Delirium in Children-Praise for the Paladins of Pediatrics

The Geezer has not said a word about hospitalized, medically ill children so far, but its high time. I talk about delirium in the elderly until I’m blue in the face, but did you know kids get delirious, too? There are a couple of reasons I don’t talk about it, one being the dearth of medical literature and that I get a little choked up about it. I’ve been in private practice briefly as a psychiatric consultant and witnessed the suffering of kids with devastating medical illness, some of them delirious.

However, there is growing interest by those I’m going to call paladins in pediatrics, or physicians who specialize in Pediatrics and Child and Adolescent Psychiatry. It’s hard to believe that many have thought delirium in children was inconsequential, but that’s false and research in this area is rapidly growing. According to a recent review, “patients with delirium constitute almost 10% of all inpatient referrals to child and adolescent consultation-liaison psychiatry services…[1]” Given the variability in reported prevalence rates, it’s fair to say delirium is probably as common in kids as it is in adults. Just like in older adults, delirium prolongs the hospital course and raises the mortality rate in children [2]. According to some researchers, the symptom presentation differs between children and adults and in geriatric adults, with more intense hallucinations and delusions, greater agitation, and more labile emotions but less severe cognitive deficits, less severe sleep-wake cycle disturbance, and less variability of symptoms over time [2].

The literature reveals possible predisposing factors for delirium in kids including younger age, male gender, intellectual disability, preexisting emotional and behavior problems, and even anxiety in caregivers [1]. A couple of precipitating factors associated with delirium in children and adolescents more than in adults are fever and general anesthesia. Virtually all of the medical problems that are associated with delirium in adults (and they are legion and include a variety of medications) can be linked to delirium in kids as well. Other features which may be preferentially associated with pediatric delirium may be developmental loss of previously acquired skills, inability of a caregiver to console the child, and other subtle indicators of a loss of emotional connection between child and caregiver.

The lack of research into the development of tools to diagnose delirium in kids has been criticized with a call for concerted efforts to develop pediatric delirium diagnostic algorithms. Some go so far as to assert that “Future algorithmic refinement is urgently required” [3]. The authors mention a new rating instrument, the pediatric version of the Confusion Assessment Method-Intensive Care Unit (pCAM-ICU), noting at the time the unvalidated status of the pCAM-ICU.

Enter the champions of delirium in the ICU, the Vanderbilt group. In fact, Dr. Heidi Smith and colleagues have validated the pCAM-ICU for use in diagnosing delirium in critically ill children who are chronologically and developmentally at least 5 years old [4]. The pCAM-ICU was developed in collaboration with child and adolescent psychiatrist, psychologists, pediatricians, and child development experts. It’s very similar to the CAM-ICU for critically ill adults originally developed at Vanderbilt by Dr. E. Wesley Ely, who was also involved in the validation study for the pCAM-ICU. The cognitive disorganization and the inattention items were among those components of the original CAM-ICU that were modified to be developmentally appropriate for children. It has  a high sensitivity of 83% and a specificity of 99%. The pCAM-ICU is for children who are in Pediatric ICU (PICU).

A very important point made in the Smith study is that many patients in the ICU receive sedatives in “quantities disproportionate to patient needs.” This elevates the risk for delirium in adults and there’s growing evidence this happens to children as well.  Using a valid and reliable instrument like the pCAM-ICU will enable ICU staff to identify delirium in kids and relate that to the use of commonly administered drugs. The prevalence of delirium in this study was 13.2% and the authors state flatly that it’s an underestimation probably related to several procedural barriers to getting timely assessments and because there was only one daily assessment. The pCAM-ICU can be used by nonpsychiatrically trained clinicians to diagnose delirium in children 5 years old or older and can be completed in about 2 minutes.

Much more research is needed in the development of management strategies for delirium in children. However, as in adults, both pharmacologic and nonpharmacologic approaches seem to be effective [1]. Psychosocial interventions include but are not limited to parents’ constant presence, familiar music and photographs, and favorite toys.  Antipsychotic medications including Haldol and Risperidone when administered carefully based on the weight of the child  have also been helpful to calm severe agitation. On the other hand, benzodiazepines can worsen delirium.

