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peds.appendicitis.v1

Acute appendicitis — pediatric (PAS-stratified; NOM-aware)

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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

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Frame

Detailed

Frame the suspected pediatric appendicitis presentation: age band (< 5 y atypical / 5-10 y / 10-19 y peak / adolescent female with mandatory OB/gyn ddx / adolescent male) drives pretest probability + atypical-presentation index + perforation rate at presentation (~ 80% in < 5 yo; ~ 30% overall; ~ 15-20% in adolescents). Sex + pregnancy status drives mandatory pelvic US + βhCG workup in post-menarchal female. Duration of symptoms drives perforation risk + NOM eligibility (typically < 48 h).

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Age + sex + duration tagged; pretest probability + atypical-presentation framing set; OB/gyn ddx triggered if applicable

Patient inputs (29)

Age band drives pretest probability + atypical-presentation index + perforation rate at presentation (~ 80% in < 5 yo; ~ 30% overall; ~ 15-20% in adolescents); also drives PAS interpretability (validated in 4-18 y cohort)

Adolescent female requires mandatory OB/gyn differential workup (pregnancy test + pelvic US); ovarian torsion, PID, ectopic pregnancy, hemorrhagic cyst are key differentials

Weight-based dosing for all fluids + analgesia + antibiotics + sedation drugs

Fever ≥ 38 °C is a PAS component (1 pt); high-grade fever > 39 °C raises perforation concern (LR+ ~ 2-3 for perforation specifically)

Tachycardia + dehydration in prolonged duration; supports peritonitis / perforation / sepsis concern

Capillary refill > 3 s + mottling = dehydration / shock — pre-op resuscitation needed; sepsis concern

Classic migration pattern (PAS 1 pt) — less reliable in < 5 yo (often diffuse from onset); LR+ ~ 3-4 in peds (less reliable than in adult)

PAS component (1 pt); present in ~ 80% of cases but non-specific; toddlers may simply refuse food

PAS component (1 pt); typically follows pain onset (vs precedes in gastroenteritis); bilious emesis raises obstruction / advanced perforation concern

PAS component (2 pts; major weight) — McBurney point ~ 1/3 ASIS-to-umbilicus; blunted in retrocecal / pelvic appendix positions

PAS component (2 pts; major weight) — surrogate for peritoneal irritation in younger child; pediatric-friendly maneuver

Recurrent NOM appendicitis ~ 30% rate within 1 year (Minneci 2020); raises low-threshold surgical management on re-presentation

Adolescent female with RLQ pain mandates pregnancy test (βhCG) + pelvic US + STI workup if sexually active; informs ovarian torsion / PID / ectopic ddx

Pregnancy with appendicitis: appendectomy safe; MRI preferred over CT; multidisciplinary peds surgery + OB + MFM; preterm labor risk 2nd-3rd trimester

WBC > 10K + neutrophilia % PMN > 75% are PAS components (1 pt each); leukocytosis LR+ ~ 2-3

CRP elevation supports diagnosis; pAIR score incorporates CRP (Kollar 2019); rising CRP despite antibiotics raises perforation / complication concern

Electrolyte derangements from vomiting + dehydration; AKI from prolonged dehydration; baseline pre-anesthesia

Pyuria + bacteriuria suggests UTI as differential; sterile pyuria from inflamed appendix abutting bladder/ureter is classic finding

MANDATORY in any post-menarchal female with abdominal pain regardless of menstrual / sexual history; rules in/out pregnancy (ectopic, intrauterine; informs imaging + management)

First-line pediatric imaging — non-compressible blind-ended tubular > 6 mm + appendicolith + peri-appendiceal fluid + hyperemia on Doppler; sensitivity ~ 88%, specificity ~ 94% (Doria 2006); no radiation; bedside-accessible; ALARA-aligned

Hypotension by age-appropriate threshold → perforation + sepsis + shock concern; routes to id.sepsis.peds.v1 if Phoenix-2024 criteria met

Raises perforation + peritonitis concern (LR+ ~ 3-5); emergent surgical evaluation; enema-type contraindication does not apply but supports OR over observation

Duration > 48 h raises perforation concern (especially in younger children with shorter symptom-to-perforation window); affects NOM eligibility (typically < 48 h)

Pre-surgical type-and-screen if surgical management likely (most cases); essential for perforation with potential transfusion need

MRI preferred over CT in pediatric + pregnancy when US non-diagnostic (radiation-aware ALARA principle; ACR Appropriateness Criteria); good performance for appendicitis + alternative diagnosis evaluation

