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BACKGROUND. Differentiated thyroid carcinoma (DTC) in juvenile patients has a risk of recurrence higher than in the adults. The optimal treatment strategy is unclear. Defining risk factors for recurrence could help to identify patients who require a more aggressive approach. METHODS. The demographic, clinical, surgical, pathological and nuclear medicine data of 67 patients aged less than 20 years who underwent surgery for DTC were reviewed and a complete follow up was obtained. RESULTS. All the patients underwent total thyroidectomy, with central neck dissection in 28 and lateral neck dissection in 14. All patients received levothyroxine suppressive treatment. Fifty-three patients underwent radioiodine ablation. At a mean follow up of 138.3+/-100 months, the overall survival rate was 98.5%. The 10-year disease free survival rate was 72%. Twenty patients (30%) experienced recurrence. Patients < 15 years old showed a significant higher recurrence rate than the older ones (70 Vs 29.8%) (P<0.05). Three out of 7 (42.9%) patients <= 15 years old with small tumours localized to the thyroid (pT1N0) experienced recurrence, but none out of 7 older. Age <= 15 years, nodal and distant metastases at diagnosis, multifocality were identified as significant risk factors for recurrence. CONCLUSIONS. An univocal aggressive approach, including total thyroidectomy, selective lymph node dissection, levothyroxine suppressive treatment and radioiodine ablation is mandatory. In all the patients <=15 years old central neck dissection should be considered. Long term surveillance should be warranted since recurrence can develop late after the first treatment.