Overview
Definition:
Delirium in children is an acute, fluctuating disturbance of consciousness, attention, cognition, and perception, often characterized by an abrupt onset and a fluctuating course.
Epidemiology:
Prevalence varies significantly by setting, ranging from 10-20% in general pediatric wards to over 50% in pediatric intensive care units (PICU)
Risk factors include younger age (infancy/toddlerhood), pre-existing neurodevelopmental disorders, and prolonged hospitalizations.
Clinical Significance:
Undetected delirium in children is associated with prolonged hospital stays, increased need for mechanical ventilation, higher rates of delirium in adulthood, and potential long-term neurodevelopmental deficits
Early identification and management are crucial for improving outcomes.
Clinical Presentation
Symptoms:
Fluctuating attention and awareness
Disorientation to time, place, or person
Cognitive deficits including memory impairment or disorganized thinking
Perceptual disturbances such as hallucinations or delusions
Hyperactive symptoms (agitation, restlessness) or hypoactive symptoms (lethargy, withdrawal)
Sleep-wake cycle disturbances.
Signs:
Inability to maintain focus or follow commands
Inappropriate speech or behavior
Motor restlessness or stupor
Increased or decreased interaction with the environment
Vital sign abnormalities including tachycardia, hypertension, or fever secondary to underlying illness.
Diagnostic Criteria:
While the DSM-5 criteria are often adapted, specific pediatric delirium screening tools are more practical
The Confusion Assessment Method for the Pediatric Intensive Care Unit (PCCM) and the Pediatric Confusion Assessment Method (pCAM) are widely used
Key elements include acute onset/fluctuating course, inattention, disorganized thinking, and altered level of consciousness or perceptual disturbances.
Diagnostic Approach
History Taking:
Detailed history of onset and fluctuation of symptoms
Baseline developmental status and cognitive function
Recent illnesses, surgeries, or medications
Known risk factors such as pre-existing conditions or sensory impairments
Parental/caregiver observations of behavioral changes.
Physical Examination:
Comprehensive neurological examination to rule out primary neurological deficits
Assessment of vital signs for instability
Evaluation for signs of infection, pain, or discomfort
Review of sensory deficits (vision, hearing) which can mimic or contribute to delirium.
Investigations:
Laboratory tests to identify underlying causes: complete blood count (CBC), electrolytes, renal and liver function tests, blood glucose, urinalysis, blood cultures, inflammatory markers (CRP, ESR)
Neuroimaging (CT, MRI) if structural brain lesions are suspected
Electroencephalogram (EEG) to rule out non-convulsive status epilepticus
Toxicology screening if substance intoxication/withdrawal is a concern.
Differential Diagnosis:
Seizure disorders (especially non-convulsive status epilepticus)
Primary psychiatric disorders (e.g., psychosis)
Severe anxiety or post-traumatic stress disorder
Neurodevelopmental disorders
Intoxication or withdrawal syndromes
Metabolic encephalopathies.
Management
Initial Management:
Address and treat the underlying cause (e.g., infection, hypoxia, metabolic derangement)
Ensure adequate hydration and nutrition
Optimize pain and symptom control
Minimize environmental stressors.
Medical Management:
Pharmacological management is typically reserved for severe agitation or distress that poses a risk to the child or staff, or when non-pharmacological methods fail
Low-dose antipsychotics (e.g., haloperidol, risperidone, olanzapine) or sedatives (e.g., dexmedetomidine for PICU patients) may be used cautiously
Doses and durations should be individualized and minimized.
Non Pharmacological Interventions:
Environmental modifications: Ensure adequate lighting, reduce noise, maintain a consistent sleep-wake cycle
Family involvement: Encourage family presence and interaction
Sensory aids: Provide glasses and hearing aids if needed
Reorientation: Gentle and consistent reorientation to time and place
Minimize physical restraints
Promote mobility and engagement in age-appropriate activities.
Supportive Care:
Continuous monitoring of vital signs and neurological status
Management of fluid and electrolyte balance
Adequate pain relief
Nutritional support
Early mobilization as tolerated
Close collaboration between medical, nursing, and allied health teams.
Prevention Strategies
Risk Factor Modification:
Proactive identification and management of risk factors such as pain, sleep deprivation, and immobility
Early mobilization protocols
Implementing non-pharmacological interventions routinely.
Environmental Optimization:
Creating a calm, quiet, and well-lit environment
Minimizing disruptions during sleep
Providing familiar objects and sensory aids.
Staff Education:
Regular training for ward staff on delirium recognition, screening tools, and management principles
Fostering a culture of vigilance for delirium.
Prognosis
Factors Affecting Prognosis:
Underlying illness severity
Duration of delirium
Presence of pre-existing neurodevelopmental issues
Timeliness of diagnosis and intervention.
Outcomes:
Children who experience delirium, particularly in the PICU, may have increased risk of neurocognitive deficits, behavioral problems, and poorer functional outcomes post-discharge
Recovery from delirium can be prolonged and may require ongoing support.
Follow Up:
Children with a history of delirium may benefit from neurodevelopmental follow-up to identify and address any persistent cognitive or behavioral sequelae
Regular assessments and early intervention are key.
Key Points
Exam Focus:
Delirium is a neurocognitive emergency in children
Screening tools (pCAM, PCCM) are essential for early detection
Differentiating delirium from primary psychiatric disorders is critical
Treatment focuses on addressing the underlying cause and non-pharmacological strategies.
Clinical Pearls:
Always consider delirium in a child with sudden behavioral or cognitive change on a pediatric ward
Parental input is invaluable
Hypoactive delirium is often missed
Aggressive management of pain and sleep disturbances can prevent delirium.
Common Mistakes:
Misdiagnosing delirium as a behavioral problem or primary psychiatric illness
Failing to screen for delirium in at-risk populations (PICU, post-op)
Over-reliance on sedatives or antipsychotics without addressing the underlying cause
Underestimating the long-term neurocognitive impact of pediatric delirium.