CT reserved for non-diagnostic US + MRI unavailable + persistent clinical concern; complex perforation / abscess characterization; obese adolescent; ALARA + low-dose pediatric protocols

MANDATORY in adolescent female with RLQ pain for OB/gyn differential (ovarian torsion with Doppler, tubo-ovarian abscess for PID, ectopic pregnancy if βhCG positive, hemorrhagic cyst)

Psoas sign positive in retrocecal position (pain on hip extension); obturator sign positive in pelvic position (pain on internal hip rotation); helps localize atypical appendix position

Elevated lactate (> 4 mmol/L) suggests perfusion failure / bowel ischemia / sepsis concern; routes to id.sepsis.peds.v1 if shock physiology

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Severity triggers (9)

9 need judgement
  • informationallife_threateningperforated_appendicitis_emergent_surgery
    Perforated appendicitis with free perforation + peritonitis OR hemodynamic compromise / shock — life-threatening surgical emergency requiring emergent OR (within 6-12 h; immediate if shock) + broad-spectrum IV antibiotics + ICU support if septic; routes to id.sepsis.peds.v1 if Phoenix-2024 criteria met (APSA 2020; Solomkin IDSA intra-abdominal 2010 PMID 20034345 peds-adapted; SSC peds 2020 for shock physiology)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereappendiceal_abscess_image_guided_drainage
    Peri-appendiceal abscess (organized; hemodynamically stable patient) — image-guided drainage by interventional pediatric radiology + IV antibiotics × 5-7 d + interval appendectomy 6-8 weeks (no consensus on optimal timing; centers vary 4-12 weeks); preferred over emergent surgery in selected stable patients (APSA 2020; Solomkin IDSA intra-abdominal 2010 PMID 20034345)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereatypical_presentation_under_5y
    Atypical presentation in young child < 5 yo — diffuse abdominal pain (classic migration pattern often absent); ~ 80% perforation rate at presentation due to shorter symptom-to-perforation window + omental immaturity (poor walling-off) + delayed parental recognition; aggressive imaging + surgical consult required (APSA 2020; pediatric surgery literature)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepas_score_above_7_high_pretest
    PAS ≥ 7 — high-probability appendicitis (PPV ~ 80-90% per Samuel 2002 + Bhatt 2009 validation); surgical consult triggered (some centers bypass mandatory imaging; others still image to confirm + characterize perforation / abscess); laparoscopic appendectomy within 12-24 h for uncomplicated cases
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverenom_failure_or_recurrence_within_1yr
    NOM failure (worsening exam, persistent fever, rising CRP, new abscess on imaging during initial NOM course) OR recurrence within 1 year (~ 30% recurrence rate per Minneci JAMA 2020 PMID 32730561) — surgical management indicated; re-presentation pathway with low threshold for laparoscopic appendectomy
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepregnancy_with_appendicitis
    Pregnancy with suspected or confirmed appendicitis — appendectomy is SAFE in pregnancy (risks of untreated appendicitis with perforation > risks of surgery + anesthesia); MRI preferred over CT (ALARA); multidisciplinary peds surgery + obstetrics + maternal-fetal medicine; preterm labor risk especially in 2nd-3rd trimester (continuous fetal monitoring during workup + post-op; tocolytics if indicated per OB); laparoscopic preferred when technically feasible (ACOG; ASGE pregnancy guidance)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepas_score_3_to_6_imaging_required
    PAS 4-6 — intermediate-probability appendicitis; abdominal ultrasound is first-line imaging (sensitivity ~ 88%, specificity ~ 94% per Doria 2006); MRI preferred over CT if US non-diagnostic + persistent clinical concern (radiation-aware ALARA principle); observation × 12-24 h with serial exam ± repeat imaging is reasonable if imaging-equivocal (ACR Appropriateness Criteria; Bhatt 2009)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatedifferential_with_obgyn_in_adolescent_female
    Adolescent female (post-menarchal) with RLQ pain — MANDATORY pregnancy test (urine or serum βhCG) + pelvic US with Doppler + STI workup if sexually active; differential includes ovarian torsion (sudden severe pain; Doppler shows reduced/absent ovarian flow; surgical emergency in own right per `gyn.ovarian-torsion.v1`), pelvic inflammatory disease (cervical motion tenderness + adnexal tenderness + vaginal discharge per CDC 2021 STI Treatment Guidelines + `gyn.pelvic-inflammatory-disease.core.v1`), ectopic pregnancy (positive βhCG + pelvic US per `ob.ectopic-pregnancy.v1`), hemorrhagic cyst rupture, mittelschmerz / dysmenorrhea (physiologic; menstrual history)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateretrocecal_or_pelvic_appendix_atypical_pain
    Retrocecal (~ 65%) or pelvic (~ 30%) or subhepatic or left-sided appendix position — classic RLQ tenderness findings blunted; pain may localize to flank/back (retrocecal — positive psoas sign on hip extension), suprapubic/pelvic (pelvic — positive obturator sign on internal hip rotation; rectal exam tenderness; urinary symptoms / diarrhea), RUQ (subhepatic — mimics cholecystitis), LLQ (left-sided; situs inversus or long mobile cecum); imaging anchor (US, MRI, CT) matters more than physical exam (pediatric surgery literature)
    Trigger could not be auto-evaluated — needs clinician judgement.

