Pain characteristics and multimodal analgesia in children hospitalised with pancreatitis: A retrospective study from a tertiary paediatric centre in India.

Pancreatitis is an inflammatory disorder of the pancreas resulting from multiple causes.[ 1 ] The International Study Group of Paediatric Pancreatitis: In Search for a CuRE (INSPPIRE) has established consensus-based criteria for the diagnosis and classification of pancreatitis in children, defining acute pancreatitis (AP), acute recurrent pancreatitis (ARP), and chronic pancreatitis (CP) [ Table 1 ].[ 2 ] Diagnostic criteria for paediatric pancreatitis Over the past decade, the occurrence of pancreatitis among children has increased globally. In Western countries, the estimated incidence of acute pancreatitis is approximately 12 cases per 100,000 children per year, while CP affects nearly 2 per 100,000 children annually.[ 3 ] In contrast, epidemiological information from India remains limited and largely derived from hospital-based reports. Available Indian studies suggest that tertiary centres manage approximately 15–20 paediatric cases of AP each year, reflecting the absence of reliable population-level incidence data.[ 4 5 ] The diagnosis of paediatric pancreatitis is based on a combination of clinical symptoms, examination findings, biochemical abnormalities, and imaging evidence, as summarised in Table 1 .[ 2 6 ] Abdominal pain, often accompanied by nausea and vomiting, is the most frequently reported presenting symptom. However, a few studies have explored the range and characteristics of pain experienced by children with pancreatitis, particularly in the Indian population.[ 5 6 ] Despite pain being one of the most distressing features of the disease, there is limited research examining structured pain assessment or analgesic management strategies in paediatric pancreatitis globally, with an even greater paucity of data from India.[ 5 7 8 ] This lack of evidence has important implications for clinical care as inadequate pain evaluation and variability in analgesic practices may influence patient comfort, recovery, and overall quality of care. A clearer understanding of pain patterns and treatment approaches is therefore essential to guide evidence-based and child-centred management strategies. The present study seeks to address this gap by evaluating pain characteristics and analgesic use among children diagnosed with pancreatitis and admitted to a tertiary paediatric hospital in India. The primary objective was to describe pain patterns in hospitalised children with pancreatitis, while the secondary objective was to analyse analgesic prescribing practices in this population.

This retrospective cohort study was conducted at a tertiary-level paediatric hospital in India. The study protocol received approval from the institutional ethics committee (approval number: ADMN/ACA/16/2025-26/EC-012 dated August 11, 2025). As the study involved a retrospective review of existing medical records, the requirement for informed consent was waived by the Ethics Committee. All patient data were anonymised and de-identified prior to analysis to maintain confidentiality. The study adhered to the ethical principles outlined in the Declaration of Helsinki and applicable national research guidelines. Clinical information was obtained from multiple institutional sources including the Acute Pain Services (APS) database, consultant case records, patient files retrieved from the medical records department (MRD), and the hospital electronic health record system. Children were eligible for inclusion if they had a documented diagnosis of AP, ARP, or CP and were referred to the APS for pain management during hospitalisation. Patients were excluded if the APS referral was for abdominal pain unrelated to pancreatitis or if pain management occurred exclusively in the outpatient setting. Baseline demographic data included age, gender, and weight. Clinical variables included the aetiology of pancreatitis and laboratory investigations such as serum lipase, amylase, creatinine, blood urea nitrogen (BUN), albumin, C-reactive protein (CRP), and complete blood counts. Information regarding imaging findings and any surgical or endoscopic interventions was also recorded. Pain-related information was extracted from standardised acute and chronic pain assessment forms, documenting pain type, duration, intensity, timing, radiation, and aggravating or relieving factors. A focused abdominal examination was recorded, including assessment for features of allodynia and hyperalgesia. Pain intensity was assessed using either the numerical rating scale (NRS) or the FLACC (Face, Legs, Activity, Cry, Consolability) scale according to the age and developmental status of the child. Pain scores were recorded by the APS team thrice a day at the least, and pain management decisions were made by the APS team led by a paediatric anaesthesiologist trained in paediatric pain. Analgesics were administered through oral or intravenous routes depending upon the child’s nil per oral status as ordered by the surgical team. Commonly prescribed medications included intravenous or oral tramadol [1–2 mg/kg, q8H (every 8 th hourly)/q12H (every 12 th hourly) not exceeding 8 mg/kg/day], intravenous or oral paracetamol [15 mg/kg, q6H (every 6 th hourly)/q8H not exceeding 75 mg/kg/day], intravenous ketorolac (0.5 mg/kg, q8H not exceeding a maximum dose of 15 mg/dose and 2 mg/kg/day for a maximum of 48 hours), intravenous or oral ibuprofen (10 mg/kg/dose, q6H/q8H, not exceeding 40 mg/kg/day), and intravenous morphine [0.05–0.1 mg/kg q4H (every 4 th hourly)/q6H/q8H]. Neuropathic agents such as oral gabapentin (an initial dose of 5 mg/kg) in three divided doses per day and amitriptyline (0.1 mg/kg/dose per oral at night dose) were used when clinically indicated. Equianalgesic opioid conversion ratios were applied to calculate parenteral morphine milligram equivalents (MME) per kilogram per day. Total opioid exposure during the first 48 hours of hospitalisation was expressed as cumulative MME. All extracted data were coded and anonymised prior to analysis. Statistical analysis was performed using International Business Machines Statistical Package for the Social Sciences Statistics. Descriptive statistics summarised patient demographics, pain characteristics, and analgesic use. Continuous variables were presented as means with standard deviations, while categorical variables were expressed as frequencies and percentages. Where appropriate, inferential analyses were performed to explore associations between variables. A P value < 0.05 was considered statistically significant.

