IACAPAP Textbook of Child and Adolescent Mental Health

PSYCHIATRY AND PEDIATRICS

ChapterI.5

PE DIAT R I C D E L I R I UM
A PRACTICAL APPROACH
Jan N. M. Schieveld, Erwin Ista, Hennie Knoester &Marja L. Molag

Jan NM Schieveld MD, PhD
Consultant, Pediatric
Neuropsychiatry, Divisionof Psychiatry and NeuroPsychology, Departmentof Child and Adolescent
Psychiatry, Maastricht
University Medical Centre+,
Maastricht, Mutsaersstichting,
Venlo; Koraal Groep, Sittard,
The Netherlands
Conflict of interest: none
declared

Erwin Ista RN, PhD
Nurse Scientist, Intensive Care
Unit, Erasmus Medical Center,
Sophia Children’s Hospital,
Rotterdam, The Netherlands
Conflict of interest: none
declaredHennie Knoester MD, PhD
Pediatric intensivist, Emma
Children’s Hospital, Academic
Medical Centre, University of
Amsterdam, Amsterdam, The
Netherlands
Conflict of interest: none
declaredChild with Pediatric Delirium.
Mark Janssen, with permission.

This publication is intended for professionals training or practicing in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2015. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Schieveld JNM, Ista E, Knoester H, Molag ML. Pediatric delirium: A practical approach. In Rey JM (ed),
IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatryand Allied Professions 2015.

Pediatric delirium

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1IACAPAP Textbook of Child and Adolescent Mental HealthM

any names have been used by different disciplines to describe the clinicalentity of delirium, such as “acute confusional state”, “toxic psychosis”,”ICU psychosis”, “organic psychosyndrome”, “encephalopathy” etc.
Pediatric delirium was described for the first time in Leo Kanner’s 1935 textbook
Child Psychiatry in the chapter “Transient cerebral infections”. “Children becomedelirious so often and quickly that this is of no interest to us” wrote Bleuler (1955)
in his Lehrbuch der Psychiatrie. After a long period in which pediatric delirium was
ignored in textbooks, the topic was dealt with in the 1991 edition of Lewis’ Textbook
of Child and Adolescent Psychiatry. In DSM-IV, the section devoted to children
and adolescents does not have a single mention of pediatric delirium but there issome mention in the section devoted to delirium in adults. Pediatric delirium is
not described in DSM-5. However, in the last few years there has been a growing
awareness of the clinical importance of pediatric delirium, consistent with anincreasing number of publications on the topic (Kudchadkar et al, 2014; Schieveld& Janssen, 2014; Schieveld et al, 2014) and concerns have been expressed about
its clinical implications, the lack of systematic evidence and the lack of treatment
guidelines (Schieveld & Janssen, 2014; Schieveld et al, 2014).

DEFINITION
Delirium, from the Latin de-lira (out of the track), is a neuro-cognitive
disorder due to a somatic illness or its treatment. The brain can react to illness,particularly critical illness, with several responses of which the more important
are sickness behavior, fever, epilepsy, catatonia, delirium, refractory agitation, andcoma.
By critical illness it is meant a life-threatening failure of the brain, heart or
major organs. Sickness behavior is the behavioral repertoire displayed by humans—
and other mammal species—in response to infection, trauma, oncologicalproblems, and their treatment. This behavior is characterized by loss of interests
and appetite, emotional irritability, tiredness, and an increased need for sleep.
According to DSM-5 (American Psychiatric Association, 2013) the essential
features of delirium are:
•
•

•

•

A disturbance of attention or awarenessThis disturbance is accompanied by changes in cognition that cannot bebetter accounted for by another pre-existing neurocognitive disorder (e.g.,
mental retardation, dementia)
The condition develops in a short period of time, hours or days, andoften fluctuates during the day, typically worsening in the evening(“sundowning”); andThere are indications from the patients’ history, examination or laboratory
results that the disturbance is probably the result of a medical condition or
its treatment.

The DSM-5 definition of delirium has been criticized because of therequirement to exclude coma without specifying how this is to be done.
Consciousness has two simultaneous aspects:•

Arousal, which goes from clarity of mind to somnolence, stupor, and tocoma; andPediatric delirium

I.5

Marja L Molag MSc, PhD
Advisor, Kennisinsituut van
Medisch Specialisten, Utrecht,
The Netherlands
Conflict of interest: none
declared
ACKNOWLEDGEMENTS
We gratefully acknowledge theother members of the Dutch
study group Multidisciplinaire
Richtlijn Pediatrisch Delier 2014
(Multidisciplinary Guidelines
Pediatric Delirium 2014), ER de
Graeff-Meeder, LJ Kalverdijk,
JAM Gerver, M de Neef, M de
Hoog, E Koomen, CE CatsmanBerrevoets, MA Witten, and H
Rippen. ME Wessels from theKennisinstituut van MedischSpecialisten (Knowledge
Institute of Medical Specialists);
Kirsten Venrooij, Petra Wiegel,
Jolien Nivelle, Nico Roozendaal
from Maastricht University
Medical Centre+; and Noortje
Sax and Marlies de Feiter fromthe Nederlandse Vereniging
voor Psychiatrie (Dutch Society
for Psychiatry).
We also thank Mark Janssen
and Roel Seidell for allowing us
to reproduce their illustrations
initially published De
Limburger, February 2008,
and K&Z magazine, December
2014, respectively.

