BACKGROUND:: Tuberculosis (TB) is among the top 10 causes of child death worldwide. Nevertheless, childhood disease has been neglected by tuberculosis control programs. METHODS:: Retrospective study of patients less than 16 years old diagnosed with active TB in two tertiary hospitals in Rome (Italy), between 1990 and 2009. RESULTS:: 214 cases of active tuberculosis were identified (132 definite, 82 probable). Pulmonary involvement was the most common form (75.5%), followed by lymphadenopathy (15.4%) and central nervous system TB (11%). Fever (51.86%) and cough (40%) were the most common presenting symptoms. 23.4% of children were asymptomatic on admission. Sensitivities of the tuberculin skin test and the quantiferon test were 93.4% and 97% respectively. Both tests performed in 52 children agreed in 49 cases (94%). Sensitivities for culture, Ziehl-Neelsen staining and polymerase chain reaction were 58%, 25% and 66.3% respectively. The adult source case was identified in 28% of cases. History of contact with a patient with active tuberculosis was associated with pulmonary TB (P=0.0014), while negative history of contact was associated with lymph node (P=0.0064) and central nervous system TB (P=0.05). CONCLUSIONS:: Our study emphasizes the difficulty in managing children with suspected TB, since the absence of constitutional symptoms cannot exclude TB and bacteriologic confirmation is the exception. Immunologic diagnosis can be a valuable tool to identify TB infected children since the quantiferon test showed high sensitivity in all age-groups. This is of primary importance since early identification of children with latent tuberculous infection and appropriate chemoprophylaxis represent, to date, the most important tool to reduce the burden of TB.