What speaks in its favor and what you should pay attention to |
Gastrointestinal infection | Vomiting and diarrhea are often the most prominent symptoms, while pain tends to come in waves. Increasing, persistent, or clearly localized pain should be investigated further. Diarrhea does not rule out appendicitis. Family members may have similar symptoms. |
Constipation | Hard, infrequent or painful bowel movements, sometimes improved after using the toilet. |
Swollen lymph nodes in the abdomen ( mesenteric lymphadenitis) | Often occurs after an infection. Pain can also be felt in the lower right corner. Examination and, if necessary, ultrasound help to differentiate between the two. |
Urinary tract infection | Burning during urination, frequent urge to urinate, or bedwetting. In young children, only fever, vomiting, or poor feeding may be noticeable. |
pneumonia | Additional symptoms may include coughing, fever, and rapid or labored breathing. Inflammation in the lower part of the lungs can cause abdominal pain. |
Intussusception (telescoping of the intestine) | More common in young children. Sudden , severe attacks of pain, paleness, vomiting, or unusual drowsiness; the child may appear more alert in between. This is an emergency. |
Intestinal obstruction or intestinal torsion | Severe pain, a bloated stomach and especially dark green vomit: seek immediate medical attention. |
Testicular torsion | Sudden, severe testicular or lower abdominal pain, often accompanied by nausea and vomiting. Swelling may or may not be present. Go to the emergency room immediately. |
Ovarian torsion | Sudden, severe, usually one-sided, extremely intense lower abdominal pain, often accompanied by severe nausea and vomiting. Possibly a slight fever or a hard, very tender abdomen. Go to the emergency room immediately. |
If symptoms persist for an extended period, other underlying medical conditions should be considered. Blood in the stool, weight loss, or stunted growth should be evaluated by a doctor.
When does your child need medical help?
On the same day: Have abdominal pain examined if it lasts for several hours, worsens, is concentrated in one area, or significantly restricts your child's walking, playing, or drinking. Repeated vomiting, unusual fatigue, and significantly reduced urine output also require medical attention.
Go to a pediatric emergency department or emergency room immediately if your child experiences severe pain, a hard or severely distended abdomen, dark green or bloody vomit, sudden attacks of intense pain accompanied by paleness or unusual drowsiness, or sudden testicular pain. Severe, sudden, one-sided lower abdominal pain with vomiting also requires immediate medical attention. In babies, the combination of a distended abdomen, vomiting, poor feeding, and a clearly unwell appearance is particularly serious.
Call 112 if your child is barely responsive, collapses, has severe breathing difficulties, or cannot be safely transported by themselves due to their condition.
For urgent but non-life-threatening complaints outside of consultation hours, the 116117 (patient service) can help to assess the situation and find the appropriate place of care.
How is appendicitis diagnosed?
The process begins with a conversation and a physical examination . When did the pain start? Is it getting worse? What came first: stomach ache or vomiting? How is your child moving? Depending on the symptoms, in addition to the abdomen, other areas such as the lungs, groin, or genitals will also be examined.
Blood tests, such as white blood cell count and C-reactive protein (CRP), can indicate inflammation. However, normal values do not definitively rule out early appendicitis.
Ultrasound is usually the first imaging technique used in children.
Ultrasound works without X-rays and can visualize not only the appendix but also other possible causes. It is therefore usually the first imaging procedure used in children.
An analysis of 22 studies involving approximately 20,900 young people under the age of 21 revealed a combined sensitivity of about 93 percent for conventional ultrasound. Under the conditions studied, approximately 93 out of every 100 people with the disease were detected.
When are MRI or CT scans helpful?
An MRI provides detailed images without X-rays. It can be helpful when ultrasound results are unclear. However, it is not always readily available everywhere and is usually more time-consuming and expensive than ultrasound. The child must lie still for a sufficient duration; sedation may be necessary for young children.
A CT scan is very fast and also accurate, but it uses X-rays. Therefore, it is not routinely used in children.
Sometimes appendicitis only becomes apparent over time.
How is appendicitis treated?
Surgery: The removal of the appendix is called an appendectomy. It is performed under general anesthesia, often through a few small incisions using a camera and fine instruments. This (laparoscopy) is the standard surgical procedure.
