Background: This study aimed to elucidate the characteristics and the risk factors for Asparaginase-associated pancreatitis (AAP) in children with acute lymphoblastic leukemia (ALL) under Taiwan Pediatric Oncology Group (TPOG)-ALL regimen. Methods: The retrospective hospital-based cohort study was conducted by reviewing the chart records of total 191 pediatric ALL patients aged 1-18 years treated with TPOG-ALL (2002 and 2013) protocols at the National Cheng Kung University Hospital, Tainan, Taiwan, from 2002 to 2019. The disease incidence, clinical presentations, laboratory data, complications, and outcomes of AAP were investigated. Results: The incidence of AAP among 191 ALL children was 4.7%. The incidence was significantly higher in children treated with the TPOG-ALL-2013 (n=62) than TPOG-ALL-2002 (n=129) protocol (11.3% vs. 1.6%, p= 0.006). Multivariate analysis identified using TPOG-ALL-2013 protocol was an independent risk factor for AAP. All of the 9 AAP cases had associated complications, such as systemic inflammatory response syndrome, thrombocytopenia, coagulopathy, liver dysfunction, hypoalbuminemia, jaundice, ascites, pleural effusion, hyperglycemia and hypertriglyceridemia. Pancreatic necrosis or pseudocysts developed in 7 (78%) patients. Notably, 1 (11%) AAP cases developed diabetes mellitus and 4 (44%) had chronic pancreatitis during a 1-year observational period. None were mortality. Conclusions: The incidence of AAP was 4.7% in ALL patients treated with TPOG-ALL protocol. Although a higher cumulative dose of Asparaginase in TPOG-ALL-2013 may attribute to the pancreatic toxicity, unidentified factors such as genetic predisposition still need further study.