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We describe the clinical presentation of appendicitis in preadolescent children and differences in symptoms among age-stratified subgroups.This is a retrospective analysis of a prospectively collected de-identified data set of patients 3 years or older and patients younger than 12 years presenting to a pediatric emergency department during a 21-month period with symptoms suspicious for appendicitis. The rates of appendicitis, perforation, negative appendectomy, as well as sensitivities, specificities, and positive likelihood ratios for historical and clinical variables associated with appendicitis were calculated for the entire cohort and for 3 age-stratified subgroups.Of 379 children, 121 (32%) had appendicitis, 75 (62%) were male, 24 (20%) had a perforated appendix, and 16 (12%) had a negative appendectomy. The perforation rate was highest (53%) in the youngest subset of patients (3-5.99 years). Patients with appendicitis presented with inability to walk (82%), maximal right lower quadrant tenderness (82%), nausea (79%), pain with percussion, hopping, coughing (79%), and anorexia (75%). Fewer patients with appendicitis presented with a history of vomiting (66%), fever (47%), or diarrhea (16%), and these findings were not associated with the diagnosis. The youngest subset of patients (3-5.99 years) presented to the emergency department with fever; however, within this age subset, there was no significant difference in temperatures between patients with and without appendicitis. Fever was an indicator for perforation. Psoas, Rovsing, and obturator signs were infrequent but very specific for appendicitis (0.86-0.98 depending on age).Nausea, right lower quadrant tenderness, inability to walk, and elevated white blood cell and neutrophil counts are sensitive indicators of appendicitis in preadolescent children. Although peritoneal signs are infrequently elicited, when present, they substantially increase the likelihood of appendicitis. Fever, vomiting, and diarrhea are not associated with appendicitis in preadolescent children.