Are antibiotics sometimes sufficient? In selected children with uncomplicated appendicitis, treatment with antibiotics without immediate surgery can be discussed. This includes careful diagnosis, pediatric surgical monitoring, and the option of rapid surgery if the condition worsens.
A large international study examined 936 children between the ages of five and sixteen . Of the children initially treated with antibiotics for whom annual data were available, approximately one in three required surgery within a year . Surgery was avoided in about two out of three cases during this period. Whether problems would recur later remains unanswered.
A 2026 analysis of seven randomized controlled trials involving 1,480 children confirmed that antibiotic treatment was more frequently insufficient within one year. However, the children initially returned to school and daily life somewhat earlier on average.
Surgery is currently the more reliable treatment to permanently remove the diseased appendix.
In the case of a perforation with extensive peritonitis, antibiotics are given and surgery is usually performed quickly.
If, however, a localized abscess has formed and the child is stable, antibiotics and, if necessary, drainage may be advisable initially. This involves draining pus through a thin tube. Whether and when surgery is necessary will be decided separately.
And what happens next?
Many children recover quickly after an uncomplicated operation. Before discharge, your child should be able to drink and eat enough, move around, and tolerate the agreed pain management well.
Recovery usually takes longer after a perforation or abscess.
The treatment team will determine when school, sports and swimming will be possible again, depending on the course of the disease.
If a new fever develops, abdominal pain increases, vomiting recurs, or the wound becomes more red, swollen, or weeping, a further medical examination is necessary.
Conclusion
You don't need to find out at home whether it's really appendicitis. It's helpful if you can describe what has changed: "My child was playing a little while ago. Now they don't want to get up." Or: "The pain is getting worse, even though we've already been to the doctor."
Such observations help with the examination. If the pain worsens, your child hardly wants to move, or seems clearly ill, have them examined by a doctor. Don't wait for a fever or for the pain to be located precisely on the lower right side.
Sources and resources
116117: The patient service.
gesund.bund.de : Acute appendicitis . Patient information from the Federal Health Portal.
https://www.kinderaerzte-im-netz.de/krankheiten/blinddarmentzuendung/
Almaramhy HH. Acute appendicitis in young children less than 5 years: review article . Italian Journal of Pediatrics . 2017;43:15. DOI: 10.1186/s13052-017-0335-2. Older review focusing on the specific characteristics of young children; historical complication rates were not applied to general current risks.
Bonomo RA, Tamma PD, Abrahamian FM, et al. IDSA Clinical Practice Guideline Update: Diagnostic Imaging of Suspected Acute Appendicitis in Adults, Children, and Pregnant People . Clinical Infectious Diseases . 2024;79(Suppl 3)–S103. DOI: 10.1093/cid/ciae348.
Castro-Luna DI, Porras-Hernandez JD, Flores-Garcia JA, et al. Contemporary ultrasound, computed tomography, or magnetic resonance imaging for acute appendicitis diagnosis in children and adolescents: systematic review and meta-analysis . Pediatric Radiology . 2025;55:1448–1464. DOI: 10.1007/s00247-025-06261-y.
St Peter SD, Noel-MacDonnell JR, Hall NJ, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomised, non-inferiority trial . The Lancet . 2025;405(10474):233–240. DOI: 10.1016/S0140-6736(24)02420-6. 936 children were randomised; data on the primary endpoint were available for 846 after one year.
Faria I, Cintra ACG, de Oliveira LGAM, et al. Reevaluating Nonoperative Management for Pediatric Uncomplicated Acute Appendicitis: A Systematic Review and Meta-Analysis . JAMA Pediatrics . 2026;180(1):26–34. DOI: 10.1001/jamapediatrics.2025.4091. Seven randomized trials, 1,480 children.
The AWMF guideline “Urinary tract infections in childhood”
Association of Scientific Medical Societies (AWMF). S1 guideline “Abdominal pain in children and adolescents – Imaging diagnostics”, registration number 064-016 .
Regarding the current status of German guidelines: The S2k guideline "Appendicitis in Childhood and Adolescence," registration number 006-003, is still listed as a pending application in the AWMF guideline registry . Therefore, it is not considered a published treatment guideline here. Accessed: September 11, 2026.
Important note: This article is for informational and guidance purposes only. It cannot replace an individual examination, diagnosis, or treatment. If your child experiences severe, unusual, or persistent symptoms, a significant worsening of their condition, or if you have any concerns, they should be examined by a doctor.