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Recommended regimen

Pediatric appendicitis perioperative antibiotics + non-operative management (NOM) + analgesia (APSA 2020 + Minneci JAMA 2020 PMID 32730561 + Solomkin IDSA intra-abdominal 2010 peds-adapted)
axis: pediatric_appendicitis_perioperative_and_nom
Selected axis "Pediatric appendicitis perioperative antibiotics + non-operative management (NOM) + analgesia (APSA 2020 + Minneci JAMA 2020 PMID 32730561 + Solomkin IDSA intra-abdominal 2010 peds-adapted)" by default fallback (first axis)
  • normal saline / lactated Ringer's
    first line
    crystalloid_isotonic
    20 mL/kg IV bolus over 30-60 min, repeat × 1-2 PRN; max ~ 60 mL/kg total before reassessing for fluid overload • IV • bolus PRN with reassessment
    triggers: pediatric_appendicitis_with_dehydration, pre_op_resuscitation_required, sepsis_physiology_with_perforation
    AAP pediatric resuscitation principles; pre-op resuscitation REQUIRED if dehydration; lower bolus thresholds vs adult sepsis given pediatric fluid-overload risk; halt or slow if hepatomegaly / rales / no response
    rxcui 9863
  • morphine
    first line
    opioid_analgesic
    0.05-0.1 mg/kg IV every 2-4 h PRN; titrate to comfort; does NOT obscure abdominal exam • IV • q2-4h PRN
    triggers: pediatric_appendicitis_pain_management
    Analgesia for visceral pain; titrate to comfort; AAP pediatric pain management — analgesia does NOT obscure abdominal exam
    rxcui 7052
  • ondansetron
    first line
    serotonin_5HT3_antagonist_antiemetic
    0.15 mg/kg IV (max 4 mg per dose) q8h PRN • IV • q8h PRN
    triggers: pediatric_appendicitis_with_nausea_emesis
    First-line pediatric antiemetic; minimal sedation; preferred over prochlorperazine in peds
    rxcui 26225
  • ceftriaxone
    first line
    third_gen_cephalosporin
    50 mg/kg IV (max 2 g) single dose at induction for uncomplicated; q24h for perforation × 5-7 d • IV • pre-op single dose; q24h for perforation
    triggers: perforation_or_surgical_management_required, pre_op_prophylaxis_uncomplicated_appendectomy
    Pre-op antimicrobial prophylaxis for uncomplicated appendectomy; combination with metronidazole for perforation; alternative to single-agent pip-tazo
    rxcui 2193
  • metronidazole
    first line
    nitroimidazole
    10 mg/kg IV q8h (max 500 mg/dose); add to ceftriaxone for anaerobic cover • IV • q8h
    triggers: perforation_or_surgical_management_required, pre_op_prophylaxis_combination_with_ceftriaxone
    Anaerobic cover combination with ceftriaxone for pre-op prophylaxis + post-perforation coverage per Solomkin IDSA intra-abdominal 2010 (peds-adapted)
    rxcui 6922
  • piperacillin-tazobactam
    first line
    penicillin_BLI
    80-100 mg/kg IV q6-8h (piperacillin component) for confirmed perforation / peritonitis or single-agent NOM IV induction • IV • q6-8h
    triggers: perforation_with_peritonitis_confirmed, nom_induction_iv_phase
    Broad Gram-positive + Gram-negative + anaerobe single-agent backbone for intra-abdominal contamination per Solomkin IDSA intra-abdominal 2010 (peds-adapted); also single-agent NOM IV induction per Minneci 2020
    rxcui 74169
  • amoxicillin-clavulanate
    first line
    penicillin_BLI
    25-45 mg/kg/day PO divided BID-TID (amoxicillin component; max 875 mg/dose) × 7 d for NOM • PO • BID-TID
    triggers: nom_oral_step_down_or_outpatient_full_course
    PO step-down (or full outpatient course) for NOM per Minneci 2020 PMID 32730561; broad-spectrum oral coverage; standard pediatric dosing
    rxcui 19711
  • meropenem
    rescue
    carbapenem
    20 mg/kg IV q8h (max 1 g per dose); for ESBL risk or MDRO concern or critically ill • IV • q8h
    triggers: esbl_or_mdro_risk, critically_ill_with_recent_broad_abx, sepsis_severe_with_perforation
    Broader Gram-negative + anaerobe + ESBL cover; reserved for ESBL risk or critically ill; alternative to pip-tazo
    rxcui 29561
  • vancomycin
    add on
    glycopeptide
    15 mg/kg/dose IV q6-8h; target AUC 400-600 (Rybak IDSA 2020 PMID 32191793) • IV • q6-8h
    triggers: mrsa_risk, cons_risk_central_line, severe_perforation_with_line_source
    Add-on for MRSA / CoNS / line-associated sepsis coinfection in perforated appendicitis; AUC target 400-600 (Rybak IDSA 2020)
    rxcui 11124
  • ketamine
    add on
    dissociative_anesthetic
    1-2 mg/kg IV by pediatric sedation team for procedural sedation (e.g., MRI in young child); supplemental 0.5 mg/kg PRN • IV • procedural
    triggers: pediatric_imaging_procedural_sedation_required
    Procedural-sedation agent for MRI in younger children unable to tolerate awake imaging; per institutional pediatric sedation protocol + AAP pediatric sedation guidance
    rxcui 6130
  • midazolam
    add on
    benzodiazepine
    0.05-0.1 mg/kg IV (max 2 mg single dose) for anxiolysis adjunct • IV • PRN procedural
    triggers: adjunct_anxiolysis_for_procedural_sedation
    Adjunct anxiolysis; not stand-alone procedural sedation in this context
    rxcui 6960
  • acetaminophen
    first line
    analgesic_antipyretic
    10-15 mg/kg PO q4-6h PRN (max 75 mg/kg/day or 4 g/day adult-equivalent) • PO • q4-6h PRN
    triggers: post_op_or_nom_oral_analgesia_pediatric
    First-line PO analgesic-antipyretic in pediatrics; safe in all age bands at appropriate dose
    rxcui 161