The study population consisted of 40 individuals, with a female predominance. Females accounted for 60% ( n = 24), while males comprised 40% ( n = 16). In terms of age distribution, the most represented group was 13–15 years, comprising approximately 30% of the population. This was followed by the 10–12-year group (25%), the 15–17-year group (22.5%), the 0–6-year group (12.5%), and the 7–9-year group (10%). The mean weight was 29.7 kg [standard deviation (SD) = 13.3]. The mean length of hospital stay was 12.3 days (SD = 12.1) [ Table 2 ]. Demographics SD: Standard deviation The distribution of diagnoses revealed that CP was the most common, observed in 40% of the patients ( n = 16). AP and ARP each accounted for 30% ( n = 12) of the cases. Continuous dull aching deep-seated pain was the most frequently reported, affecting 34% of patients, followed by colicky pain in another 28% of children. In 36% of children, radiation to the back was noted. Nausea and vomiting were the most reported associated symptoms, present in 44% of patients. Interestingly, 22% of patients reported no associated symptoms. Pain aggravated on having food in 16 patients and was noted to be relieved with skipping meals ( n = 8) and crouched positioning ( n = 5). The patient cohort exhibited a variety of associated risk factors for the development of acute, recurrent, and CP [ Table 3 ]. Idiopathic pancreatitis accounted for the majority, with 22 patients (approximately 56%) having no identifiable cause. Pancreatic divisum, a common pancreatic duct malformation characterised by the persistence of two drainage systems, was observed in 15% of cases. Specific aetiologies included mumps infection in one patient and drug-induced pancreatitis in two patients—one on antiretroviral therapy (ART) and the other on carbamazepine. Choledochal cysts were identified in two cases, and two patients had a history of traumatic pancreatitis. Additionally, one patient had a coexisting chronic kidney disease, one had type 1 diabetes mellitus, one had glycogen storage disease type III, and another had chronic liver disease. Risk factors for the development of acute, recurrent, and chronic pancreatitis The overall mean NRS score at presentation was 7.43 ± 1.24, indicating severe pain at admission. In children with AP ( n = 12), pain scores were highest at initial assessment, typically ranging between 6 and 9 on a standardised pain scale. The pain scores in children with ARP and CP varied from 6 to 10. There was a significant reduction in pain scores over time, with the mean NRS scores decreasing to 3.13 ± 1.38 at 24 hours and 1.13 ± 0.64 at 48 hours in all three categories [ Table 4 ]. The mean difference in NRS scores exceeded the minimum clinically significant difference of 2, and this reduction was statistically significant ( P < 0.01) [ Figure 1 ]. Numerical rating scale scores for pain SD: Standard deviation; NRS: Numerical rating scale Numerical pain scores. AP: Acute pancreatitis; ARP: Acute recurrent pancreatitis; CP: Chronic pancreatitis As regards analgesic prescription patterns, opioids were commonly prescribed across all diagnostic categories, with usage reported in 75% of AP, 92% of ARP, and 94% of CP cases. Tramadol was the most frequently used opioid in all patients other than one boy who had minimal pain relief and needed escalation to intravenous morphine. Nonsteroidal anti-inflammatory drugs (NSAIDs) and paracetamol were used in 100% of AP, 75% of ARP, and 81% of CP patients. Ibuprofen and ketorolac were the most used NSAIDs. Neuropathic agents (gabapentin and amitriptyline) were used less frequently, primarily in children with ARP (25%) and CP (19%) [ Figure 2 ]. Analgesic usage in acute pancreatitis, chronic recurrent pancreatitis, and chronic pancreatitis and opioid consumption in MME 24 (24 hour morphine milligram equivalent). AP: Acute pancreatitis; ARP: Acute recurrent pancreatitis; CP: Chronic pancreatitis; SD: Standard deviation; NSAIDs: Non-steroidal anti-inflammatory drugs; PCT: Paracetamol; MME: Morphine milligram equivalents The mean 24-hour morphine milligram equivalent (MME24) consumption for the cohort was 0.57 ± 0.22 mg/kg. Subgroup analysis showed mean MME values of 0.63 ± 0.27 for AP, 0.49 ± 0.27 for ARP, and 0.59 ± 0.14 for CP The difference in opioid consumption between diagnostic (AP, ARP, and CP) groups was not statistically significant ( P = 0.346). Several invasive procedures were employed across the study group. Endoscopic sphincterotomy was the most common, performed in 16 patients (37.2%), followed by endoscopic stenting in 11 patients (25.6%) and longitudinal pancreatico-jejunostomy in 6 patients (14%). Less frequently performed procedures included epidural catheterisation which involved placing an epidural catheter at the thoracic level (T10-T12) running an infusion of 0.1% levobupivacaine at 0.3 ml/kg/hour for a duration of 48–72 hours. The other procedures that were performed were laparotomy with feeding jejunostomy (each in two patients), and cystogastrostomy in one patient.

