Delirium in children

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:

Synonyms and keywords: Delirium in kids

Overview

Delirium in children is a serious but understudied neuropsychiatric disorder. Delirium is an acute change in attention, awareness, cognition , perceptual disturbances sometimes causing hallucinations, and psychomotor agitation. Because of its heterogeneous clinical presentation there is no clear definition about it. Numerous conditions can cause delirium; therefore, early recognition and treatment are critical. Hypoactive subtype of delirium is often missed by paediatric practitioners, but can be reduced by mitigating risks and effectively managed by early detection.

Historical Perspective

• In the early 1960s, Eckenhoff et al. were the first to report the signs of hyperexcitation in patients emerging from anesthesia (cyclopropane, ketamine ) especially when administered for surgery like tonsillectomy, thyroidectomy, and circumcision in children.
• With the introduction of the new, short-acting, volatile anesthetics sevoflurane and desflurane into clinical practice, as compare to long acting halothane during surgical procedures the problem of emergency Delirium reemerged.
• In [year], [gene] mutations were first identified in the pathogenesis of [disease name].
• In [year], the first [discovery] was developed by [scientist] to treat/diagnose [disease name].

Classification

• [Disease name] may be classified according to [classification method] into [number] subtypes/groups:

• [group1]
• [group2]
• [group3]

• Other variants of [disease name] include [disease subtype 1], [disease subtype 2], and [disease subtype 3].

Pathophysiology

• The pathogenesis of delirium in pediatric patients is describe as the role of brain maturation in the development of this phenomenon. It is thought that if we compare a child brain to normal age-related regressive process with a consequent decrease in norepinephrine, acetylcholine, dopamine, and γ-aminobutyric acid (GABA). Thus, the decline of of cholinergic function and the hippocampus may suggest clues about the relative susceptibility of younger children to delirium.
• The [gene name] gene/Mutation in [gene name] has been associated with the development of [disease name], involving the [molecular pathway] pathway.
• On gross pathology, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].
• On microscopic histopathological analysis, [feature1], [feature2], and [feature3] are characteristic findings of [disease name].

Causes

Disease name] may be caused by [cause1], [cause2], or [cause3].

OR

Common causes of [disease] include [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

Differentiating [disease name] from other Diseases

• Delirium may be confused with agitation, but it may also be a cause of agitation. As most of the literature on this subject cannot differentiate between these two terms. For further information about the differential diagnosis, click Agitation .

Epidemiology and Demographics

• Children experienced post anesthesia agitation more often than adults (12%–13% vs 5.3%)
• Odds ratio of having one or more new-onset postoperative maladaptive behavior changes like delirium/agitation is 1.43 for children with marked emergence status when compared with children with no symptoms of Delirium.
• The incidence of emergency delirium largely depends on age, anesthetic technique, surgical procedure, and use of adjunct medication. Generally, it ranges from 10% to 50%, but may be as high as 80%
• Parents claim the Child's behavior upon emergence of anesthesia after surgery was the same as when he was suddenly awakened from deep sleep .

Age

• Patients of all age groups may develop delirium but it is more commonly observed among patients old aged as compare to young. It has been less addressed in children and adolescents
• Older children and adults usually become oriented rapidly after surgery, whereas preschool-aged children, tend to become agitated and delirious who are less able to cope with environmental stresses because psychological immaturity of preschool children
• The subpopulation of those aged 2–5 yr seems to be the most vulnerable as they are easily confused and frightened by unexpected and unpredictable experiences

Gender

• It affects men and women equally.

Race

• There is no racial predilection for delirium in children.

Risk Factors

Non-modifiable risk factors of delirium include

• Young age (age <2 years)
• Cognitive or neurological disabilities
• Need for invasive mechanical ventilation
• Severe underlying illness
• Pre-existing chronic conditions
• Poor nutritional status.

Children who are more emotional, more impulsive, introvert, and stubborn to environmental changes were identified to be at risk for developing post anesthesia delirium.

