Background <p>The aim of this study is to determine whether initial conservative surgical treatment of acute mastoiditis (AM) leads to an increase of morbidity, and to report on recent developments in epidemiology and microbiology.</p> Methods <p>At the end of 2016, a new guideline for treatment of pediatric AM was introduced at our tertiary referral center. Mastoidectomy in case of a retroauricular abscess was changed to retroauricular needle aspiration or incision. All patients diagnosed with AM 2017—2021 were identified retrospectively in our patient file records and all relevant clinical data retrieved, including data on epidemiology and microbiology (<i>n</i> = 73; 26 with subperiosteal abscess).</p> Results <p>Overall, the conservative management strategy led to resolved disease without further treatment in 94% of cases. Cases presenting with a subperiosteal abscess and receiving initial conservative surgical treatment healed in 92%, although 8% needed repeated aspiration or incision. Two children (8%) had secondary mastoidectomy due to disease progression. At 1.4%, complications were rare and the hospital stay short (mean 2.9&#xa0;days). The incidence of AM was low during the Covid pandemic. Bacterial spectrum was comparable to earlier findings, resistance to penicillin/ampicillin slightly increased at 11%/33%.</p> Conclusion <p>Conservative initial management of pediatric AM leads to favorable outcomes not inferior to a more aggressive approach including primary mastoidectomy in case of subperiosteal abscess. Complications are (as) rare and hospital stay shorter. Incidence of AM was lower during the Covid pandemic, but otherwise unchanged compared to previous years, despite intercurrent introduction of pneumococcal vaccines.</p>