outpatient playbook — drug actions (5)

  1. 1. PO analgesia transition + taper
    acetaminophen 10-15 mg/kg PO q4-6h PRN ± ibuprofen 5-10 mg/kg PO q6h PRN; rare short-course opioid for severe pain • PO • PRN
    trigger: Post-op or post-NOM mild discomfort
    Standard pediatric multimodal analgesia; opioid-sparing approach
  2. 2. amoxicillin-clavulanate PO continuation for NOM × 7 d total
    25-45 mg/kg/day PO divided BID-TID (max 875 mg amox/dose) × 7 d total course • PO • BID-TID
    trigger: NOM outpatient continuation
    Minneci 2020 PMID 32730561 + APSA 2020 — outpatient completion of NOM course
  3. 3. NO ongoing antibiotic prophylaxis for uncomplicated post-op
    N/A • N/A • N/A
    trigger: Uncomplicated post-op recovery
    No prophylactic antibiotics post-appendectomy (APSA 2020 + Cantey 2016 stewardship principles)
  4. 4. continue routine vaccines per ACIP
    per ACIP age-based schedule • IM or PO • per ACIP
    trigger: Routine well-child care
    AAP standard schedule; appendicitis history does not modify vaccination schedule
  5. 5. continue OB-managed pregnancy care if applicable
    per OB / MFM regimen • per agent • per agent
    trigger: Pregnant patient with prior appendicitis
    Multidisciplinary follow-up; preterm labor surveillance per OB / MFM