Pain in paediatric pancreatitis represents a significant clinical burden but can be effectively managed through structured multimodal analgesia. In our cohort, the combined use of paracetamol, NSAIDs, and carefully titrated opioids provided effective pain relief without observed adverse effects. These findings support multimodal, opioid-sparing strategies as a pragmatic approach for managing pain in children with pancreatitis, particularly in resource-constrained settings. Prospective studies are required to better define optimal analgesic protocols and long-term outcomes. SJ: Acquisition of data, analysis and interpretation of data, and drafting of the article. AG: Conception and design, Acquisition of data, Drafting and critical revision of the article. SN: Design, Statistical analysis of the article. BDV: Conception and design, critical revision of the article. CYR: Conception and design, critical revision of the article. This study was presented at the 16 th National Conference of Indian Association of Paediatric Anaesthesiologists at Pune, India held on 14-16 th February 2025, at the Asian Society of Paediatric Anaesthesiologists (ASPA) conference held on April 4-5 th 2025, Hyatt, Kathmandu, Nepal and at the online 2025 Annual Pain Centre Conference, Advancing Paediatric Pain Care Equity-Addressing Challenges and Opportunities in low-and middle Income countries on November 5 th 2025. De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared after approval as per the authors’ Institution policy. AI-assistive or generative tools have been used only for language refinement and formatting. All intellectual content, interpretations, and conclusions are the responsibility of the authors. We hereby declare that, in the preparation of this work, we have used only those tools and resources that are permitted under the applicable guidelines and policies. The permitted tools include a free version of Grammarly, ChatGPT and MS Excel, MS PPT. There are no conflicts of interest.

The pain patterns observed in children with pancreatitis in this study were largely consistent with those reported in the existing paediatric literature.[ 9 10 ] Children across all diagnostic categories presented with severe pain at admission, as reflected by comparable initial NRS scores, underscoring the substantial symptom burden associated with paediatric pancreatitis, irrespective of subtype. Analgesic prescription practices varied across patients; however, there was a marked reliance on multimodal analgesia. A combination of opioids, paracetamol, and NSAIDs was used in 87.5% of patients, while the remaining children were managed with non-opioid analgesics alone. The adoption of multimodal analgesia was associated with a clinically and statistically significant reduction in pain scores, as demonstrated by a decrease exceeding the minimum clinically significant difference. Pain management in paediatric pancreatitis remains heterogeneous, with most available evidence originating from North America and Europe.[ 11 12 13 14 ] In AP, published paediatric studies have predominantly relied on opioid-based analgesia, with fewer studies evaluating NSAIDs alone and multimodal analgesia being infrequently emphasised. This contrasts with adult practice, where opioid-sparing and multimodal strategies are increasingly advocated.[ 15 16 ] A recent review on analgesic practices, trends, and outcomes in paediatric AP reported that analgesia was administered in 67% of patients, with opioids used in approximately 60%, paracetamol in 20–77%, and NSAIDs in 8–40% of cases. The authors concluded that opioids continue to be the mainstay of pain treatment in paediatric AP in North America, while highlighting significant knowledge gaps regarding determinants of analgesic choice, the impact of analgesic modality on post-pancreatitis outcomes, and long-term analgesic exposure. They stressed on the need for future studies to guide evidence-based analgesic strategies in children with AP.[ 17 ] Guidance from the North American Society for Paediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) Pancreas Committee, based on a MEDLINE review encompassing adult and paediatric AP, recommends that opioids may be used when opioid-sparing measures are inadequate, reinforcing a stepwise and individualised approach to analgesia rather than routine opioid use.