Delirium is acute brain
failure in man
─Lipowski, 1980)••

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2

IACAPAP Textbook of Child and Adolescent Mental Health•Content of thought, from logical reasoning according to age and education
to thought disorder.

Without an appropriate level of arousal thinking is not possible; that is,arousal is necessary for thinking. Arousal allows mental processes and the ability tofocus, sustain and shift attention to take place. With somatic disorders, attention is
the first to be lost and the last back.
ICD-10 (World Health Organization, 2015) defines delirium as an
etiologically nonspecific organic cerebral syndrome characterized by concurrent
disturbances of consciousness and attention, perception, thinking, memory,
psychomotor behavior, emotion, and the sleep-wake schedule. The duration isvariable and the degree of severity ranges from mild to very severe.

The brain is wider than
the sky
For put them side byside
The one the other will
includeWith ease - and you
beside.
─Emily Dickinson(1830-1886)

EPIDEMIOLOGY
Delirium has a high prevalence; it affects 10% to 30% of general hospitalpatients and up to 80% in tertiary intensive care units (ICUs). Delirium in adults
and the elderly is strongly associated with increased length of hospital stay, morbidity
and mortality. In the elderly it is associated with a faster cognitive decline, loss of
independence, and increased mortality in the year following hospital discharge.
Delirium is the most important predictor of the proximity of death in the elderly
and in oncological patients, young or old (terminal delirium).
The reported prevalence of delirium in critically ill children varies from 20%
to 30%. Rates depend on age (more common in younger children), severity of theillness, number of medications, diagnostic tools used, and group under study (e.g.,pediatric ICU patients, general ward). Mental retardation and a previous episodeof delirium are also known risk factors.

CLINICAL CHARACTERISTICS
According to seriousness, pediatric delirium can be benign and non-benign.
There are two types of benign pediatric delirium: emergence delirium and thecommon delirium seen in general practice.
Emergence delirium, also known as emergence agitation, is a welldocumented phenomenon occurring in children—and adults—in the immediate
postoperative period, after the withdrawal of anesthetic drugs. It frequently occurs
in an otherwise healthy child even after minor surgery or a diagnostic procedure.
Clinically, it fulfills all the criteria for pediatric delirium but has a benign course
and usually resolves completely—mostly without any intervention—in 30 to 45
minutes.
In general practice pediatric delirium frequently occurs in the context of
an infection (febrile delirium). It is characterized by confusion, which can beintense, in a sick child with a waxing and waning course, increasing in the evening
and night, usually coinciding with an increase in the fever. Although it can bedramatic, more often than not the underlying infection resolves within two or
three days and so does the delirium. In cases of persistent delirium of this kind an
emergency medical assessment is indicated.

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Paul Eugen Bleuler(1857-1939) was a Swiss
psychiatrist known forhis contribution to theunderstanding of mental
illness. He coined the term“schizophrenia”. Bleuler
considered pediatric delirium
to be unimportant because
children became delirious
easily and often. Opinion
has changed since then.

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IACAPAP Textbook of Child and Adolescent Mental Health

