DOI: 10.1097/CCM.0000000000001491

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PMID: 26901555

Issn Print: 0090-3493

Publication Date: 2016/03/01


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Delirium in Preschool Children: Diagnostic Challenge, Piece of Cake, or Both?*

Jan N. M. Schieveld; Ingeborg P. M. Hermus; Jack W. A. M. Oomen

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Excerpt

“This is NOW not my child anymore” is a classic common exclamation at the PICU. The differential diagnosis of this observation is broad and includes pediatric delirium (PD) (1). The Diagnostic and Statistical Manual of Mental Disorders (DSM)-V (2) distinguishes five main characteristics of (adult) delirium: 1) a disturbance in attention and awareness, 2) the disturbance develops over a short period of time (hours to days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day, 3) an additional disturbance in cognition, 4) the disturbances mentioned in criteria 1 and 3 are not better explained by a pre-existing established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal, and 5) there is evidence from the history, physical examination, or laboratory findings that the disturbance is a direct physiologic consequence of another medical condition. However, criterion 4 is already considered controversial (3).
In the past years, several screening tools for PD were developed based on these adult criteria. This is an uncomfortable fact because the DSM-V criteria for delirium are only applicable in children of 5 years and older. In the clinically important subgroup of younger children (80% of PICU population is younger than 5 yr and 50% is younger than 3 yr), PD is of course difficult/impossible to diagnose because the neuropsychologic criterion regarding the change in cognition cannot be assessed reliably. Despite the high prevalence of PD (20–30% in critically ill children [4], with an occurrence in even 3-month-old babies [5–7]), there exist no specific diagnostic criteria for these young patients yet, as the DSM-IV, DSM-V, and International Classification of Diseases, 10th Edition, do not recognize PD as a separate clinical entity. Therefore, one has to rely on behavioral symptoms (4). In 2012, Silver et al (6) modified the already existing Pediatric Anesthesia Emergence Delirium to the Cornell Assessment of Pediatric Delirium (CAPD). This modification included 1) three extra criteria regarding the specifically hypoactive PD and 2) age-dependent anchor points (0–2 yr). The CAPD has a sensitivity of 94% and a specificity of 79% (4) and is easy to use (< 2 min) by clinicians and nurses. It is an observational screening tool, which covers the whole pediatric population (0 to 21 yr). These characteristics and the fact that it captures all delirium types make this tool important.
However, one can wonder whether a neuropsychologic criterion could still be useful to diagnose PD in the very youngest. After all, attention deficits actually are the most essential feature. So we welcome the article by Smith et al (8) published in this issue of Critical Care Medicine, in which they describe a new delirium screening tool for preschool children: the Preschool Confusion Assessment Method for the ICU (psCAM-ICU). They designed an objective and interactive, developmentally targeted delirium screening tool, determined its validity and reliability, and determined the PD prevalences in their cohort of 300 pediatric patients (age 6 mo to 5 yr, admitted to a PICU). First, they developed a long (“research”?) form of the psCAM-ICU (for details, see the article by Smith et al [8]).

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