Home Clinical Topics Managing delirium in the pediatric patient

Managing delirium in the pediatric patient

Author(s): Jodi E. Mullen, MS, RN-BC, CCRN, CCNS, ACCNS-P, FCCM

A strategic, team approach ensures optimal results.

Takeaways:

  • Delirium may go unrecognized in pediatric patients.
  • Strategies used to manage the symptoms of delirium also aid in prevention.
  • Effective management of pediatric delirium requires interprofessional collaboration.

Today you’re caring for 8-year-old Ethan*, who ran between two parked cars while chasing his basketball and was struck by a passing vehicle 2 days ago. His left femur was badly fractured and repaired yesterday. Surgery went well, but the night nurse tells you that Ethan has been agitated, confused, and trying to get out of bed. Sometimes he acts like he doesn’t know where he is, and he was incontinent twice overnight. Because of this behavior, Ethan’s provider ordered a computed tomography scan of his brain, which was normal. Based on the night nurse’s assessment, Ethan’s condition isn’t due to pain. Most concerning to his parents is that he’s using curse words that they didn’t even realize he knew. When you enter Ethan’s room to perform an assessment, his mother tells you, “He’s not acting like my son.” Could Ethan be experiencing pediatric delirium? 

What’s pediatric delirium?

Delirium in children frequently goes unrecognized because many believe it affects only adults. However, nurses who care for children should be on the lookout for this condition. Children experiencing delirium have an acute onset of cerebral dysfunction with inattention, a change in mental status, and either disorganized thinking or an altered level of consciousness. Their behavior may be described as hyperactive, hypoactive, or mixed. Delirium symptoms include disorientation, restlessness, sleep-wake cycle disturbances, mood changes, delusions, and problems with memory or perception. (See Types of delirium.)

Types of delirium

Pediatric delirium can be described as hyperactive, hypoactive, or mixed.

Type Patient’s behavior
Hyperactive The patient’s behavior mimics agitation or mania and may include

  • irritability
  • restlessness
  • thrashing or moving around in bed
  • emotional instability.
Hypoactive The patient appears apathetic and uninterested. They may

  • withdraw from the environment
  • lie quietly in bed, not making eye contact or engaging in play.
Mixed The patient’s behavior may fluctuate between hypoactive and hyperactive, moving from irritable to apathetic and distant.

Delirium is medically diagnosed using criteria from the Diagnostic and Statistical Manual of Mental Disorders5th edition, and nurses can use reliable screening tools to detect pediatric delirium. Screening effectiveness requires using the same tool consistently and performing screenings at least twice a day or when a change in the patient’s mental status occurs. Don’t screen a patient who’s unconscious or responds only to noxious stimuli; the results will reflect the child’s altered state of consciousness, not the delirium symptoms. (See Common screening tools.)

Common screening tools

These reliable tools are available to screen for pediatric delirium.

Tool Age Use Comments
Cornell Assessment of Pediatric Delirium All ages
  • Nurse completes eight screening questions and scores each item.
  • Scores range from 0 (not at all) to 4 (extremely).
  • A final score of ≥9 indicates delirium.
  • The tool doesn’t require patient participation or cooperation.
  • It may be better at identifying hyperactive vs. hypoactive delirium.
  • The bedside nurse observes the child over multiple periods of time before completing the tool.
Preschool and Pediatric Confusion Assessment Method-Intensive Care Unit (psCAM-ICU, pCAM-ICU)
  • psCAM-ICU: 6 months to 5 years old
  • pCAM-ICU: >5 years old
  • The nurse observes the patient for cardinal features of delirium (change/fluctuation in mental status and inattention).
  • If cardinal features are present, the nurse tests the patient for an altered level of consciousness and disorganized thinking.
  • The screen is positive for delirium if the cardinal features are present and there is an altered level of consciousness OR disorganized thinking is observed.
  • The patient must participate.
  • Developmentally appropriate picture cards are used to assess inattention in younger children.
  • Older children are asked specific questions (e.g., Is sugar sweet?).

Who’s at risk for pediatric delirium?

Any pediatric patient can develop delirium, but several factors can increase the risk, including younger age (<3 years old); pre-existing cognitive, emotional, or behavioral conditions; developmental delays; history of delirium; serious illness; and male gender. In addition, elements in the hospital environment (including noise levels, poor lighting, no windows, unfamiliar staff, medications [such as benzodiazepines], and physical restraints) may be contributing factors.