Case vignette 1
A 6-year-old boy was admitted to the pediatric ICU with respiratory insufficiency due
to an asthma attack. Despite asthma treatment he deteriorated and needed intubation andmechanical ventilation with high doses of sedatives and even muscle relaxation for a few
hours because of high ventilation parameters. Before intubation he said he was afraid to die
because of his breathing difficulty.
After two days his asthma improved and he was weaned from the ventilator. Afterextubation, on the third day after admission, he became confused, extremely anxious and had
hallucinations about flying objects and monsters; he became verbally aggressive (swearing
using words his parents believed he did not know). Besides, his parents did not recognize his
behavior as that of their child anymore. He was diagnosed as being delirious and treated withlorazepam (because of his extreme anxiety) and haloperidol intravenously.
Twenty-four hours after starting treatment his delirium improved, his behavior
normalized and he told his parents that he was feeling well again. This is a typical presentationof hyperactive pediatric delirium.
Case vignette 2
A 4-year-old boy was admitted to the pediatric ICU with epiglottitis and was mechanicallyventilated for three days. The boy was very agitated during the ventilation period (e.g., fightingwith the ventilator, extreme restlessness) and was sedated with midazolam, ketamine, andmorphine. After 48-hours he improved and was weaned from the ventilator. On the third dayof his admission he no longer required invasive ventilation support and was extubated. The
sedatives were tapered off and stopped.
On the fourth day of admission he was scheduled to be transferred to the referring
hospital. In the afternoon, two hours before the transfer was due, the boy suddenly becamevery agitated and anxious. Despite his parents being present, he made no eye contact withthem or the nurses. Shortly after he did not seem to be aware of his surroundings (e.g., of his
parents’ presence) and appeared to “live in his own world”. He scored seven on the SOS-PD
scale (a score of 4 or higher is consistent with pediatric delirium). A child psychiatrist was
consulted who concluded that the boy had developed delirium and advised starting treatment
with risperidone. Twelve hours after starting treatment his behavior normalized and he wasable to be transferred back to the referring hospital. This is a case of a combined type of
pediatric delirium (initially hyperactive and then hypoactive).
Case vignette 3
A 3-year-old girl was admitted for tracheal surgery. After surgery she wasmechanically ventilated for six days during which she was sedated with midazolam, ketamine,dexmedetomidine, levomepromazine, and morphine in various combinations. She was also
treated with dexamethasone. To prepare her for extubation this sedation was tapered off
except for the morphine which was changed to methadone. The day after extubation she
suddenly became slightly agitated, disoriented and was unable to focus her attention. Thatsame evening she became apathetic and unresponsive. She seemed to look through us with
an empty gaze and without making eye contact. She scored 21 points on the CAP-D (a scoreabove 10 is consistent with pediatric delirium) with high scores particularly on the hypoactive
delirium criteria. Her parent’s remarked: “We do not recognize our daughter anymore”. This isa typical case of hypoactive pediatric delirium.

Zbigniew J Lipowski(1924-1997) was a PolishCanadian neuro-psychiatrist
who wrote several books
on consultation-liaison
psychiatry, delirium andpsychosomatic illness
as well as numerous
articles. Lipowski had an
abiding interest in andknowledge about theinterface of consultation
liaison psychiatry andneurology, in particular
the problem of delirium.
His work culminatedwith the publication in1980 of his influential
monograph Delirium: Acute
Confusional States.

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IACAPAP Textbook of Child and Adolescent Mental Health

Delirium can also be hyperactive (children are agitated, irritable and thrash
about), hypoactive (they appear apathetic, uninterested) and mixed (see casevignettes for clinical examples).
Overall, there are more similarities than differences between children, adults
and the elderly:•

In general, critically ill children with delirium have a higher resilience(and better prognosis) than adults. This is probably owing to a better
vascularization of their brains, hearts, lungs etc. and they mostly have noother comorbidities or polypharmacy
The negative neuro-cognitive effects of delirium in adults and the elderly are
well known, but we do not know yet whether this is also true for children.

•

ETIOLOGY
Increasing evidence suggests there is a positive association between illness
severity and pediatric delirium, that is, severity of disease is a major risk factor fordelirium—the most common cause of severe delirium is a critical illness. Dependingon the local facilities, the most frequent places to encounter pediatric delirium are
hospitals or pediatric ICUs. The differential diagnosis of conditions potentiallyleading to delirium is summarized by the acronym “I WATCH DEATH” (Wise etal, 1987; see Table I.5.1).

Table I.5.1. Possible causes of delirium, summarized by the acronym ‘I WATCH DEATH’*
I

Infections

Encephalitis, meningitis, urinary tract infection, pneumonia…

W

Withdrawal

Alcohol, barbiturates, benzodiazepines…

A

Acute metabolic

Electrolyte imbalance, hepatic or renal failure…

T

TraumaHead injury, postoperative…

C

CNS pathology

Stroke, haemorrhage, tumour, seizure disorder…

H

Hypoxia

Anaemia, cardiac failure, pulmonary embolus…

D

Deficiencies

Vitamin B12, folic acid, thiamine…

E

Endocrinopathies

Thyroid, glucose, parathyroid, adrenal…

A

Acute vascular

Shock, vasculitis, hypertensive encephalopathy…

T

Toxic or drugs

Toxins, substance intoxication, medications (alcohol, anaesthetics,
anticholinergics, narcotics etc.)

H

Heavy metals

Arsenic, lead, mercury…

*Wise et al, 1987.

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The differential diagnosis of hypoactive delirium—given its high prevalence
and frequently disappointing response to treatment deserves particular attention:••

In the context of withdrawal of medication (too fast)
When there is an underlying intoxication with psychotropics or aneuroleptic-induced syndrome due to sensitivity to antipsychotics• The possibility of non- convulsive status epilepticus, major depressive
disorder and catatonic inhibition should be excluded.
An EEG may be helpful in these cases, although frequently there is a mix ofconflicting or co-occurring signs and potential explanations.

