Pediatric Delirium: Recognition, Management, and Outcome.

PURPOSE OF REVIEW: This review seeks to provide an update on the diagnosis, management, and outcome of pediatric delirium. RECENT FINDINGS: Care of patients with delirium depends on correct diagnosis and treatment of its underlying cause. A variety of instruments are available to aid diagnosis. Management of delirium currently depends on atypical antipsychotics, while avoiding agents that may precipitate or exacerbate it. While most critically ill children survive delirium, many children die or have worsening function after their illness. The longer the duration of delirium, the more severe its subsequent problems including postintensive care syndrome and posttraumatic stress disorder. Possible serious long-term consequences emphasize the importance of efforts to improve diagnosis and outcome in critically ill children suffering from delirium.

Pediatric Delirium: Evaluation, Management, and Special Considerations.

Delirium describes a syndrome of acute brain dysfunction with severe consequences on patient outcomes, medical cost, morbidity, and mortality. It represents a final common pathway of numerous pathophysiologic disturbances disrupting cerebral homeostasis. The diagnosis is predicated on recognition of the clinical features of the syndrome through ongoing clinical assessment. Early identification can be aided by routine screening, particularly in high-risk populations. Evaluation and management are continuous and simultaneous processes involving a multidisciplinary care team including child psychiatry consultation. Prevention, early identification and management are critical in alleviating symptoms, improving outcomes, and reducing distress for patients, families, and care teams. This review highlights our current understanding regarding pediatric delirium, its mechanisms, clinical manifestations, detection and management.

Symptoms before and after posterior fossa surgery in pediatric patients.

UNLABELLED: The posterior fossa syndrome (PFS) is common after cerebellar tumor resection in pediatric patients. It is characterized by postoperative mutism and ataxia and associated with persistent abnormalities in mood and cognition. METHOD: A 2-year prospective study of children and adolescents with cerebellar tumors identified by neuroimaging was performed at the Children's Hospital Los Angeles. RESULTS: There were 8 girls and 14 boys in the study, aged 14 months to 17 years. The tumor sizes ranged from 2 to 6.5 cm in diameter. The patients presented with ataxia, headache, vomiting, depressed or irritable mood and inattention. Symptoms of PFS were present postoperatively in all except for the 2 patients with lateral tumors. The symptoms began before resection, were most prominent immediately after surgery, and improved over time. Neuropsychological assessment of 10 patients documented a persistent cognitive decrement. CONCLUSION: This small, descriptive study provides information on the natural history of pediatric posterior fossa tumors from before surgery through the postoperative period.

Recurrent delirium after surgery for congenital heart disease in an infant.

OBJECTIVE: The objective of this article is to describe a case of recurrent delirium after cardiac surgery in an infant. DESIGN: Case report. The institutional review board at Children's Hospital Los Angeles waived the need for informed consent. SETTING: Cardiothoracic intensive care unit in a freestanding children's hospital. PATIENT: A male infant with hypoplastic left heart syndrome who developed delirium on consecutive admissions to the cardiothoracic intensive care unit after cardiac surgery. INTERVENTION: Pharmacologic intervention using the atypical antipsychotic olanzapine. MEASUREMENTS AND MAIN RESULTS: The symptoms of delirium resolved with the initiation and continuation of olanzapine on both occasions. CONCLUSION: Delirium is a common, but often unrecognized, diagnosis in the intensive care unit. Its early recognition and treatment may prevent unnecessary use of narcotics and benzodiazepines, decrease length of stay and may improve long-term neurocognitive function. This case report describes an infant who developed discrete, consecutive episodes of delirium following surgery for congenital heart disease. Both episodes were treated effectively with olanzapine.

When Mind Meets the Brain: Essentials of Well-Coordinated Management of Psychiatric Disorders in Neurological Diseases.

BACKGROUND: The management of psychiatric disorders in neurological diseases (PDND) creates special challenges that cannot be adequately addressed by either psychiatry or neurology alone. However, the literature on clinician-friendly recommendations on how to coordinate neurological and psychiatric care is limited. OBJECTIVE: This narrative review will provide practical instructions on how to efficiently integrate psychiatric and neurological care in inpatient management of PDND. METHODS: We reviewed articles published as recently as January, 2021 in five electronic databases. We included articles that assessed human care, focused on adults, and examined how to better coordinate care between different medical specialties, particularly, between psychiatry and neurology. RESULTS: Eighty-four manuscripts were included in this review, of which 23 (27%) discussed general principles of well-coordinated care of PDND in inpatient settings (first part of this review), and 61 (73%) were used to provide recommendations in specific neurological diseases (second part of this review). CONCLUSIONS: General principles of well-coordinated care of PDND include recommendations for both the primary team (usually neurology) and the consulting team (psychiatry). Primary teams should delineate a specific question, establish roles, and follow up on the recommendations of the consulting team. Consultants should do their independent assessment, be organized and specific in their recommendations, and anticipate potential problems. One of the most important aspect to develop well-coordinated care is the establishment of clear, frank and, preferably oral, communication between the teams. Practical difficulties in the management of PDND include pharmacodynamic and pharmacokinetic interactions as well as mutual dependency between psychiatry and neurology.