Etiological risk factors of pediatrics emergence delirium post-operatively includes:

• Rapid emergence
• Intrinsic characteristics of anesthesia
• Medication use like anticholinergics, droperidol, barbiturates, opioids, benzodiazepines, and metoclopramide
• Surgery type
• Post-operative pain
• Anxious child
• Child's temperature

Natural History, Complications and Prognosis

• The majority of patients with [disease name] remain asymptomatic for [duration/years].
• Early clinical features include [manifestation 1], [manifestation 2], and [manifestation 3].
• If left untreated, [#%] of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].
• Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].
• Delirium is often caused by a potentially life-threatening underlying condition and carries a poor prognosis if unrecognized.

Diagnosis

Diagnostic Criteria

• Diagnosing delirium occurs at the bedside by the emergency physician and includes objective screening measures for level of consciousness and cognition followed by confirmatory testing. Further evaluation, including interviewing any available surrogates, medications review, considering a broad differential diagnosis, including infection, trauma, stroke, and performing comprehensive diagnostic testing. To investigate and develop a risk scale for Emergency Delirium(ED), only children who are pain free should be studied because pain shares many of the characteristics of ED.

• There more than 15 different rating scales to measure Delirium in clinical investigations suggests that none are sufficiently specific and sensitive to assess children's behavior upon emergence because of difficult to interpret behavior in small children who are not able to verbalize pain, anxiety, hunger, or thirst.

• Predictors for mortality in pediatric delirium used were the Pediatric Index of Mortality (PIM) and Pediatric Risk of Mortality (PRISM II) for ruling in, or out, patients at risk of pediatric delirium.

• Most authors developed 3–5-point rating scales that used either crying or thrashing requiring restraint as their threshold for delirium, which had a significant influence on the calculated incidence of the event. Cravero et al. recorded delirium in 80% of sevoflurane patients considering crying as a threshold for delirium, but in 33% of patients only when thrashing was applied as the threshold for delirium. Several studies have tried to distinguish pain-related agitation from other sources by incorporating both pain and agitation scales into the methodology.
• Przybylo et al. described an assessment tool that is based on the items listed in the Diagnostic and Statistical Manual of Mental Disorders-IV for the diagnosis of delirium but eliminated signs and symptoms that required children participation like verbalization or skill demonstration as it is difficult in young children who are unable or unwilling to answer sometimes. Their scoring system studied perceptual disturbances, hallucinations, and psychomotor agitation in 25 children aged 2–9 yr. The authors concluded that while 44% of children showed altered behavior upon awakening after surgery, only 20% had complex symptoms that were consistent with delirium. Furthermore, none of these children either verbalized pain or received pain medication during the assessment period, reflecting the measurement of the phenomenon that was independent of pain-induced agitation.[10][10][10][10]
• Sikich and Lerman developed the pediatric anesthesia emergence delirium (PAED) rating scale that consists of five psychometric items for the measurement of ED in children. According to the Diagnostic and Statistical Manual of Mental Disorders -IV, three of these items are an important part of delirium and may be crucial to its differentiation from pain A decreased ability of the child to make eye contact with the caregiver and a declined awareness of his surroundings reflect disturbances in consciousness with a reduced ability to focus, sustain, or shift attention. Less purposeful actions suggest cognitive changes that include perception and memory impairment as well as disorganized thinking patterns. Two other items, restlessness and inconsolable crying, reflect a disturbance in psychomotor behavior and emotion. But pain was not controlled appropriately during study which may have contributed towards compromised results.

• [criterion 4]

Sign and Symptoms:

Patient appear in dissociated state of consciousness in which the child is

• Irritability
• Uncompromising
• Uncooperative
• Incoherent
• Inconsolably crying
• Moaning
• Kicking
• Thrashing
• Paranoid delusions
• Combative behavior
• These children do not recognize or identify familiar objects or people around them.