[ 18 ] In ARP and CP, insights from the INSPPIRE cohorts further highlight the burden of pain and opioid exposure. INSPPIRE-1 (2012–2015) reported that 45% of children were on pain medications, with 17% reporting frequent opioid use, which was significantly higher in CP (65%) compared to ARP (41%). In contrast, INSPPIRE-2 (2017) demonstrated a shift towards reduced opioid exposure, with 40% receiving pain medications, 3.5% on opioids, and only 1% reporting frequent opioid use, suggesting evolving practice patterns towards opioid minimisation.[ 19 20 21 ] Against this backdrop, our study demonstrates that multimodal pain management, incorporating paracetamol, NSAIDs, and judicious opioid use, resulted in clinically and statistically significant reductions in pain scores across all pancreatitis subtypes, with minimal adverse effects. Importantly, opioid requirements (MME24) in our cohort were comparable to international data, and length of hospital stay was independent of analgesic modality, supporting the safety and efficacy of multimodal approaches.[ 22 ] With the United States Food and Drug Administration (FDA) issuing a black box warning on the use of tramadol in children, current guidelines recommend morphine as the preferred opioid for the management of moderate to severe nociceptive pain. Tramadol should be reserved for acute pain and used only at the minimal effective dose, in an age-appropriate formulation, and after clear counselling of parents or caregivers regarding dosing, potential adverse effects, and safety considerations. However, in the Indian context, the application of these recommendations is challenged by the well-described “opioid paradox”, wherein access to morphine remains limited due to regulatory, logistical, and supply-chain barriers despite high clinical need and India being one of the world’s largest producers of opium, access to morphine remains severely limited for patients in pain.[ 23 24 ] Consequently, tramadol continues to be widely relied upon for the management of moderate to severe pain in children in many centres. This reflects a pragmatic response to limited opioid availability rather than a deviation from evidence-based care. However, it highlights the urgent need for context-sensitive pain management guidelines. It also emphasises the need to improve access to essential opioids and to strengthen systems for safe opioid prescribing and monitoring in low- and middle-income countries.[ 24 ] Despite escalation of systemic analgesics, two patients in the current study required epidural analgesia for adequate pain control, highlighting the presence of refractory pain in a small subset of children and the need for individualised pain management strategies in severe cases. A 7-year-old boy with CP secondary to pancreatic divisum needed escalating pain management strategies varying from intravenous paracetamol, NSAIDs (ketorolac and ibuprofen used at different time intervals), tramadol, morphine, and clonidine to thoracic epidural infusion of 0.1% levobupivacaine run at 6 ml/hour for pain relief during the in-patient hospital admission period of over 10 days. The other 3-year-old child with acute necrotising pancreatitis secondary to cholelithiasis needed a thoracic epidural infusion of 0.1% levobupivacaine (3 ml/hour) after poor response to intravenous paracetamol and ketorolac after 3 days of treatment. Interventional procedures formed an important component of overall disease management. Endoscopic interventions were performed in 20 patients, and drainage procedures were required in 10 patients, primarily to reduce the frequency and severity of acute pain exacerbations. These findings highlight the role of a multidisciplinary approach, combining medical, interventional, and pain-focused strategies, in the comprehensive management of paediatric pancreatitis. The limitations of this study are the retrospective nature of the chart review, which is inherently limited by missing or incomplete data and dependence on documentation accuracy. Analgesic usage after hospital discharge and during follow-up was not analysed, limiting insights into longer-term pain management and opioid exposure. Pain assessment relied on unidimensional pain scores (NRS), without evaluation of the broader impact of pain on functional status or quality-of-life indicators. However, this study represents one of the first reports from South or Southeast Asia documenting pain patterns and analgesic use in children with pancreatitis, contributing region-specific data to a largely Western-dominated literature. The consistent use of multimodal analgesia across patients demonstrated good efficacy, supporting its role as a feasible and effective strategy; however, larger prospective studies are required to corroborate these findings and inform standardised protocols. The continued use of tramadol for acute pain in children, despite an FDA black box warning, highlights global disparities in opioid availability, regulatory barriers, and the need for context-appropriate pain management guidelines in low- and middle-income countries.