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Child or adolescent with RLQ abdominal pain + anorexia ± nausea/emesis ± migration from periumbilical region — classic peds appendicitis presentation (Samuel 2002 PAS scoring criteria); Young child < 5 y with diffuse abdominal pain (atypical presentation; classic migration pattern often absent; ~ 80% perforation rate at presentation per pediatric surgery literature); Child with RLQ tenderness + fever ≥ 38 °C + leukocytosis WBC > 10K with neutrophilia — high PAS components (Samuel 2002; Bhatt 2009).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute appendicitis — pediatric (PAS-stratified; NOM-aware)** (peds.appendicitis.v1).
Phenotype framing: Mesenteric adenitis (post-viral; commonly mimics appendicitis in younger child); acute gastroenteritis (vomiting + diarrhea preceding pain pattern); Meckel's diverticulitis (rare; nuclear medicine scan post-recovery); constipation (KUB shows fecal loading); urinary tract infection (pyuria + bacteriuria); pyelonephritis (CVA tenderness + UA + urine culture); ovarian torsion (adolescent female; pelvic US with Doppler; surgical emergency); pelvic inflammatory disease (sexually active adolescent female; cervical motion tenderness; CDC 2021 STI); ectopic pregnancy (positive βhCG; pelvic US); ruptured / hemorrhagic ovarian cyst (pelvic US); mittelschmerz / dysmenorrhea (physiologic; menstrual history); diabetic ketoacidosis (rare presentation with abdominal pain; check BG); inflammatory bowel disease (chronic pattern); intussusception (younger band 6 mo - 3 y; target sign on US — `peds.intussusception.v1`).
Scope: Frame the suspected pediatric appendicitis presentation: age band (< 5 y atypical / 5-10 y / 10-19 y peak / adolescent female with mandatory OB/gyn ddx / adolescent male) drives pretest probability + atypical-presentation index + perforation rate at presentation (~ 80% in < 5 yo; ~ 30% overall; ~ 15-20% in adolescents). Sex + pregnancy status drives mandatory pelvic US + βhCG workup in post-menarchal female. Duration of symptoms drives perforation risk + NOM eligibility (typically < 48 h).

No severity triggers fired against current inputs.

Plan

Regimen axis: **Pediatric appendicitis perioperative antibiotics + non-operative management (NOM) + analgesia (APSA 2020 + Minneci JAMA 2020 PMID 32730561 + Solomkin IDSA intra-abdominal 2010 peds-adapted)**.
1. normal saline / lactated Ringer's 20 mL/kg IV bolus over 30-60 min, repeat × 1-2 PRN; max ~ 60 mL/kg total before reassessing for fluid overload IV bolus PRN with reassessment (crystalloid_isotonic, first line) — AAP pediatric resuscitation principles; pre-op resuscitation REQUIRED if dehydration; lower bolus thresholds vs adult sepsis given pediatric fluid-overload risk; halt or slow if hepatomegaly / rales / no response
2. morphine 0.05-0.1 mg/kg IV every 2-4 h PRN; titrate to comfort; does NOT obscure abdominal exam IV q2-4h PRN (opioid_analgesic, first line) — Analgesia for visceral pain; titrate to comfort; AAP pediatric pain management — analgesia does NOT obscure abdominal exam
3. ondansetron 0.15 mg/kg IV (max 4 mg per dose) q8h PRN IV q8h PRN (serotonin_5HT3_antagonist_antiemetic, first line) — First-line pediatric antiemetic; minimal sedation; preferred over prochlorperazine in peds
4. ceftriaxone 50 mg/kg IV (max 2 g) single dose at induction for uncomplicated; q24h for perforation × 5-7 d IV pre-op single dose; q24h for perforation (third_gen_cephalosporin, first line) — Pre-op antimicrobial prophylaxis for uncomplicated appendectomy; combination with metronidazole for perforation; alternative to single-agent pip-tazo
5. metronidazole 10 mg/kg IV q8h (max 500 mg/dose); add to ceftriaxone for anaerobic cover IV q8h (nitroimidazole, first line) — Anaerobic cover combination with ceftriaxone for pre-op prophylaxis + post-perforation coverage per Solomkin IDSA intra-abdominal 2010 (peds-adapted)
6. piperacillin-tazobactam 80-100 mg/kg IV q6-8h (piperacillin component) for confirmed perforation / peritonitis or single-agent NOM IV induction IV q6-8h (penicillin_BLI, first line) — Broad Gram-positive + Gram-negative + anaerobe single-agent backbone for intra-abdominal contamination per Solomkin IDSA intra-abdominal 2010 (peds-adapted); also single-agent NOM IV induction per Minneci 2020
7. amoxicillin-clavulanate 25-45 mg/kg/day PO divided BID-TID (amoxicillin component; max 875 mg/dose) × 7 d for NOM PO BID-TID (penicillin_BLI, first line) — PO step-down (or full outpatient course) for NOM per Minneci 2020 PMID 32730561; broad-spectrum oral coverage; standard pediatric dosing
8. meropenem 20 mg/kg IV q8h (max 1 g per dose); for ESBL risk or MDRO concern or critically ill IV q8h (carbapenem, rescue) — Broader Gram-negative + anaerobe + ESBL cover; reserved for ESBL risk or critically ill; alternative to pip-tazo
9. vancomycin 15 mg/kg/dose IV q6-8h; target AUC 400-600 (Rybak IDSA 2020 PMID 32191793) IV q6-8h (glycopeptide, add on) — Add-on for MRSA / CoNS / line-associated sepsis coinfection in perforated appendicitis; AUC target 400-600 (Rybak IDSA 2020)
10. ketamine 1-2 mg/kg IV by pediatric sedation team for procedural sedation (e.g., MRI in young child); supplemental 0.5 mg/kg PRN IV procedural (dissociative_anesthetic, add on) — Procedural-sedation agent for MRI in younger children unable to tolerate awake imaging; per institutional pediatric sedation protocol + AAP pediatric sedation guidance
11. midazolam 0.05-0.1 mg/kg IV (max 2 mg single dose) for anxiolysis adjunct IV PRN procedural (benzodiazepine, add on) — Adjunct anxiolysis; not stand-alone procedural sedation in this context
12. acetaminophen 10-15 mg/kg PO q4-6h PRN (max 75 mg/kg/day or 4 g/day adult-equivalent) PO q4-6h PRN (analgesic_antipyretic, first line) — First-line PO analgesic-antipyretic in pediatrics; safe in all age bands at appropriate dose

