Acute appendicitis under five years of age: a challenge for the paediatrician

Key words: Appendicitis, Abdominal pain, Children, Newborn, Appendicitis complications

Acute appendicitis is one of the most frequent causes of abdominal surgery in paediatric ages, with the peak incidence in the second decade of life. Acute appendicitis in the first years of life is an uncommon but not so rare event. The clinical presentation is often pleomorphic and the diagnosis may be overshadowed by other medical conditions. Gastroenteritis is the most common misdiagnosis, with a history of diarrhoea present in 33% to 41% of patients. Pain is the most common early symptom in children younger than 5 years old, followed by vomit, fever, anorexia and diarrhoea. The most common physical sign is focal tenderness (61.3% of the patients) followed by guarding (54.8%), diffuse tenderness (38.7%), rebound (32.3%), and mass (6.5%). Neonatal appendicitis is a very rare disease with high mortality; the early symptoms are non-specific and the abdominal distension is the main clinical manifestation. As a matter of fact, there is evidence that the younger is the patient the earlier the perforation occurs: 70% of patients younger than 3 years old develop a perforation in less than 48 hours from the onset of the symptoms. The challenge for the paediatrician is to perform a prompt diagnosis of “acute appendicitis” in order to reduce the risk of complications, mainly early in life. The paper highlights the epidemiology, pathophysiology, clinical signs and laboratory clues of appendicitis in younger children and suggests an algorithm for early diagnosis.