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Nonoperative management — Although appendectomy for early appendicitis remains the treatment of choice for many surgeons and caregivers, nonoperative treatment (NOM) of early appendicitis may be appropriate in selected children and according to patient and caregiver preference. Specifically, it may be safe and effective for older children who can better describe their symptoms (over six years of age) and have features of early appendicitis as follows [33]:

●Abdominal pain for <48 hours

●White blood cell (WBC) count ≤18,000/microL

●Normal C-reactive protein

●No appendicolith present on imaging

●Appendix diameter ≤1.1 cm on imaging

●No preoperative concern for rupture based upon clinical findings


NOM should only be performed by a surgeon with pediatric expertise. Only a minority of children presenting with appendicitis are potential candidates for NOM. For example, in one large, nonrandomized, multicenter trial, approximately 20 percent of children presenting with appendicitis met similar criteria .However, NOM may be especially appropriate in children who meet the above criteria and who have comorbidities that raise the risk of appendectomy.

Antibiotic protocols vary widely but typically include 1 to 2 days of inpatient broad spectrum IV therapy (eg, piperacillin-tazobactam, ceftriaxone and metronidazole, or ciprofloxacin and metronidazole) until resolution of symptoms and normalization of WBC count occur followed by oral antibiotics (eg, amoxicillin-clavulanic acid or ciprofloxacin and metronidazole) as an outpatient