Setting playbook (outpatient) — Post-discharge pediatric surgery + pediatrician + (if indicated) pediatric GI + gyn + MFM follow-up. Most uncomplicated cases recover completely with no long-term sequelae. NOM cases need structured follow-up (24-48 h, 7 d, 1-3 months) with ~ 30% recurrence within 1 year. Perforated cases need extended monitoring for post-op abscess + interval appendectomy if applicable.
13. PO analgesia transition + taper acetaminophen 10-15 mg/kg PO q4-6h PRN ± ibuprofen 5-10 mg/kg PO q6h PRN; rare short-course opioid for severe pain PO PRN — Post-op or post-NOM mild discomfort (Standard pediatric multimodal analgesia; opioid-sparing approach)
14. amoxicillin-clavulanate PO continuation for NOM × 7 d total 25-45 mg/kg/day PO divided BID-TID (max 875 mg amox/dose) × 7 d total course PO BID-TID — NOM outpatient continuation (Minneci 2020 PMID 32730561 + APSA 2020 — outpatient completion of NOM course)
15. NO ongoing antibiotic prophylaxis for uncomplicated post-op N/A N/A N/A — Uncomplicated post-op recovery (No prophylactic antibiotics post-appendectomy (APSA 2020 + Cantey 2016 stewardship principles))
16. continue routine vaccines per ACIP per ACIP age-based schedule IM or PO per ACIP — Routine well-child care (AAP standard schedule; appendicitis history does not modify vaccination schedule)
17. continue OB-managed pregnancy care if applicable per OB / MFM regimen per agent per agent — Pregnant patient with prior appendicitis (Multidisciplinary follow-up; preterm labor surveillance per OB / MFM)

Non-pharmacologic actions:
- Family education reinforcement on return precautions
- Pediatric surgery wound / scar / bowel function review at 2-4 weeks post-op
- NOM structured follow-up calendar shared with family (24-48 h, 7 d, 1-3 months)
- Interval appendectomy scheduling at 6-8 weeks if abscess drained
- Gyn follow-up if adolescent female with OB/gyn ddx or PID treated
- OB / MFM follow-up if pregnant patient
- Activity + school return progression per surgeon (typically 1-2 weeks uncomplicated; longer perforated)
- Family caregiver psychosocial check at follow-up (acute illness in young child can be traumatic)

AVOID / contraindication checks:
- Laparoscopic appendectomy is standard for uncomplicated; open for complicated or hemodynamically unstable (APSA 2020)
- Emergent surgery for perforated with peritonitis or shock; image guided drainage acceptable for stable abscess with interval appendectomy 6 8 weeks (APSA 2020)
- NOM requires shared decision making + eligibility criteria + structured follow up (Minneci 2020 PMID 32730561 + APSA 2020)
- Pre op antibiotic single dose (ceftriaxone + metronidazole OR pip tazo) at induction; no prolonged course for uncomplicated appendectomy (APSA 2020 + Cantey 2016 PMID 27452782)
- Post perforation antibiotic course 5 7 d (pip tazo OR ceftriaxone + metronidazole); longer if uncontrolled source (Solomkin IDSA 2010 peds adapted PMID 20034345)
- US first line in pediatric; MRI preferred over CT if US non diagnostic (ACR Appropriateness Criteria; ALARA principle)
- Pregnancy test mandatory in adolescent female with abdominal pain (ACOG; standard ED practice)
- Ceftriaxone avoid under 28 days bilirubin displacement (FDA 2009; AAP Puopolo 2018 — applies only if neonatal presentation < 28 d which is atypical for appendicitis but possible)
- Fluid bolus 20 mL per kg with reassessment pediatric AAP DDC (AAP pediatric resuscitation principles)
- Vancomycin AUC target not trough (Rybak IDSA 2020 PMID 32191793) — applies if MRSA risk in perforation
- Appendectomy safe in pregnancy; risks of untreated appendicitis > risks of surgery + anesthesia (ACOG + ASGE; multidisciplinary peds surgery + OB + MFM)
- MRI preferred over CT in pregnancy + younger pediatric + radiation sensitive populations (ACR + ALARA)