DIAGNOSIS
According to the literature, delirium is underdiagnosed, especially in young,critically ill children (Schieveld & Janssen, 2014; Schieveld et al, 2009). A possible
reason is that nurses and physicians do not specifically look for the symptoms ofdelirium and it is difficult to assess symptoms in pre-verbal patients. A number ofdelirium symptoms overlap with those observed in other conditions, such as pain,
distress, and opioid or benzodiazepine withdrawal (Ista et al, 2007). There areimportant clinical reasons for assessing pediatric delirium and taking it seriously(Schieveld & Janssen, 2014):•

Delirium is an acute brain failure and the consequences of such a failure canbe severe•

The neuro-metabolic stress of delirium probably has a negative impact on
the outcome and recovery from critical illness•

A hyperactive delirium is accompanied by various risks, such as pulling outof IV lines and catheters, auto-detubation, stepping or falling out of bed etc.

•

It is stressful for the patient who may experience terrifying hallucinations ordelusions (sometimes without amnesia) that may lead to a post-traumaticstress disorder (PTSD) and•It can also be very stressful for the child’s family and clinical staff (up to 25% of parents of children who have been in a pediatric ICU may develop
PTSD) (Colville & Pierce, 2012).

The acute occurrence of a disturbance of cognition, emotions, consciousness,or a behavioral disturbance in a critically ill child should raise the suspicion ofpediatric delirium and the need to consult a child psychiatrist, if available. Nurses andphysicians may find it difficult to assess symptoms of delirium, including cognitivechanges, especially in pre-verbal and critically ill and mechanically ventilatedchildren. In these children, other aspects, such as behavioral characteristics andnon-verbal interactions between parent and child, should be considered.
One of the most challenging issues is how to diagnose pediatric delirium
accurately in critically ill children. In adults, tools that rely on neurocognitive
parameters can be used. However, because most critically ill pediatric patientsare younger than 3 years or may have intellectual disabilities, one has to rely on
behavioral symptoms. In principle there is no lower limit to the age in which
delirium can occur; the youngest cases described have been in 3-month-olds(Schieveld, 2008; Silver et al, 2012; Turkel & Tavare, 2003). In the last few years,

Pediatric delirium

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6

IACAPAP Textbook of Child and Adolescent Mental Healthsteps had been taken to develop observational screening tools—variations on thetheme of parents’ comment that “this NOW is not my child!”
The most frequently described early symptoms are subtle: cognitive (e.g.,they do not remember what they have just been told, are unable to concentrate,
do not know where they are), perceptual (e.g., visual hallucinations), thought(e.g., delusions), language, emotional (e.g., may be frightened, irritable) andpsychomotor disturbances (e.g., restless, agitated, unable to be still). Answering
the following questions (based on the CAP-D; Silver et al, 2012) can be helpful inraising the possibility of delirium:•

Does the child make eye contact with the parents?

•

Are the child’s actions purposeful?

•Is the child aware of their surroundings?

•

Does the child communicate needs and wants?

•

Is the child restless?

•Is the child inconsolable?

•

Is the child underactive (moves very little while awake)?

•

Does the child take a long time to respond to interactions?

The diagnosis of delirium in children older than 5 years with normal
development is based on DSM-5 or ICD-10 criteria. Accurately diagnosing
pediatric delirium requires using a reliable, valid and clinically suitable bedside
tool that may also serve for screening and to guide treatment such as the Pediatric
Anesthesia Emergence Delirium Scale (PAED; Sikich & Lerman, 2004); thepediatric Confusion Assessment Method for ICU (pCAM-ICU; Smith et al,Child with pediatric delirium.
Roel Seidell, with permission.

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Table I.5.2 Characteristics of validated tools for the assessment of delirium in critically ill
childrenAge group

PAED

pCAM-ICU

CAP-D

SOS-PD

1-17 years> 5 years

0-21 years

0-16 years••

Variables
assessed•

Eye contact
with caregiver•

Purposefulactions

1.

•

Awareness ofsurrounding

2.
3.

•

Restlessness•

Inconsolability

4.

Acute changeor fluctuating
course ofmental status
Inattention
Altered level ofconsciousness
Disorganized
Thinking

•
•
•

•
•
•
•

Eye contact
with caregiver
Purposefulactions
Awareness ofsurroundings
Ability tocommunicate
needs
Restlessness
Inconsolability
Underactivity
Response tointeraction

•
•
•
•
•
•
•
•
•
•

Agitation(restlessness),anxiety, eyecontact,
grimacing
Impaired
attention
SpeechTremor
Muscle tone
Purposefulactions
Sleeplessness
Hallucinations
Disorientation
Sweating
Acute change /fluctuation.

Score range(cut off point)

0-25
(10)

Delirium* if 1, 2 and3 or 4 present

0-40
(9)

0-15
(4)

Reliability
data

+

+

+

+/-

Forms ofvalidity
established

Criterion

Criterion

Criterion

Sensitivity

91%

83%

94%

91%

Specificity

98%

99%

79%

97%

Feasibility and utility
established bedside

Feasibility

Utility establishedbedsideFeasibility

Clinical utility

Face(criterion pilot)

PAED: Pediatric Anesthesia Emergence Delirium scale (Janssen et al, 2011).
pCAM-ICU: Pediatric Confusion Assessment Method-Intensive Care Unit (Smith et al, 2011).
CAP-D: Cornell Assessment of Pediatric Delirium (Silver et al, 2012; Traube et al, 2013);
SOS-PD: Sophia Observation withdrawal Symptoms-Pediatric Delirium scale (van Dijk et al, 2012; Ista et al, 2014).
*There is no score range.

