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Delirium in the pediatric patient: On the growing awareness of its clinical interdisciplinary importance.

“Delirium in the elderly patient” was the headline of the important article Lipowski wrote in 1989.2 It was the first landmark article in the midst of a slowly growing number of publications, dating back to 1968. The response to these first, largely conceptual, articles ignited a fast-growing number of research studies regarding all the positive correlations between the onset of delirium on the one hand and all kinds of negative patient outcomes—for example, regarding quality of life in the cardiac intensive care unit, morbidity, and mortality—on the other. With the passing of time, the knowledge developed that these findings not only apply to cardiac patients, but to all adult and elderly patients with critical illness. Owing to critical illness, the brain can react with several neuropsychiatric presentations of which the most important in this context are sickness behavior, fever, epilepsy, catatonia, delirium, refractory agitation, and coma. In general, delirium is defined as a neuropsychiatric condition secondary to a general medical condition and/or its treatments. Unfortunately, the lack of a proper description of all the neuropsychiatric aspects of critical illness in general, and pediatric delirium (PD) in particular, still remains a serious drawback in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition), the International Statistical Classification of Diseases, 10th Revision, and Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition).3 This is surprising because recent data suggest that PD also is a similarly serious condition, a finding that is in contradiction to the famous remark of Bleuler (1857-1939), “Children get delirious so often and quickly that this is of no importance to us.”4 However, this statement was made before World War II as opposed to both the concept of critical illness and the first intensive care unit, which both date back to around 1952 at the time of the polio epidemic in Copenhagen, Denmark. Bearing in mind that the first pediatric intensive care unit was set up in 1955 by Goran Haglund, Bleuler probably meant to discuss only the very common daily life occurrence of delirium febrile because the awareness of delirium in critical illness did not exist in those days. Then why is PD so important? Although the prevalence of delirium in adults varies between 40% and 80%, PD’s prevalence in critical illness is estimated to be at least 20%.5,6 Furthermore, research in the medical field has shown that there exists more overlap than differences between children and adults, not only in the reactions to critical illness, but in the presentation of delirium as well.3 Thus, it is remarkable that for a long time almost nobody realized that there is no scientific justification for not trying to generalize the knowledge available in adults to pediatric patients. There are at least 5 reasons for reevaluating PD: (1) According to Lipowski,2 delirium is “acute brain failure in man” and as the brain is the director of the autonomic nervous and endocrine systems the consequences of such a failure may be very severe; (2) the neurometabolic stress of residing in a state of delirium probably has a negative influence on the outcome and recovery from critical illness; (3) the hyperactive phase is accompanied by various other risks, such as pulling out of catheters and autodetubation; (4) being confronted with delirium can be very stressful for the patient who can experience frightening hallucinations and/or delusions; and (5) this holds for the family and interdisciplinary staff as well. The impact of a pediatric intensive care unit stay is best illustrated by the fact that one-third of pediatric patients are diagnosed as having serious posttraumatic stress disorder 3 months after hospital discharge. Finally, growing evidence suggests there is a positive association between pediatric disease severity measure scores and the onset of PD, implicating that disease severity is a risk factor for this condition.5 Taken together, we conclude that it is about time to change the way of thinking about PD. One of the most challenging questions remains how to properly diagnose PD in critically ill children.7 In adults, tools that rely on neurocognitive aspects can be used. However, because most critically ill pediatric patients are either younger than 3 years old, and make up an important group, and/or have intellectual disabilities, we have to rely on behavioral symptoms. In the last few years, an important stride forward had been made in the development of screening tools for PD. Most recently, the Cornell Assessment of Pediatric Delirium (CAP-D) was introduced, which is an adaptation of the Pediatric Anesthesia Emergence Delirium scale.5 Two major adjustments were made: (1) 3 items were added to enhance detection of hypoactive delirium and (2) developmental anchor points were formulated to be suitable for the screening of children who are very young and/or have a developmental delay. However, if these anchor points would not only be used to assess current functioning, but also premorbid baseline functioning, it would even become possible to assess person-specific changes over time. One way to further increase PD detection would be continuously monitoring the patient (eg, after each nurse shift). In this way, one can evaluate the well-known exclamation of parents and caregivers more VIEWPOINT