Monitoring

Regimen monitoring:
- PAS score documented at triage + reassessed after labs and imaging
- continuous vitals during ED workup + pre-op + post-op
- serial abdominal exam q2-4h during observation period
- pain re-assessment q2-4h with FLACC or age-appropriate scale
- CBC + CRP trend at 24 + 48 h post-op or during NOM
- serial diet advance from clear liquids → full liquids → soft → regular as tolerated post-op
- wound inspection daily post-op (laparoscopic incisions)
- antibiotic course duration documented (uncomplicated: pre-op single dose; perforated: 5-7 d; NOM: 7 d)
- family-bedside-instruction documentation on return precautions for recurrence / complication signs
- NOM structured follow-up at 24-48 h, 7 d, 1-3 months per Minneci 2020 protocol

Setting (outpatient) monitoring:
- Pediatric surgery follow-up at 2-4 weeks
- Pediatrician visit at 1-2 weeks, 4-6 weeks, then routine well-child care
- NOM structured follow-up at 24-48 h, 7 d, 1-3 months
- Interval appendectomy at 6-8 weeks if abscess drained
- Vaccination catch-up review at every well-child visit

Follow-up plan: Post-op uncomplicated: pediatric surgery follow-up at 2-4 weeks for wound check + scar inspection + bowel function review; activity progression per surgeon; school return typical 1-2 weeks. Post-op perforated: pediatric surgery follow-up at 2-4 weeks; pediatric infectious disease follow-up if prolonged antibiotic course; nutrition follow-up if extensive resection. NOM: structured pediatric surgery + pediatrician follow-up at 24-48 h, 7 d, 1-3 months; ~ 30% recurrence within 1 year (Minneci 2020) → re-presentation pathway with low threshold for surgical management; family education on recurrence signs (return of RLQ pain, fever, vomiting → ED). Interval appendectomy 6-8 weeks if abscess drained (no consensus on optimal timing; centers vary 4-12 weeks). Adolescent female: ongoing primary care + gyn follow-up if indicated. Pregnant patient: ongoing OB + MFM follow-up; preterm labor surveillance.
- Close-out criterion: Follow-up scheduled + return precautions delivered + interval appendectomy queued if abscess drained

Monitoring phase: Post-op uncomplicated: vitals q4h × first 24 h then per protocol; serial abdominal exams q4h; diet advance from clear liquids → regular as tolerated; pain management with transition to PO acetaminophen ± ibuprofen ± opioids PRN; wound inspection daily; early ambulation; bowel function (flatus + first BM) documented before discharge. Post-op perforated: as above + IV antibiotic course continuation × 5-7 d + drain monitoring if applicable + serial labs (CBC + CRP + metabolic panel) + watch for post-op abscess (rising CRP + persistent fever + worsening exam → CT for evaluation). NOM: vitals q2-4h first 24 h; serial abdominal exams; CRP + WBC trend; transition to PO antibiotics; discharge home with structured follow-up; family education on return precautions (return of pain, fever, vomiting → ED).

Disposition

Current setting: outpatient — Post-discharge pediatric surgery + pediatrician + (if indicated) pediatric GI + gyn + MFM follow-up. Most uncomplicated cases recover completely with no long-term sequelae. NOM cases need structured follow-up (24-48 h, 7 d, 1-3 months) with ~ 30% recurrence within 1 year. Perforated cases need extended monitoring for post-op abscess + interval appendectomy if applicable.