As Ethan’s nurse, you complete a delirium screening tool, which is positive. You then notify Ethan’s medical team for a more thorough evaluation.

Preventing and managing delirium

The same strategies used to manage delirium also can help prevent it. Identify and, if possible, correct any underlying conditions that may be contributing to the delirium. For example, if the patient is experiencing pain or anxiety, initiate relief measures and then reassess the patient for improvement. Also correct conditions such as hypoxia and metabolic disturbances (for example, electrolyte abnormalities or hypoglycemia). Review the patient’s medication list for drugs—such as anticholinergics and benzodiazepines—that can increase the likelihood of delirium and stop them if possible. Other strategies include mitigating hospital environmental disturbances, promoting sleep, pharmacologic agents, and supporting the family.

Hospital environment

Think about all of the unfamiliar sights, sounds, and smells children experience in the hospital. Noise, bright lights, and frequent sleep interruptions disturb the normal sleep-wake cycle, worsening misperceptions, disorientation, and inattention. To decrease noise, minimize conversations inside and directly outside the patient’s room, and maintain the alarm volume on medical equipment only as high as needed for patient safety. Consider placing a hyperactive delirious child in a quieter room, away from foot traffic and activity. A patient with hypoactive delirium may benefit from being placed in a more active area, such as a room near the nurses’ station, where they can receive age-appropriate interactions from healthcare team members. Other steps to create a more supportive hospital environment include providing patients with their favorite toys, blankets, and music and decorating the room with pictures of home, family, friends, and pets. Allow children who need glasses or hearing aids to wear them whenever possible. And avoid using physical restraints; their use can prolong a child’s confusion and reduce mobility.

Sleep disturbances

Normal sleep-wake cycles are important for immunity and thermoregulation. Although a direct relationship between sleep disturbances and delirium hasn’t been established, children with delirium sometimes are described as having their days and nights mixed up. Creating an individualized schedule of daytime activities and nighttime sleep can help prevent inadequate sleep quality and duration. Hang the schedule in the patient’s room where family members, staff, and the medical team can see it. Other ways to promote sleep include discouraging sleeping during the day, except for quiet rest times that are age appropriate. Older children might benefit from eye masks, earplugs, or background noise from a fan when sleeping at night. Be creative. For example, post a picture of the sun during the day and the moon at night as a visual cue to help the child know what time it is. Visitors and staff also can help reorient the child to place and time and why they’re in the hospital.

Pharmacologic agents

The Food and Drug Administration hasn’t approved any medications for preventing or treating pediatric delirium. However, medications may be prescribed to help manage the patient’s behavior, especially if it interferes with their safety or tolerance for things like medical devices. Other medication goals may include restoring the child’s attention, alleviating hallucinations and unstructured thoughts, and improving sleep. Psychotropic medications may treat delirium symptoms, but they won’t correct the underlying cause. A psychiatric consultant may be requested to help with medication management.

Medication options may include antipsychotics (typical or atypical) or adjunct medications such as melatonin or alpha-2-agonists. If a medication is started, the lowest dose usually is administered and then titrated up or down based on the patient’s response. Discontinue the drug as soon as possible after the patient’s condition improves. These medications come in different forms, so the choice of which medication is selected may depend on multiple factors, including administration route and the patient’s condition. Be aware of potential adverse effects, monitor the patient for them, and notify the team if they occur. Typically, side effects improve when the medication is stopped. Before initiating antipsychotic medications, obtain a baseline ECG and labs, including basic metabolic panel, magnesium, creatinine phosphokinase, complete blood count, liver function tests, and triglycerides. (See Pharmacologic options.)

Pharmacologic options

The Food and Drug Administration hasn’t approved any medications to prevent or treat pediatric delirium. However, the provider may prescribe medications to treat delirium symptoms. Consult your hospital’s formulary or pediatric clinical pharmacist.