Alcohol use in congenital central hypoventilation syndrome.

Congenital central hypoventilation syndrome (CCHS) is a rare disorder where there is failure of automatic control of breathing. With improved recognition of CCHS, more children are appropriately diagnosed and treated in infancy, allowing survival into adult years. Because most of these children are able to participate in regular school, they are exposed to common adolescent behaviors, such as abusing alcohol and drugs. Alcohol and many illicit substances are known respiratory depressants. We report on 3 cases of adolescents/young adults with CCHS who had severe adverse events related to alcohol, including coma and death. This series illustrates the dangers of alcohol abuse in CCHS. We speculate that adolescents with CCHS may be less able to perceive the risks of substance abuse and impulsive behavior, leading to increased morbidity and mortality. Patients with CCHS appear to lack anxiety and the awareness that their inability to perceive physiologically dangerous levels of hypercarbia and hypoxia deprives them of important protective mechanisms.

Disordered respiratory control in children with partial cerebellar resections.

While the cerebellum is not traditionally thought of as having an important role in respiratory control, breathing involves cyclic motor acts that require cerebellar coordination. We postulate that children with partial cerebellar resections have disordered respiratory control due to altered synchronization of ventilatory muscles. We reviewed the records of 36 children following partial cerebellar resections due to neoplasms confined to the cerebellum. P aCO2 values were elevated in 19% of patients. Six patients had apneic or bradypneic events documented within the first month after resection. Two patients required intubation with assisted ventilation, and one needed assisted ventilation for 7.3 weeks. Those with apnea had lower oxygen saturations, and a longer need for supplemental oxygen. Patients with apnea were older than those without apnea. Swallowing, which uses many of the same muscles as those needed to maintain upper airway patency, was dysfunctional in 50% of those with apneas. We conclude that children with cerebellar resections have an increased incidence of apnea, hypoventilation, and hypoxemia not otherwise explained by pulmonary disease, and some require prolonged assisted ventilation. We speculate that these abnormalities are manifestations of altered respiratory control caused by dysfunctional cerebellar coordination of ventilatory muscles.

The pharmacologic management of delirium in children and adolescents.

Delirium is a serious and common problem in severely medically ill patients of all ages. It has been less addressed in children and adolescents. Treatment of delirium is predicated on addressing its underlying cause. The management of its symptoms depends on the off-label use of antipsychotics, while avoiding agents that precipitate or worsen delirium. Olanzapine, quetiapine, and risperidone are presently considered first-line drugs, usually replacing haloperidol. Other agents have shown promise, including melatonin to address the sleep disturbance characteristic of delirium, and dexmedetomidine, an α2-agonist, that may facilitate lower doses of benzodiazepines and opioids that may worsen delirium.

Olanzapine reduces delirium symptoms in the critically ill pediatric patient.

Delirium is a neuropsychiatric disorder characterized by acute disturbances in attention, consciousness, cognitive processing, perception, and the sleep-wake cycle. The few studies investigating treatment of delirium in critically ill children and adolescents have used differing diagnostic criteria, and have not employed control groups or procedures to blind observations. The objective of this study was to examine the efficacy of olanzapine for the treatment of delirium in the pediatric intensive care unit (ICU) using methodological procedures to reduce bias and allow greater generalization. Psychiatric records of 59 patients admitted to the pediatric ICU or cardiothoracic ICU over a 4 yr period with the diagnosis of delirium were examined. The delirium rating scale was used to assess delirium severity at the time of initial psychiatric evaluation and five days later. Raters were blinded to medication administration. Patients who were diagnosed with delirium, but did not receive olanzapine, or any other antipsychotic medication, served as the control group. Greater improvement of delirium symptoms was found for the olanzapine group (n = 31) than the control group (n = 28) (F (1,40) = 4.86, r = 0.33, 95% confidence interval = 0.020-0.58). This finding remained statistically significant after controlling for initial delirium severity (F (1, 20) = 28.62, r = 0.77, 95% confidence interval = 0.50-0.90). This study demonstrates patients with delirium administered olanzapine had greater reduction of delirium symptom severity than controls. It supplements the existing literature by using a study design that reduces expectancy effects and allows examination of the natural history of delirium symptoms without medication administration.