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8IACAPAP Textbook of Child and Adolescent Mental Health2011); the Cornell Assessment Pediatric Delirium tool (CAP-D; Silver et al,2012; Traube et al, 2013); and the Sophia Observation Withdrawal SymptomsPediatric Delirium scale (SOS-PD; van Dijk et al., 2012, Ista et al, 2014). No tool
stands out; therefore the choice is a matter of context and personal preference. The
characteristics of the better studied rating scales are summarized in Table I.5.2.
It must be emphasized however that the right diagnosis and treatment forpediatric delirium cannot be made merely on the basis of scores on an observational
screening tool. It is also necessary to evaluate all other possible diagnostic
explanations of a sudden emotional or behavioral disturbance in a critically ill
child (as listed in Table I.5.1). After a positive score on a pediatric delirium rating
scale and before starting treatment one should answer three questions to exclude
other explanations for a positive delirium score (e.g., as described by Esseveld etal, 2013). Only after a negative response to these questions a diagnosis of delirium
would be made and treated accordingly. These questions are:•Are symptoms the manifestation of a somatic complication developing(e.g., pneumonia)?

•

Has there been a change of medication?

•

Is there physical discomfort (a full bladder, full bowel, stomach distension,
hunger, thirst, itching, pain due to lines, IV lines, catheters, etc.?

TREATMENT
Non-pharmacological interventions
Minimizing risk factors
Many risk factors for delirium have been identified. These can be classified
as relating to the patient, iatrogenic, and environmental (e.g., hospital, ward,
pediatric ICU). The conditions for which children are admitted to the ICU
often predispose them to delirium, for example infections, metabolic disorders,
hypertension, pain, and withdrawal from medications. Iatrogenic factors thatprecipitate delirium in ICU patients include mechanical ventilation, restraints,
sleep disturbance, catheters, and IV lines.
Minimizing these factors is a logical and important approach in preventing
the onset of pediatric delirium. Non-pharmacological interventions appear tohave been successful in several studies (Tabet & Howard, 2009). For example, a
40% decrease in the incidence of delirium was achieved in adults using a multicomponent approach, which included repeated reorientation, early mobilization,
noise reduction, and a non-pharmacological sleep management (Marcantonio
et al, 2001). In adults, the effectiveness of preventive interventions such as early
mobilization, ear plugs, and staying in a single room is well established (Colombo
et al, 2012; van Rompaey et al, 2012; Zaal et al, 2013).

Click on the image (andselect “Multidisciplinaire
Richtlijn pediatrisch delier’)to access the Dutch
Multidisciplinary Guideline
for Pediatric Delirium (inDutch)Can these findings from adults be extrapolated to children? There islimited evidence that this is the case. However, common sense suggests that theseinterventions (for example promoting orientation and day-night rhythm, andavoiding overstimulation by light and sounds) may be effective for children as well.

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Table I.5.3 Non-pharmacological interventions for delirium in children*•

Constant presence of a parents and a soothing stimulation of all the
five senses:•

A dim nightlight, day/night lighting schedule•

Familiar music/ sounds/ voices, or smells•

Favorite toys, pets, blankets, and familiar photographs on thebedside•Staff psycho-education (to give reassurance and improve orientation)•

Information leaflet for parents on pediatric delirium•

Optimization of the level of sensory stimulation (in case of hyperactive
delirium move to single quiet room; if hypoactive delirium, increasesocial interaction)•

If possible, discontinuation of drugs that reinforce delirium•

Early mobilization*Hatherill et al, 2010; Schieveld et al, 2007.

The role of parents
Apart from involvement in the daily care of their hospitalized child, parents
can have a major role in the prevention, detection and treatment of delirium. A
model that recognizes and respects the uniqueness of each family and empowers
and encourages them to partner with health care providers is useful. Opinions
are asked, values are respected and family members are viewed as key elementsin their child’s health care. With this partnership one seeks to create a soothing
environment for the child in order to prevent or mitigate the onset of delirium andto optimize the child’s chances of recovery.
Symptoms associated with delirium, such as delusions or hallucinations,
may come as a complete surprise, something the family has never encountered
before, and can be very frightening for both child and parents. This may lead toparents not recognizing their child’s behavior, becoming afraid that neurologicaldamage has occurred or that their child is going to die (Schieveld et al, 2007).
Not knowing how to cope with these behaviors in their child makes parents
insecure and anxious; this in turn can influence the child, causing the delirium
to worsen. A soothing stimulation of all the five senses of the child with delirium
is advocated. The constant presence of one parent during the hospitalization,
hearing parents’ voices, readily visible photographs of parents or other well-known
family members, and favorite toys decrease the severity of delirium (Kim et al,
2010; Hatherill et al, 2010; Schieveld et al, 2007). Therefore it is essential thatparents and family members are informed extensively about all aspects of pediatricdelirium and are allowed to be close to the child as much and as often as possible.

