Times Are Changing in Pediatric Delirium*

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In adult units, delirium is associated with increased risk of mortality, prolonged ICU and hospital stay, ongoing neurophysiologic deficits, poor quality of life after leaving the unit, and increased cost (1). While adult clinical practice guidelines for sedation and analgesia have included evaluation for delirium since 2002 (2), the pediatric literature about pediatric delirium (PD) was scarce, especially in relation to critical care illness. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, published in 2000 (3), defined delirium as an acute cerebral dysfunction, with disturbance of consciousness and main elements of disordered attention and cognition, a fluctuating course, directly triggered by a general medical condition. Due to difficulties of diagnosing PD related to age and neurodevelopmental stage, the ICU practitioners relied on help from psychiatric consultation whenever they suspected PD. One early screening tool, Pediatric Anesthesia Emergence Delirium (PAED) Scale, first introduced in 2004 to screen for delirium as emerging from anesthesia, was only validated in ages over 19 months, and lacked items to account for observation of hypoactive delirious symptoms (4).
In 2009, the Vanderbilt Delirium Group developed the Pediatric Confusion Assessment Method (pCAM-ICU) which follows closely the CAM-ICU tool for screening for delirium in adults. Validated in 2011, this is an elegant and accurate tool but restricts the age of the patient to 5 years and over and it is of limited use in patients with developmental delay (5). In 2016, the preschool Confusion Assessment Method for the ICU was validated in children 6 months to 5 years old but excluded developmentally delayed children (6). In 2012, the Cornell Assessment of Pediatric Delirium (CAPD) instrument was first introduced as an adaptation of the PAED scale by adding criteria for diagnosing hypoactive delirium and age dependent anchor points to eliminate the age restrictions (7). CAPD was further developed to reflect DSM IV diagnosis of delirium and validated in 2014 (8). Currently, it is the instrument recommended by the European Society of Paediatric and Neonatal Intensive Care to assess PD (grade A recommendation) (9). It requires less than 2 minutes for trained staff to perform (7) and is able to differentiate PD from oversedation, pain, and agitation (8).
In 2012, Kudchadkar et al (10) surveyed pediatric intensivists regarding the practice of screening for PD in mechanically ventilated children. Three hundred fourteen responders, 70% from North America, reveal a startling truth: less than 30% attest that their respective units screen for PD, and only 2% say this screening is performed on every child at least once per nursing shift. Only six responders reported using a validated screening tool (pCAM-ICU). This is in the context of a 2016 worldwide PICU point prevalence of PD of 25% (11).
In this issue of Critical Care Medicine, the authors describe the epidemiology and in-hospital outcomes of PD in the largest single-center study to research PD to date (12). The study enrollment occurs over the span of one calendar year and the data collection is comprehensive. PD is screened bid by means of CAPD. It includes the full spectrum of pediatric critically ill patients, including developmentally delayed children with a pediatric cerebral performance category of at least four (conscious but dependent on others) for which the authors make an additional effort to obtain an accurate diagnosis by using psychiatrist or intensivist additional evaluations to ascertain an alteration from mental status at prehospital baseline. The study shows that critically ill children that develop delirium have 4.39 higher odds of dying during their hospital stay than those that do not, independent of their predicted risk of mortality at admission.

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