Review of delirium in the pediatric intensive care unit.

Delirium is an acute neuropsychiatric syndrome reflecting serious cerebral dysfunction. The characteristic core symptoms of delirium include the inability to direct, focus, sustain, and shift attention; abnormalities of the sleep-wake cycle; impaired consciousness and awareness; disturbance of thought processes; and behavioral dyscontrol. Delirium is particularly prevalent in critically ill and post-operative patients in the intensive care unit, and may result from hypoxia or infection. It is most likely in the most severely ill, and length of stay is prolonged, and morbidity and mortality and higher with delirium. A variety of clinical instruments have been developed to facilitate the diagnosis of delirium. The Delirium Rating Scale, and its 1998 revision (DRS and DRS-R98) are for psychiatrists to use and are based on DSM criteria. The Pediatric Confusion Assessment Method, adapted for pediatric patients in the ICU (pCAM-ICU), is designed for non-psychiatrists and nurses in the intensive care unit. The Pediatric Anesthesia Emergence Delirium scale (PAED) is the basis for the Cornell Assessment of Pediatric Delirium (CAP-D), and both are for nurses and doctors in the pediatric ICU to use to identify delirium in their patients. Delirium is typically multifactorial and its pathogenesis reflects neurotransmitter changes associated with metabolic and inflammatory processes. Benzodiazepines and anticholinergic drugs, including opioids and antihistamines, are widely used in the pediatric ICU and may precipitate or exacerbate delirium. Benzodiazepines especially are best used sparingly, in the lowest dose possible, if at all. The treatment of delirium is predicated on detecting and addressing its underlying cause, which usually results in its rapid resolution. Environmental interventions may ameliorate the risk for delirium, and drugs which may precipitate or worsen delirium should be avoided. Antipsychotics can provide benefit in managing agitation, perceptual disturbances, sleep-wake cycle abnormalities, and behavioral dyscontrol. Atypical antipsychotics, including olanzapine, risperidone, and quetiapine, have largely replaced haloperidol in newer approaches to management because of lower risk for adverse side effects. The risk for delirium may be mitigated by vigilance, and awareness of its presentation, pathogenesis, and management. Its prevention will be of significant benefit in reducing morbidity, improving outcome, and providing comfort to these very ill and fragile children.

The diagnosis and management of delirium in infancy.

OBJECTIVE: Atypical antipsychotics have been documented to be effective in the management of delirium in adults and older children, but despite considerable need, their use has been less studied in the very young. A retrospective chart review was undertaken to describe the use of atypical antipsychotics in controlling symptoms of delirium in infants and toddlers. METHODS: All psychiatric inpatient consultations performed during a 3 year period were reviewed to identify children <36 months old diagnosed with delirium. Delirium Rating Scale (DRS) scores were retrospectively calculated when the antipsychotic was initiated and discontinued, to confirm the diagnosis of delirium and evaluate symptom severity, and then to assess symptom response to pharmacologic intervention. RESULTS: There were 10 boys and 9 girls in the study population (ages 7-30 months, mean 20.5 months). Olanzapine (n=16) and risperidone (n=3) were used, and length of treatment and response were comparable for both medications. Mean DRS scores decreased significantly (p<0.001) with antipsychotic administration, without significant adverse side effects. CONCLUSIONS: Although randomized placebo controlled studies are needed to better characterize the indications, risks, and benefits, these atypical antipsychotic medications appeared to be effective and safe for managing delirium symptoms in very young pediatric patients.

Atypical antipsychotic medications to control symptoms of delirium in children and adolescents.

BACKGROUND: Atypical antipsychotics have been documented to be effective in the management of delirium in adults, but despite considerable need, their use has been less studied in pediatric patients. OBJECTIVE: A retrospective chart review was done to describe the use of atypical antipsychotics in controlling symptoms of delirium in children and adolescents. METHODS: Pharmacy records at Children's Hospital Los Angeles were reviewed to identify patients to whom antipsychotic agents were dispensed over a 24-month period. Psychiatric inpatient consultations during the same 24-month period were reviewed. Patients 1-18 years old diagnosed with delirium given antipsychotics constituted the study population. Delirium Rating Scale-Revised-98 (DRS-R98) scores were retrospectively calculated, when possible, at time antipsychotic was started to confirm the initial diagnosis of delirium and evaluate symptom severity, and again when antipsychotic was stopped, to assess symptom response. RESULTS: Olanzapine (n=78), risperidone (n=13), and quetiapine (n=19) were used during the 2 years of the study. Mean patient age, length of treatment, and response were comparable for the three medications. For patients with two DRS-R98 scores available (n=75/110), mean DRS-R98 scores decreased significantly (p<0.001) with antipsychotic without significant adverse side effects. CONCLUSION: Although randomized placebo-controlled studies are needed, atypical antipsychotic medications appeared to be effective and safe for managing delirium symptoms in pediatric patients while underlying etiology was addressed.