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It is equally important to recognize that a critically ill child is a major burden forthe parents, can exhaust them and lead to arguments between them and with themultidisciplinary team, affecting the parents’ relationship, their relationship withthe care team, the care of their other children, and neglect of their work. Theseissues should be approached within the multidisciplinary team with an open mind
and heart. A leaflet providing information for parents and relatives may be of help.
An example is presented in the Appendix.

Intensive care units arescary places.
Photo: Dayton Children’s

Pharmacological prevention
Prevention of pediatric delirium by pharmacological means is not advisedin children, although it is sometimes recommended in adults, especially in patientsthat have experienced delirium previously. There are no studies on pharmacologicalprevention of delirium in children although there are studies on prevention of
emergence delirium in children. These studies are very variable in quality and nofirm conclusions for the prevention of pediatric delirium can be drawn from them.

Pharmacological treatment
Hyperactive delirium
Medication may be considered to reduce symptoms such as anxiety,agitation, hallucinations and disturbed sleep. Pharmacokinetics in children isdifferent from adults. Before starting pharmacological treatment the risk of side
effects and interactions with other medications and the route of administration
have to be considered and weighed against the potential benefits of treatment.
The same antipsychotics (typical antipsychotics, such as haloperidol, andatypical antipsychotics, such as risperidone) are used in children as in adults.
Benzodiazepines and clonidine are used in the treatment of delirium due tobenzodiazepine withdrawal; clonidine and methadone are used in the treatment of
delirium due to opiate withdrawal.

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Table I.5.4. Recommended dose of intravenous (IV) haloperidol for hyperactive pediatricdeliriumAge(years)

Weight(kg)

0-1

3,5-10

1-3

10-15

3-18

Maximumloading dose (IV)•0.05 mg in 30
minutes•0.15 mg in 30
minutes•> 15 kg

0.3-0.5 mg in 30
minutes

Maintenancedose (IV)•

Dose not exactly
known

•

0.01-0.05 mg/
kg/day, divided
into 2-4 times
daily

•

0.025 mg/kg/
day divided into
2-4 times daily•

0.05 mg/kg/day
divided into 2-4
times daily

Maximum dose (IV)•

Unknown•

Unknown•

Unknown inchildren younger
than 16 years•

In children aged 16
years or older: 5
mg per day divided
into 2-4 doses

Studies on the pharmacological treatment of pediatric delirium are scarceand have serious methodological flaws: small numbers of patients with large
age differences and very different physical illnesses, interventions or outcomesare poorly described, and the studies often have no control group. Therefore
recommendations are based on consensus rather than on evidence. However, there
are suggestions that haloperidol and risperidone are effective in reducing symptoms
of pediatric delirium in seriously ill children.
Haloperidol is mostly given intravenously; risperidone is only available
orally. In a sophisticated pediatric ICU setting the IV route is preferable because it
is faster and easier to control. The oral administration of haloperidol or risperidone
is also acceptable. Dosage varies in the different studies. The recommended
dosages are summarized in Tables I.5.4 and I.5.5. Benzodiazepines are not usually
recommended due to their potential deliriogenic effects in adults and the elderly.
Most experts recommend to start pharmacological treatment of pediatricdelirium when, in spite of non-pharmacological interventions, the child shows
extreme agitation or anxiety, hallucinations or delusions, especially when this leads
to discomfort, stress or danger to the child (e.g. loss of IV catheters or endotracheal
tubes), when delirium leads to extreme stress in parents or when it interferes
seriously with the care of other patients in the ICU or ward. When the child iscomfortable, it is easier for the parents to take care of their child. Some studies
indicate that patients who are treated pharmacologically may be more comfortable
and weaned earlier from the ventilator than patients that are not treated.
Adverse effects are extrapyramidal symptoms, such as dystonia, oculogyric

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IACAPAP Textbook of Child and Adolescent Mental Health

Table I.5.5 Recommended dose of haloperidol or risperidone orally (PO) for hyperactive
pediatric delirium. Oral doses of haloperidol and risperidone are the same.