Medication class
Examples
Desired effects
Administration route and adverse effects
Antipsychotics Typical antipsychotics:

  • fluphenazine
  • haloperidol

Atypical antipsychotics:

  • olanzapine
  • risperidone
  • quetiapine
  • ziprasidone
Relief from

  • agitation, hallucinations
  • sleep-wake abnormalities
  • behavioral dyscontrol (inappropriate behavior such as physical or verbal aggression) .
Administration

  • V. route available (haloperidol)

Adverse effects

  • Cardiac (e.g., tachycardia, prolonged QTc) require ECG monitoring
  • Hypotension
  • Laryngeal spasm
  • Sedation
  • Anticholinergic effects
  • Extrapyramidal movement disorders
  • Neuroleptic malignant syndrome
  • Note: Atypical antipsychotics have lower risk of neurologic side effects
Alpha-2-agonist
  • dexmedetomidine
  • clonidine
  • Blunted sympathetic stress response
  • Reduced autonomic arousal
  • Decreased need for benzodiazepines
Administration

  • Transdermal patch available (clonidine)

Adverse effects

  • Monitor for bradycardia and hypo/hypertension.
  • Abrupt discontinuation may cause hypertension.
Herbal supplement melatonin
  • Improved sleep onset and quality
Administration

  • Oral
  • Dose may not be uniform among different manufacturer’s products
  • No established dosing in children

Adverse effects

  • Drowsiness
  • Headache
  • Dizziness

After the medical team evaluates Ethan and creates a plan of care to manage his delirium, his mother confides to you that she’s frightened by his condition and worried that the changes she sees in his behavior may be permanent. What can you say in response to her concerns?

Family support

Nurses can help family members handle their own anxiety. Strategies include giving them written information describing delirium, providing anticipatory guidance about their child’s behavior and the delirium management plan, and inviting them to participate in medical team rounds. Teach parents and visitors to be a calm presence in the child’s room and explain how they can help reorient the child. In addition, the patient and family may benefit from working with a certified child life specialist who can help to improve coping skills and reduce anxiety.

Teamwork

Caring for patients with pediatric delirium requires team collaboration. Many healthcare providers aren’t familiar with delirium, its signs and symptoms, or prevention and management strategies. Ongoing education is a necessary part of any unit’s comprehensive plan for improving delirium care. Weekly or biweekly multidisciplinary rounds that focus specifically on delirium monitoring and treatment can be helpful. Some organizations refer to these as “brain rounds.” Using a checklist during these rounds can help the team focus on a consistent approach to assessing and monitoring patients’ pain, sedation, and delirium. Order sets and practice guidelines should be available to direct care decisions. 

Review your practice

Nurses who care for pediatric patients must be familiar with the signs and symptoms of pediatric delirium. Because of their continued presence at the bedside, nurses are positioned to recognize symptoms and initiate strategies to prevent and treat the condition. Review the practice in your own unit and look for ways to improve the care of patients at risk for delirium. (See Nurse-driven strategies.)

Nurse-driven strategies

These nurse-driven strategies can help prevent and manage pediatric delirium.

  • Establish consistent schedules and encourage sleep by
    • clustering care when possible
    • following home bedtime routines (for example, bath, story time, warm blanket)
    • providing uninterrupted sleep
    • keeping doors closed at night
    • turning off TV and lights
    • using a night light to decrease child’s fears and misperceptions at night
    • discouraging daytime sleeping.
  • Control noise in and around the patient’s room.
  • Create a friendly environment with
    • pictures of family, friends, home, pets
    • family presence
    • consistent caregivers when possible (nurses, support staff)
    • favorite music and TV shows
    • familiar toys.
  • Use effective communication tactics.
    • Frequently reorient the patient to person, place, and time.
    • Use visual cues for time of day.
    • Speak calmly.
    • Explain what you’ll be doing when performing tasks and assessments.
    • Don’t argue with the patient about hallucinations.
    • Refocus the patient’s attention to current events or favorite topics.
  • Review the need for lines, drains, and tubes and remove them as soon as possible, per provider’s order.
  • Minimize or avoid using physical restraints.
  • Mobilize the patient.
    • Elevate the head of the bed.
    • Move the bed into a chair position.
    • Get the patient out of bed when possible.
    • Consult physical therapy, occupational therapy, and the child life specialist for strategies to enhance mobilization.

You teach Ethan’s parents about his condition and give them strategies to help him. His mother is relieved after learning that his behaviors aren’t permanent. She speaks calmly to Ethan and frequently reminds him where he is and why he’s in the hospital. They watch his favorite TV shows together. With sleep hygiene strategies implemented, Ethan gets 6 hours of uninterrupted sleep and awakes the next morning better rested and more focused.  

*Name is fictitious.

Jodi E. Mullen is a clinical leader in the pediatric intensive care unit at University of Florida Health Shands Children’s Hospital in Gainesville. 

References

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