Much more study is urgently needed to increase our ability to provide high quality medical care to children and adolescents who are at risk for delirium and who become delirious. Prevention strategies using simple, family centered interventions designed to reduce preoperative anxiety have been reportedly effective.

That’s what little the Geezer knows from a brief literature search. What it tells me is how little we all know about delirium in kids and how grateful we can be that a few paladins of pediatrics are looking out for them, ensuring that hospitals are the safest possible havens for promoting healing in the very young.

1. Hatherill, S. and A. J. Flisher (2010). “Delirium in children and adolescents: A systematic review of the literature.” Journal of Psychosomatic Research 68(4): 337-344.
Objectives The purpose of this study was to collate all works relating to delirium and probable delirium in children and adolescents published since 1980. Methods A systematic review of the literature in all languages published between 1980 and March 2009 was conducted. Results The literature is limited to small case series and case reports including a total of 217 children or adolescents with definite delirium and a further 136 children and adolescents with “probable delirium.” These articles, in addition to unsystematic reviews, overviews, editorials, journal commentaries, and pertinent book chapters, are discussed in relation to prevalence, predisposing and precipitating factors, phenomenology, residual psychopathology, mortality, management, and prevention of delirium in childhood and adolescence. Conclusions Delirium is an important but neglected disorder of childhood associated with significant morbidity and high mortality. Current clinical practice for management is based on slim empirical evidence.

2. Leentjens, A. F. G., J. N. M. Schieveld, et al. (2008). “A comparison of the phenomenology of pediatric, adult, and geriatric delirium.” Journal of Psychosomatic Research 64(2): 219-223.
Background The phenomenology of delirium in childhood is understudied. Objective The objective of the study is to compare the phenomenology of delirium in children, adults and geriatric patients. Population and Methods Forty-six children [mean age 8.3, S.D. 5.6, range 0–17 years (inclusive)], admitted to the pediatric intensive care unit of Maastricht University Hospital, with Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) delirium, underwent assessment with the Delirium Rating Scale (DRS). The scores are compared with those of 49 adult (mean age 55.4, S.D. 7.9, range 18–65 years) and 70 geriatric patients (mean age 76.2, S.D. 6.1, range 66–91 years) with DSM-IV delirium, occurring in a palliative care unit. Score profiles across groups, as well as differences in individual item scores across groups are analysed with multiple analysis of variance, applying a Bonferroni correction. Results Although the range of symptoms occurring in all three groups was similar, DRS score profiles differed significantly across the three groups (Wilks lambda=0.019, F=804.206, P<.001). On item level, childhood delirium is characterized by a more acute onset, more severe perceptual disturbances, more frequent visual hallucinations, more severe delusions, more severe lability of mood, greater agitation, less severe cognitive deficits, less severe sleep-wake cycle disturbance, and less variability of symptoms over time. Adult and geriatric delirium do not differ in their presentations, except for the presence of more severe cognitive symptoms in geriatric delirium (P=.001). Conclusion Childhood delirium has a different course and symptom profile than adult and geriatric delirium. Adult and geriatric delirium differ only in the severity of cognitive symptoms.

3. Schieveld, J., J. van der Valk, et al. (2009). “Diagnostic considerations regarding pediatric delirium: a review and a proposal for an algorithm for pediatric intensive care units.” Intensive Care Medicine 35(11): 1843-1849.
Context If delirium is not diagnosed, it is unlikely that any effort will be made to reverse it. Given evidence for under-diagnosis, tools that aid recognition are required. Objective Relating three presentations of pediatric delirium (PD) to standard criteria and developing a diagnostic algorithm. Results Delirium-inducing factors, disturbance of consciousness and inattention are common in PICU patients: a pre-delirious state is present in most. An algorithm is introduced, containing (1) evaluation of the sedation-agitation level, (2) psychometric assessment of behavior and (3) opinion of the caregivers. Discussion It may be argued that the behavioral focus of the algorithm would benefit from the inclusion of neurocognitive measures. Limitations No sufficiently validated diagnostic instrument covering the entire algorithm is available yet. Conclusion This is the first proposal for a PD diagnostic algorithm. Given the high prevalence of pre-delirious states at the PICU, daily evaluation is mandatory. Future algorithmic refinement is urgently required.