Weight(kg)

Loading dose (mg)(PO)

<45 kg•0.02 mg/kg••

0.5-1 mg
Maximum 2 mg/
day, divided into 2
to 4 doses>45 kgMaintenance dose(mg) (PO)•0.01-0.08 mg/kg/day
divided into 2 to 4
doses

•

0.01-0.08 mg/kg/day
divided into 2 to 4
doses

Maximum dose (mg)(PO)•

4 mg/day divided into 2
to 4 doses•

6 mg/day divided into 2
to 4 doses.
Dosages >6mg havenot been studied•

crisis, akathisia, and hyperpyrexia. Extrapyramidal symptoms are seen frequently,
particularly if antipsychotics are increased rapidly. Start low and go slow is an
important principle. It can take 24 to 48 hours before an adequate response isachieved. To cover this time-window of ongoing agitation the short term additionof levomepromazine (also known as methotrimeprazine) has been described (witha total starting dosage of 1 to 3 mg/IV slowly in 30 minutes and then titrating
according to the clinical response, up to a maximum dosage of 1mg/kg/IV in 24
hours).
Recognizing and treating adverse effects is important. Treatment consists
in reducing the dose of antipsychotic and administration of an anticholinergic
drug such as biperiden (50 micrograms/kg/IV in 15 minutes). In adult patients
lengthening of the QTc interval has been reported with the possibility of Torsades
de Pointes. This has not been reported in children. Experts, however, recommend
performing an ECG before starting treatment with haloperidol when the child hasother risk factors for increased QTc interval (e.g., electrolyte abnormalities, othermedications that can lengthen the QTc interval, or medications that influence
CYP2D6 or CYP3A4 metabolism).
More adverse effects have been reported for haloperidol than for risperidone.
Therefore risperidone is the treatment of choice when symptoms are not extreme
and oral administration is possible. When no benefit is obtained with one of them,a switch to the other should be considered.
The consensus is that a pediatric delirium rating scale should be used at least
three times daily, to score delirium when medication is started and for as long as
the patient receives medication. It is not known for how long treatment should
continue. Experts advice to continue treatment at least until symptoms havedisappeared and until risk factors that possibly led to the delirium have lessened.
Medication should be weaned gradually, over a few days.

Hypoactive delirium
There are no studies and no consensus on the pharmacological treatment of
hypoactive pediatric delirium.

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IACAPAP Textbook of Child and Adolescent Mental Health

SEQUELAE OF DELIRIUM IN CHILDREN AND
PARENTS
There are no studies on the long term sequelae of pediatric delirium.
The published studies—on long term sequelae in children that had a hospital
admission—have been performed in premature-born children admitted to neonatal
intensive care units, children with cancer, or children admitted to a pediatric ICU.
PTSD symptoms are often reported in these children and their parents. Somestudies describe an association between psychological and psychiatric problems
after discharge and the occurrence of “delusional memories” (possibly a symptom ofdelirium) about their ICU stay and invasive procedures during the ICU admission(Colville et al, 2008; Colville & Pierce, 2012)
In adults, there is evidence that some cognitive problems after ICU discharge
are related to benzodiazepine use and delirium. Possible causes of cognitive
problems in children after pediatric ICU admission are hypoxia, hypoperfusion,
infection, and trauma. Long term effects of medications such as benzodiazepines,
opioids and anesthetics have not been studied in children. Animal studies, showthat these drugs can be neurotoxic, especially to the developing brain.

••

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Ista E, de Beest H, de Hoog M et al (2014). A preliminary
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Colombo R, Corona A, Praga F et al (2012). A reorientation
strategy for reducing delirium in the criticallyill. Results of an interventional study. Minerva
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Colville G, Pierce C (2012). Patterns of post-traumatic stresssymptoms in families after paediatric intensive care.
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s00134-012-2612-2
Colville G, Kerry S, Pierce C (2008). Children’s factual anddelusional memories of intensive care. American
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Ely EW, Inouye SK, Bernard GR et al (2001). Deliriumin mechanically ventilated patients: validity andreliability of the confusion assessment method for theintensive care unit (CAM-ICU). JAMA, 286:27032710.
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Ista E, van Dijk M, de Hoog M et al (2009). Constructionof the Sophia Observation Withdrawal SymptomsScale (SOS) for critically ill children. Intensive Care
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Janssen NJ, Tan EY, Staal M et al (2011). On the utility ofdiagnostic instruments for pediatric delirium in critical
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88, and the Delirium Rating Scale-Revised R-98.
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Schieveld JN, Brouwers AG, Schieveld BR (2014). On the lackof standardized essential PICU guidelines. Critical
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Traube C, Silver G, Kearney J et al (2013). Cornell Assessmentof Pediatric Delirium: A valid, rapid, observational
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Trzepacz PT, Mittal D, Torres R et al (2001). Validation of
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Turkel SB, Tavare CJ (2003). Delirium in children andadolescents. Journal of Neuropsychiatry and Clinical
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van Dijk M, Knoester H, van Beusekom BS et al (2012).
Screening pediatric delirium with an adapted versionof the Sophia Observation Withdrawal Symptoms
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van Rompaey B, Elseviers MM, van Drom W et al (2012).
The effect of earplugs during the night on the onset
of delirium and sleep perception: A randomized
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Wise M ( 1987). Delirium. In Hales R and Yudofsky S (eds)
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The Catherine Hayes Hospital circa 1870; a forerunner of the
Sydney Children’s Hospital, Australia.

