Pediatric Delirium: Recognition and Management

• Pediatric delirium is an area of growing interest, with research shifting from definitions and symptoms to management and outcomes
• The active focus of current studies is consensus on minimizing delirium risk and mitigating negative consequences

Pediatric Delirium: Recognition and Management

• Core symptoms include impaired consciousness/awareness, inattention, sleep-wake cycle abnormalities, thought disturbance, behavioral dyscontrol, and fluctuating symptoms
• Risk factors include younger age, male gender, pre-existing cognitive impairment/developmental delay, prior delirium, family history, and pre-existing emotional/behavioral issues
• Sedatives like benzodiazepines, opioids, propofol, and ketamine are often linked to delirium
• Continuous infusion of sedatives correlates with prolonged mechanical ventilation, longer hospitalization, and refractory agitation
• "Sickness behavior" often precedes delirium, involving reduced appetite, fatigue, sleep disturbance, loss of interest, isolation, and exaggerated pain responses
• Delirium rates were highest in patients with infectious or inflammatory disorders, based on a study of over 800 subjects, where 25% screened positive for delirium
• Delirium is usually diagnosed within the first few days of PICU admission, where prevalence increases with PICU stays of 6+ days, mechanical ventilation, physical restraints, and younger age (under 5)
• Pediatric delirium subtypes include hyperactive, hypoactive, and mixed; hypoactive is most common
• Motoric subtypes in children/adolescents do not differ in symptoms, risk factors, or outcomes
• Disrupted sleep-wake cycles are typical, particularly in mechanically ventilated patients on sedatives/analgesics, resulting in decreased sleep quality and efficiency
• Melatonin and ramelteon, a selective melatonin receptor agonist, may reduce delirium risk
• Catatonia symptoms often overlap with delirium, including incoherence, altered awareness, agitation, and behavioral change
• Delirium can be distinguished from catatonia through hallucinations, perceptual disturbances, disorientation, impaired memory, and retained language skills
• Catatonia may occur with or following delirium in approximately one third of patients
• Neuroleptics can worsen symptoms of catatonia and address delirium, while benzodiazepines can worsen delirium & manage catatonia symptoms
• Delirium may stem from both opioid and benzodiazepine use, as well as their withdrawal
• The Vanderbilt Assessment for Delirium in Infants and Children aims to standardize pediatric delirium assessment by psychiatrists
• The Pediatric Confusion Assessment Method (pCAM-ICU) is for verbal children 5+, while the psCAM-ICU is for younger children (6 months-5 years)
• The Cornell Assessment of Pediatric Delirium (CAP-D) is applicable for younger/nonverbal children
• The pCAM-ICU and CAP-D are designed for use by nurses and non-psychiatric physicians, and are widely used

Pediatric Delirium: Treatment

• Treatment is fundamentally addresses the underlying cause
• Effective control of distressing/dangerous symptoms and collaboration among medical specialties are key
• Establishing a therapeutic environment with good lighting, clocks, familiar objects and limiting staff changes decrease fear and confusion
• Environmental management is often sufficient, and medication may not be needed
• Pharmacologic management depends on off-label use of antipsychotics, while avoiding agents that may cause or worsen delirium, especially benzodiazepines
• Benzodiazepines can precipitate or prolong delirium and agitation, particularly in children
• Antipsychotics manage confusion and agitation effectively, allowing for less prolonged use and lower doses of benzodiazepines and opioids
• Haloperidol can be given orally or intravenously, atypical antipsychotics can only be given orally
• Quetiapine, risperidone, and olanzapine are the most studied atypical antipsychotics and are first-line choices
• Quetiapine appears least likely to cause hepatic complications, and is useful in patients with hepatic compromise
• Light sedation or no sedation is the goal in caring for critically ill adults
• Dexmedetomidine provides sedation, anxiolysis, and sympatholysis without significant respiratory compromise/hypotension/increased delirium risk
• Oral clonidine is typically used to ameliorate opioid withdrawal

Pediatric Delirium: Consequences in Survivors

• Physical, functional, neurocognitive, and psychological consequences can substantially impact survivors and families
• The postintensive care syndrome includes new or worsening physical, cognitive, or mental health status after critical illness which persist beyond hospitalization
• Risk factors for developing the PICS include younger age, lower socioeconomic status, increased invasive procedures/interventions, type of illness, and increased benzodiazepine/narcotic administration
• An episode of delirium increases the risk for subsequent delirium, anxiety, depression, delusional memories, and posttraumatic stress disorder
• Longer delirium duration is correlated to more severe subsequent cognitive and memory problems
• Posttraumatic stress disorder (PTSD) after PICU admission is recognized in 5–28% of survivors
• Adult survivors most remember visual hallucinations and feeling afraid and confused, and a large majority are distressed by their experience (86%)
• Morbidity and mortality increase after discharge from the PICU
• Poor outcome is associated with greater severity of illness, mechanical ventilation, more ventilator days, use of vasoactive medications, and greater PICU length of stay
• The highest risk for mortality following PICU stay is in pediatric patients with an oncologic or neurologic diagnosis
• The acute alteration in consciousness that characterizes delirium implies significant CNS dysfunction from a variety of etiologies
• Environmental interventions are often sufficient to ameliorate its distress.
• Avoidance of benzodiazepines may decrease its occurrence, and utilization of antipsychotic medications is effective in managing its symptoms.