4. Smith, H. A. B., D. C. Fuchs, et al. (2011). “Delirium: An Emerging Frontier in the Management of Critically Ill Children.” Anesthesiology Clinics 29(4): 729-750. Abstract: Delirium is a syndrome of acute brain dysfunction that commonly occurs in critically ill adults and most certainly is prevalent in critically ill children all over the world. The dearth of information about the incidence, prevalence, and severity of pediatric delirium stems from the simple fact that there have not been well-validated instruments for routine delirium diagnosis at the bedside. This article reviewed the emerging solutions to this problem, including description of a new pediatric tool called the pCAM-ICU. In adults, delirium is responsible for significant increases in both morbidity and mortality in critically ill patients. The advent of new tools for use in critically ill children will allow the epidemiology of this form of acute brain dysfunction to be studied adequately, will allow clinical management algorithms to be developed and implemented following testing, and will present the necessary incorporation of delirium as an outcome measure for future clinical trials in pediatric critical care medicine.

5. Smith, H. A., J. Boyd, et al. (2011). “Diagnosing delirium in critically ill children: Validity and reliability of the Pediatric Confusion Assessment Method for the Intensive Care Unit.” Critical care medicine 39(1): 150-157.
OBJECTIVE: To validate a diagnostic instrument for pediatric delirium in critically ill children, both ventilated and nonventilated, that uses standardized, developmentally appropriate measurements. DESIGN AND SETTING: A prospective observational cohort study investigating the Pediatric Confusion Assessment Method for Intensive Care Unit (pCAM-ICU) patients in the pediatric medical, surgical, and cardiac intensive care unit of a university-based medical center. PATIENTS: A total of 68 pediatric critically ill patients, at least 5 years of age, were enrolled from July 1, 2008, to March 30, 2009. INTERVENTIONS: None. MEASUREMENTS: Criterion validity including sensitivity and specificity and interrater reliability were determined using daily delirium assessments with the pCAM-ICU by two critical care clinicians compared with delirium diagnosis by pediatric psychiatrists using Diagnostic and Statistical Manual, 4th Edition, Text Revision criteria. RESULTS: A total of 146 paired assessments were completed among 68 enrolled patients with a mean age of 12.2 yrs. Compared with the reference standard for diagnosing delirium, the pCAM-ICU demonstrated a sensitivity of 83% (95% confidence interval, 66-93%), a specificity of 99% (95% confidence interval, 95-100%), and a high interrater reliability (kappa = 0.96; 95% confidence interval, 0.74-1.0). CONCLUSIONS: The pCAM-ICU is a highly valid reliable instrument for the diagnosis of pediatric delirium in critically ill children chronologically and developmentally at least 5 yrs of age. Use of the pCAM-ICU may expedite diagnosis and consultation with neuropsychiatry specialists for treatment of pediatric delirium. In addition, the pCAM-ICU may provide a means for delirium monitoring in future epidemiologic and interventional studies in critically ill children.

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Comments

  1. Seleena Shrestha says:

    I feel happy to read this article and find a zest of something that I have been interested in. I am a General Psychiatric resident and will be joining Child and Adolescent fellowship program soon. Every adult patient I was sent to evaluate made me curious how would a child with delirium look like and I would start to feel delirious myself! I also did some self research in the internet and was disappointed to know how less the topic has been studied. This article has given me hope that in few years more research will emerge unraveling the unknown and throwing light to something so important.

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    • I am thrilled you responded to this. I’m a psychiatric consultant for adults to the general hospital in an academic medical center and so I never get called to consult on cases of delirium in children. However, I worked very briefly as a consultant in private practice. I saw first hand how delirium presents in children, and they are very sad situations. There are too few Child and Adolescent Psychiatrists to justify the cost of hiring them for exclusive work as pediatric unit psychiatric consultants. Consequently, adult general psychiatrists in private practice are called upon to help children and families when delirium afflicts kids.

      I am so thankful for the researchers who are doing work in this area, enhancing our understanding of pediatric delirium pursuant to preventing this scourge of medically ill young people.

      And I wish you all the luck in the world in your upcoming fellowship training program in Child and Adolescent Psychiatry.

      Best wishes,

      Jim Amos, MD

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