Introduction: Due to structural differences between pediatric and adult corneas, keratoconus (KC) is considered more aggressive in pediatrics than in adults. It is controversial whether therapeutic intervention in pediatric KC should differ from adult KC. Areas covered: We investigate if there is a substantial difference between pediatric and adult KC regarding disease severity and progression rate, factors important for treatment timing and prognosis. Then, feasibility of current treatment modalities is discussed based on current evidence. Expert opinion: Despite several conflicting reports, pediatric KC is more severe at initial diagnosis with faster progression. Progression can be tracked in a variety of ways, including with the Belin ABCD progression system. Controlling ocular allergy and eye rubbing is the first step in treatment. The epithelium-off Dresden protocol remains the gold standard CXL approach to stop progression in pediatric KC, whereas epithelium-off accelerated CXL might be an alternative. In pediatric patients, both penetrating and lamellar keratoplasty can be challenging; however, lamellar keratoplasty seems to offer the advantage of lower graft rejection rate. Epithelium-on CXL, intracorneal ring segment implantation, excimer laser ablation + CXL protocols are not recommended in pediatric KC. Nevertheless, there remains a need for evidence-based clinical practical guidelines in pediatric KC.