Background: Simple appendicitis may be self-limiting or require antibiotic treatment or appendectomy. The aim of this study was to assess the feasibility and safety of a nonoperative, antibiotic-free approach for suspected simple appendicitis in children. Methods: This single-center, retrospective study included patients (0–17 years old) who were hospitalized at the pediatric surgery department due to suspected appendicitis between 2011 and 2012. Data from patients who primarily underwent appendectomy were used as controls. The follow-up of nonoperatively managed patients was conducted in 2014. The main outcome of interest was appendicitis recurrence. Results: A total of 365 patients were included: 226 were treated conservatively and 139 underwent appendectomy. Fourteen (6.2% of 226) of the primarily nonoperatively treated patients required secondary appendectomy during follow-up, and histology confirmed simple, uncomplicated appendicitis in 10 (4.4% of 226) patients. Among a subset of 53 patients managed nonoperatively with available Alvarado and/or Pediatric Appendicitis Scores and sonographic appendix diameters in clinical reports, 29 met the criteria for a high probability of appendicitis. Three of these patients (10.3% of 29) underwent secondary appendectomy. No complications were reported during follow-up. Conclusions: A conservative, antibiotic-free approach may be considered for pediatric patients with suspected uncomplicated appendicitis in a hospital setting. Only between 6 and 10% of these patients required secondary appendectomy. Nevertheless, the cohort of patients treated nonoperatively was likely to have also included individuals with further abdominal conditions other than appendicitis. Active observation and clinical support during the disease course may help patients avoid unnecessary procedures and contribute to spontaneous resolution of appendicitis or other pediatric conditions as the cause of abdominal pain. However, further studies are needed to define validated diagnostic and management criteria.