Critically ill children with delirium: a hidden challenge in intensive care

Disease and treatment 29. aug 2023 3 min PhD Fellow Rikke Louise Stenkjaer Written by Morten Busch

Delirium is an acute disturbance of brain functions that does not solely affect adults. Children in intensive care can also experience delirium, but the attending healthcare professionals often have challenges in identifying delirium, since many of the symptoms overlap with other conditions such as pain, undersedation and withdrawal syndrome. Now researchers from Denmark have tested the Sophia Observation Withdrawal Symptoms-Paediatric Delirium (SOS-PD) screening instrument, which shows diagnosis accuracy of 94%. The researchers therefore hope to be able to roll this out combined with nonpharmacological management of children with delirium in hospitals in Denmark in the coming years.

Many associate delirium with people with years of alcohol problems who suddenly stop drinking. Illusions, hallucinations and other unreal sensory impressions are frequent. The fact that infants and other children can experience delirium is also unexpected and frightening to most people. Nevertheless, this is the reality for many critically ill children and especially their parents. New research may therefore prove very important for both the affected children and their loved ones.

“Until a few years ago, the dogma was that delirium only affected adults and that children could not experience the severe cognitive and behavioural disturbances associated with delirium. Instead, it was believed that the children either experienced severe pain or had withdrawal syndrome. The problem is that these conditions need to be treated completely differently. We tested a very simple instrument that can help to identify children with delirium quickly so that this can be treated and especially reassure the children and their parents about their experiences,” explains one author, Rikke Louise Stenkjaer, PhD Fellow, Department of Neonatology, Rigshospitalet, Copenhagen.

Delirium can be similar to other conditions

Delirium is an acute neurocognitive disorder that acutely disturbs brain functions – attention, awareness and cognition – also in connection with serious somatic disorders and is therefore frequent in intensive care units. Children with delirium develop it rapidly, but it also varies in intensity – often within the same day. Delirium has three subtypes among children: hyperactive, hypoactive and mixed delirium.

“Hyperactive delirium is characterised by restlessness, agitation and aggressive behaviour, and the child seems insecure and anxious. Children with hypoactive delirium may be noticeably apathetic, lethargic, passive, sleepy and withdrawn. Both types can severely affect children, but especially also the parents, who may suddenly not be able to recognise their child’s behaviour,” says Rikke Louise Stenkjaer.

Parents can be shocked when their child suddenly behaves very differently, showing signs of discomfort and perhaps even delusions. Most parents are poorly prepared for such situations and therefore do not know what to do.

“Many parents are already stressed if their child is in intensive care for heart surgery, for example, and then suddenly are in the terrible situation of not recognising their child’s behaviour. They worry about whether their child’s brain has been affected long term and whether the child will ever return to normal. We have spoken to parents who thought their child had permanent brain damage,” adds Rikke Louise Stenkjaer.

The problem, however, is that many of the symptoms associated with delirium among children resemble those of other conditions, such as pain and withdrawal syndrome. Distinguishing these conditions can therefore be challenging.

“Identifying delirium is essential to provide relief to the child and the parents and to ensure the right treatment. Many of the symptoms are similar to those of other conditions such as pain and stress, which are also common in intensive care. Distinguishing between these conditions requires validated screening instruments,” explains Rikke Louise Stenkjaer.

Near 100% accuracy

Four recognised screening instruments have been developed to detect children with delirium in clinical practice. One is SOS-PD, which was originally developed and tested at Sophia Children’s Hospital in Rotterdam, Netherlands on critically ill children 3 months to 18 years old. SOS-PD has the advantage of being able to identify both delirium and withdrawal syndrome in the same assessment.

“An attractive feature of SOS-PD is that it does not require the child’s cooperation. This makes it particularly useful, since young children cannot always express their symptoms verbally. Instead, SOS-PD is based on careful observing the child’s behaviour over a period of 4 hours. It aims to involve the parents by asking whether they can recognise their child’s mental behaviour, partly because they know the children’s usual behaviour better than anyone else,” says Rikke Louise Stenkjaer.

If a symptom is present during the observation period, the child is assigned a point. The maximum score is 17 points, and a score of 4 or more, the presence of hallucinations alone or the parents not recognising their child’s behaviour indicates delirium. The English version was carefully translated into Danish, and nurses from four intensive care units were trained to use it. The nurses’ assessments were compared with the diagnostic assessment of a child and adolescent psychiatrist, which is considered the gold standard. The study included 141 critically ill children 3 months to 18 years old.

“The results show that the SOS-PD had 94% accuracy in diagnosing delirium. It very effectively excluded conditions that were not delirium. There were a few false-positives and false-negatives, and there were minor uncertainties especially among the very young children,” adds Rikke Louise Stenkjaer.

Effective nonpharmacological interventions

Overall, SOS-PD proved to be a promising method for identifying delirium among critically ill children, and the researchers therefore hope to roll it out in hospitals in Denmark.

“In our study, more than one in five children had delirium. These children are usually not detected or are treated incorrectly either because they are thought to be in pain or have withdrawal syndrome. In reality, these children have delirium and therefore need to be treated quite differently,” explains Rikke Louise Stenkjaer.

To tackle this problem, a study was recently carried out involving experts from around the world to develop effective nonpharmacological interventions by focusing on strategies supporting cognition, sleep and physical activity. Experts assessed the feasibility of 61 initiatives within these areas and reached agreement on the 11 highest-ranked measures.

“The experts agreed that establishing a daily routine, planning sleep, sensory aids, adjusting light and especially the presence of parents could relieve and treat delirium. The parents want to be involved as partners in treating and relieving their child’s suffering. They thus become an essential part of the solution,” explains Rikke Louise Stenkjaer.

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