Late consequences of chronic pediatric illness.

There are many challenges in coping with and adapting to life with a chronic disease, and increased survival cannot be assumed to be associated with increased quality of life. A recent systematic review shows there is wide variation in outcomes depending on the definitions and measurements used to estimate the prevalence of chronic health conditions, making the impact of disability on children's health and social functioning difficult to assess; various authors have called for an international consensus about the conceptual definition of chronic health conditions in childhood. It frequently is difficult to determine if problems in psychosocial functioning are caused by the underlying illness, by treatment, or by the resultant effects of either illness or treatment on physical growth or cognitive development. Assessment and treatment of mental health should be an integral component of the comprehensive care of chronically ill children and adolescents. Transition of care is an important process that addresses significant changes from child-oriented to adult-oriented care. Adults who have chronic health conditions should continue to be evaluated periodically for late consequences of the childhood illness and early medical care, and attention should be paid to their ongoing psychosocial, psychiatric, educational, and vocational needs.

Late onset psychosis in survivors of pediatric central nervous system malignancies.

Survivors of pediatric intracranial malignancies are at recognized high risk for neurocognitive and psychosocial dysfunction, endocrinopathies, growth abnormalities, and second neoplasms. The late onset of persistent psychosis may represent an additional serious psychiatric consequence of childhood intracranial malignancies. The authors report eight survivors of pediatric intracranial malignancies whose course was complicated by the delayed onset of hallucinations, delusions, and bizarre behavior 2 to 12 years after diagnosis and treatment of brain tumors. The purpose of this report is to alert others to the generally unrecognized risk of psychosis following the treatment of brain tumors in children and adolescents.

Comparing symptoms of delirium in adults and children.

Delirium is presumed to be the same syndrome in all ages. Comparing pediatric and adult studies, the authors found many of the same symptoms reported, but often at significantly different rates. Sleep-wake disturbance, fluctuating symptoms, impaired attention, irritability, agitation, affective lability, and confusion were more often noted in children; impaired memory, depressed mood, speech disturbance, delusions, and paranoia, more often in adults; impaired alertness, apathy, anxiety, disorientation, and hallucination occurrence were similar. These may represent true differences in the presentation of delirium across the life-cycle, or may be attributable to inconsistent methodologies. Prospective studies are needed to resolve this question.

Mood and behavioral dysfunction with opsoclonus-myoclonus ataxia.

Opsoclonus-myoclonus ataxia syndrome is a paraneoplastic syndrome of cerebellar damage associated with neuroblastoma. The authors assessed psychiatric symptoms of opsoclonus-myoclonus ataxia syndrome in 17 children, who were 16 months to 12(1/2) years of age. Psychiatric symptoms examined included disruptive behavior, affective dysregulation, irritability, impulsivity, cognitive impairment, and poor attention.

Delirium in children and adolescents.

Rarely reported in pediatric patients, the characteristic symptoms and course of delirium are well known in adults. This retrospective study was undertaken to describe the clinical presentation, symptoms, and outcome of delirium in children and adolescents. Eighty-four patients age 6 months to 18 years were identified with delirium, from 1,027 consecutive psychiatric consultations during a 4-year period. Mortality was high (20%), and length of stay was prolonged. Symptoms of psychosis and disorientation were less characteristic, but overall the presentation and course of delirium were similar to adults, and the current Diagnostic and Standard Manual of Mental Disorders (DSM) criteria were found applicable in the pediatric population.

The delirium rating scale in children and adolescents.

The study of delirium has been neglected in pediatric patients, and there are no diagnostic criteria or rating scales adapted for use in this age group. The Delirium Rating Scale is widely used to diagnose and rate the severity of delirium in adults. It was retrospectively administered to 84 children and adolescents diagnosed with delirium to evaluate its applicability in pediatric patients. Delirium Rating Scale scores were comparable to those reported for delirium in adults, although single cross-sectional Delirium Rating Scale scores did not predict length of hospital stay or mortality outcome. Therefore, the Delirium Rating Scale can be used to evaluate delirium in the pediatric population.