Disposition criteria:
- Sustained recovery — normal diet + bowel function + growth at age-appropriate baseline + no recurrent episodes in 12 mo + interval appendectomy completed if applicable + family demonstrating return-precaution knowledge

Escalation triggers (move to higher acuity):
- New RLQ pain + fever + vomiting post-NOM → return to ED for repeat US + reassessment; ~ 30% NOM recurrence within 1 year per Minneci 2020
- New post-op fever + worsening pain + wound concern → urgent pediatric surgery reassessment; possible post-op abscess
- New peritoneal signs / hemodynamic compromise at any follow-up → return to ED + emergent surgical reassessment
- New pregnancy in adolescent female with prior appendicitis → routine OB care + low threshold for re-imaging if pain recurs (appendectomy safe in pregnancy)
- Family caregiver acute distress / PTSD symptoms after traumatic illness → mental-health referral

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Perforated appendicitis with free perforation + peritonitis OR hemodynamic compromise / shock — life-threatening surgical emergency requiring emergent OR (within 6-12 h; immediate if shock) + broad-spectrum IV antibiotics + ICU support if septic; routes to id.sepsis.peds.v1 if Phoenix-2024 criteria met (APSA 2020; Solomkin IDSA intra-abdominal 2010 PMID 20034345 peds-adapted; SSC peds 2020 for shock physiology)
- [SEVERE] Peri-appendiceal abscess (organized; hemodynamically stable patient) — image-guided drainage by interventional pediatric radiology + IV antibiotics × 5-7 d + interval appendectomy 6-8 weeks (no consensus on optimal timing; centers vary 4-12 weeks); preferred over emergent surgery in selected stable patients (APSA 2020; Solomkin IDSA intra-abdominal 2010 PMID 20034345)
- [SEVERE] Atypical presentation in young child < 5 yo — diffuse abdominal pain (classic migration pattern often absent); ~ 80% perforation rate at presentation due to shorter symptom-to-perforation window + omental immaturity (poor walling-off) + delayed parental recognition; aggressive imaging + surgical consult required (APSA 2020; pediatric surgery literature)

Citations

- APSA 2020 (American Pediatric Surgical Association) statement on pediatric appendicitis management + Minneci PC et al JAMA 2020 PMID 32730561 (NOM non-inferiority cohort) + Samuel M J Pediatr Surg 2002 (original Pediatric Appendicitis Score) + Bhatt M Acad Emerg Med 2009 (PAS prospective validation) + Doria AS Radiology 2006 (US vs CT meta-analysis) + Kollar A 2019 + Macco S 2020 (pAIR pediatric appendicitis inflammatory response) + ACR Appropriateness Criteria — Right Lower Quadrant Pain — Suspected Appendicitis + Solomkin IDSA Complicated Intra-Abdominal Infection 2010 PMID 20034345 (peds-adapted for perforation management) + CDC 2021 STI Treatment Guidelines (PID differential) + SSC peds 2020 (for shock physiology if perforation precipitates sepsis) [PMID:32730561](https://pubmed.ncbi.nlm.nih.gov/32730561/)
- Cited evidence (PMID 20034345) [PMID:20034345](https://pubmed.ncbi.nlm.nih.gov/20034345/)
- Cited evidence (PMID 32191793) [PMID:32191793](https://pubmed.ncbi.nlm.nih.gov/32191793/)
- Cited evidence (PMID 27452782) [PMID:27452782](https://pubmed.ncbi.nlm.nih.gov/27452782/)
- Cited evidence (PMID 30455342) [PMID:30455342](https://pubmed.ncbi.nlm.nih.gov/30455342/)

Last reconciled with current guidelines: 2026-05-15.
References
  • APSA 2020 (American Pediatric Surgical Association) statement on pediatric appendicitis management + Minneci PC et al JAMA 2020 PMID 32730561 (NOM non-inferiority cohort) + Samuel M J Pediatr Surg 2002 (original Pediatric Appendicitis Score) + Bhatt M Acad Emerg Med 2009 (PAS prospective validation) + Doria AS Radiology 2006 (US vs CT meta-analysis) + Kollar A 2019 + Macco S 2020 (pAIR pediatric appendicitis inflammatory response) + ACR Appropriateness Criteria — Right Lower Quadrant Pain — Suspected Appendicitis + Solomkin IDSA Complicated Intra-Abdominal Infection 2010 PMID 20034345 (peds-adapted for perforation management) + CDC 2021 STI Treatment Guidelines (PID differential) + SSC peds 2020 (for shock physiology if perforation precipitates sepsis) — PMID:32730561
  • Cited evidence (PMID 20034345) — PMID:20034345
  • Cited evidence (PMID 32191793) — PMID:32191793
  • Cited evidence (PMID 27452782) — PMID:27452782
  • Cited evidence (PMID 30455342) — PMID:30455342