Analgesia and Imaging Practices in Pediatric Appendicitis: A 14-Year Retrospective Trend Analysis

To examine 14-year temporal patterns and demographic differences in analgesic prescribing and imaging use among children with appendicitis in a tertiary pediatric emergency department (ED).

We conducted a retrospective cross-sectional study of children <18 years presenting with acute appendicitis (ICD-9/10 codes) to a large urban pediatric ED from 2010 to 2023. Analgesic categories included ketorolac, ibuprofen, acetaminophen, opioids, combination therapy, or no analgesia. Imaging modalities included ultrasound (US), computed tomography (CT), both, or none. Primary outcomes were calendar-year trends in analgesic prescribing and imaging modality use. Secondary analyses evaluated demographic/clinical factors associated with analgesic and imaging patterns using multivariable logistics regression.

Among 2275 children (mean [SD] age, 11.0 [3.6] years; 59.7% male; 70.4% White). Overall, 62.9% received analgesics; 43.6% single agents, 19.3% combinations. Opioid-only prescribing declined (32.3% in 2010 to 8.4% in 2023), while combination analgesics (9.2% to 24.2%), acetaminophen only (6.9% to 21.4%), and ketorolac (0% to 9.8%) increased. CT-only imaging decreased sharply (53.1% to 5.1%), while US-only imaging increased (5.4% to 41.9%). In regression analyses, older age was associated with greater odds of ketorolac (AOR 1.17; 95% CI: 1.08-1.26) and opioid use (AOR 1.15; 95% CI: 1.09-1.21). Male sex was associated with higher odds of no analgesia (AOR 1.33; 95% CI: 1.10-1.62). Black children had greater odds of combination analgesics versus White peers (AOR 1.54; 95% CI: 1.06-2.26). Perforation was strongly associated with combination analgesics (AOR 1.84; 95% CI: 1.27-2.65).

In a single-center study, pediatric appendicitis care shifted toward reduced opioid and CT use and increased nonopioid multimodal analgesia and US-based imaging over 14 years.