Physical Examination

• Physical examination may be remarkable for:

• [finding 1]
• [finding 2]
• [finding 3]
• [finding 4]
• [finding 5]
• [finding 6]

Laboratory Findings

• There are no specific laboratory findings associated with [disease name].

• A [positive/negative] [test name] is diagnostic of [disease name].
• An [elevated/reduced] concentration of [serum/blood/urinary/CSF/other] [lab test] is diagnostic of [disease name].
• Other laboratory findings consistent with the diagnosis of [disease name] include [abnormal test 1], [abnormal test 2], and [abnormal test 3].

Electrocardiogram

There are no ECG findings associated with [disease name].

OR

An ECG may be helpful in the diagnosis of [disease name]. Findings on an ECG suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

X-ray

There are no x-ray findings associated with [disease name].

OR

An x-ray may be helpful in the diagnosis of [disease name]. Findings on an x-ray suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no x-ray findings associated with [disease name]. However, an x-ray may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Echocardiography or Ultrasound

There are no echocardiography/ultrasound findings associated with [disease name].

OR

Echocardiography/ultrasound may be helpful in the diagnosis of [disease name]. Findings on an echocardiography/ultrasound suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no echocardiography/ultrasound findings associated with [disease name]. However, an echocardiography/ultrasound may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

CT scan

There are no CT scan findings associated with [disease name].

OR

[Location] CT scan may be helpful in the diagnosis of [disease name]. Findings on CT scan suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no CT scan findings associated with [disease name]. However, a CT scan may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

MRI

There are no MRI findings associated with [disease name].

OR

[Location] MRI may be helpful in the diagnosis of [disease name]. Findings on MRI suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

OR

There are no MRI findings associated with [disease name]. However, a MRI may be helpful in the diagnosis of complications of [disease name], which include [complication 1], [complication 2], and [complication 3].

Other Imaging Findings

There are no other imaging findings associated with [disease name].

OR

[Imaging modality] may be helpful in the diagnosis of [disease name]. Findings on an [imaging modality] suggestive of/diagnostic of [disease name] include [finding 1], [finding 2], and [finding 3].

Other Diagnostic Studies

• [Disease name] may also be diagnosed using [diagnostic study name].
• Findings on [diagnostic study name] include [finding 1], [finding 2], and [finding 3].

Treatment

Medical Therapy

Treatment of delirium includes treating the underlying cause as well as careful administration of antipsychotic drugs when nonpharmacologic treatments are insufficient.

• Emergency delirium usually occurs during recovery from anesthesia within the first 30 min and is self-limited (5–15 min), and often resolves spontaneously so, the mainstay of therapy is supportive care.

• If delirium persists, The management of its symptoms depends on the off-label use of antipsychotics, while avoiding agents that precipitate or worsen delirium.
• Use of antipsychotics as Olanzapine, quetiapine, and risperidone are presently considered first-line drugs, usually replacing haloperidol because of its extra-pyramidal side-effects .
• Other medications have shown good results are those that improve sleep disturbances that is important characteristic of delirium, it include melatonin and dexmedetomidine, an α2-agonist.
• Avoid use of benzodiazepines and opioids that may worsen delirium.

Surgery

• Surgery is the mainstay of therapy for [disease name].
• [Surgical procedure] in conjunction with [chemotherapy/radiation] is the most common approach to the treatment of [disease name].
• [Surgical procedure] can only be performed for patients with [disease stage] [disease name].

Prevention

To reduce delirium in hospitalised children, health-care providers should optimise the hospital environment by

• Reducing sleep disruption
• Keep the child stimulated and awake during the day
• Good pain management
• Decrease sedation especially decrease use of benzodiazepines
• Effective measures for the primary prevention of Post-operative delirium is by reducing preoperative anxiety, removing postoperative pain, and providing a quiet, stress-free environment for postanesthesia recovery. Parents who witness delirium may worry about permanent sequelae in their children.

• Once diagnosed and successfully treated, patients with [disease name] are followed-up every [duration]. Follow-up testing includes [test 1], [test 2], and [test 3].