Purpose <p>Disease risk stratification is essential for clinical decision-making, prognostication, and outcomes reporting. Pediatric appendicitis is typically described and treated as a binary entity of simple versus perforated, ignoring the wide variation in its presentation and outcomes. We performed a systematic review to assess and synthesize the available literature on risk stratification for pediatric appendicitis.</p> Methods <p>From inception to July, 2024, a comprehensive search of ten databases was conducted without language restrictions. We included any study that stratified pediatric appendicitis into three or more risk groups based on outcomes, using clinical, laboratory, imaging, surgical, or histopathologic criteria, or any combination of the five. Two independent reviewers performed the initial screening, with conflicts adjudicated by two additional reviewers. The study adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.</p> Results <p>Of 4,332 studies screened, 64 were selected for full-text evaluation, and seven met the inclusion criteria. The only prospective cohort study utilized a pediatric perforated appendicitis grade assigned at operation. Of the 6 retrospective studies, two employed the American Association for the Surgery of Trauma (AAST) classification, one described a surgeon-reported categorization, one used a pathology-defined appendicitis severity scale, and two multicenter studies used a set of binary (present or absent) findings. In all studies, increased postoperative infectious complications and hospital stays were seen in the higher-risk categories.</p> Conclusions <p>Few pediatric appendicitis studies report risk-stratified outcomes with no widely accepted or utilized risk stratification system. A universal pediatric appendicitis grade is needed to improve clinical care, prognostication, benchmarking, outcomes reporting, and resource allocation.</p>