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IACAPAP Textbook of Child and Adolescent Mental HealthAppendix I.5.1
INFORMATION ABOUT PEDIATRIC DELIRIUM FOR FAMILY, OTHER
CAREGIVERS, AND INTERDISCIPLINARY MEDICAL AND NURSINGTEAM*

Introduction
Your child has been admitted to hospital
due to one or more physical conditions,accidents or operations, which have led yourchild to become seriously ill. You may havenoticed that your child’s reactions are not
the same as usual and you may have been
worried by your child’s condition. The child
you know is now behaving differently fromusual, is agitated or apathetic and it is difficult
to make contact or have a conversation withhim/her. This state of confusion is called
delirium. This leaflet gives information about
delirium, its origin and how to deal with it best.

never drank alcohol can also become delirious
because of an infection (for example an ear
infection, pneumonia), a major operation,
heart or lung diseases, brain disorders,
infections etc. Acute confusion can also be
caused by trauma to the head. Stopping somemedications such as strong painkillers, ordrugs used in anesthesia, or too little sleep
can sometimes cause delirium.
Children with acute confusion or delirium
can show some of the following:•

Agitation or apathy•

Not being as clear-minded as usual,
like if everything just passes them by,and not recognizing where they are.
Establishing contact with them can bedifficult in these circumstances•

They may not remember things they
have just been told and may not beaware of this lack of memory•

Because sometimes they do notrecognize their surroundings, theirreactions can be different from usual.
They may appear watchful, suspicious,
angry or even aggressive. They may
want to pull off intravenous lines orother medical instruments. Somechildren may withdraw into themselves
when they would not normally do that•

It is important to realize that very
ill children, especially if delirious,
regress, behaving like when they
were much younger, and should beapproached as if they were younger

What is delirium?
Delirium is a state of confusion that cansuddenly appear when a child has an illness.
Children with delirium behave differently thanusual; they are agitated or apathetic and may
act strangely. A delirious state is transitory.
When the physical illness improves theconfusion usually disappears. The confusedstate can last from several hours to days oreven weeks depending on:•

The severity of the illness•

Your child’s age•

Your child’s physical condition.

CausesA delirious state can have many causes.
For example, in adults alcohol withdrawal is acommon cause of delirium. Children who have

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IACAPAP Textbook of Child and Adolescent Mental Health••

They may have a distorted view ofreality, for instance seeing or hearing
things that aren’t there. For them,
however, these experiences are very
real, can be frightening, and it is betterno to argue with the child about them
Often the symptoms vary during
the day usually getting worse in theevening; periods of agitation may
alternate with periods of calm or
sleepiness.

not argue but reassure them andmake clear that you perceive things
differently. Try to change the subject toactual events and real people.

Medical treatment

How to handle delirious children

Before treatment, the attending
physician will try to determine the medical
causes of the delirium as quickly as possible(delirium after anesthesia is very common andcan be worrying but almost always disappears
in less than one hour without treatment otherthan reassurance).

Children suffering from delirium havedifficulty communicating or responding
emotionally. Hearing familiar voices andseeing familiar people helps them. You cangive your child your utmost support by:

Non-medication treatment tries to orient
the child and reduce stress and discomfort
by stimulating all senses in a soothing way,
as described in the section “How to handledelirious children”.

•

Speaking calmly in clear, short
sentences•Telling your child who you are andwhat you are doing there, repeating it ifnecessary•

Explaining where they are and why
they are there•

Trying to involve your child in what ishappening now•

Bringing pictures from home, closefamily and friends•

Asking simple, single questions (e.g.:“did you sleep well?” instead of “didyou sleep well, or were you often
awake?”).

•

When people ask too many questions
these children can become agitated. It
is often enough to just being there•

Visiting is important, but make surethere are not too many visitors at once.
If more than two people visit at thesame time, remain to one side of thechild, so that your child can focus on
one point•

Making sure that, if possible, your childwears their glasses, hearing aids etc.

•

If children have unusual experiences(e.g., seeing things that are not there)
it is better not to go along with it. Do

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I.5

There are medications that can reduceor even remedy the delirium although they
can also have side effects, usually mild.
The two medications more often used are
haloperidol and risperidone. Preferably achild psychiatrist, if available, or other medical
or nursing specialist with expertise in delirium
is involved in these circumstances.
If children are agitated, it is often
necessary to take precautions to prevent
them from hurting themselves, for example byfalling out of bed or pulling out an intravenous
line. In case of severe agitation, it may benecessary to immobilize the child to prevent
injuries.
It is difficult to predict how long thesymptoms of delirium will last. It varies fromhours to days. Some children may havesymptoms for some time.
If you have further questions after
reading this leaflet, you can ask them to theattending physician or nurse.

*Modified from: Leaflet on Pediatric Delirium, Jan NM
Schieveld et al, 2009. internal publication MUMC+.

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