Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry.

Introduction: Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. Methods: Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED. Results: Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use. Conclusion: These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.Reprinted from West J Emerg Med 2019; 20:409-418, with permission from the authors. Copyright © 2019.

Delirium in the NICU: A Point Prevalence Study.

OBJECTIVES: Delirium is a well-described complication of critical illness, with occurrence rates of >25% in the PICU, and associated morbidity. Infants in the NICU are likely at risk. There have been no previous screening studies to quantify delirium rates in the neonatal population. We hypothesized that delirium was prevalent in term neonates in the NICU. In this pilot study, our objective was to estimate prevalence using a validated pediatric delirium screening tool, which has not yet been tested in NICUs. METHODS: In this point prevalence study, all term or term-corrected infants admitted to the NICU on designated study days were screened for delirium using the Cornell Assessment of Pediatric Delirium. RESULTS: A total of 149 infants were eligible for screening over 8 study days. A total of 147 (98.6%) were successfully screened with the Cornell Assessment of Pediatric Delirium. Overall, 22.4% (n = 33) screened positive for delirium. Delirium was more commonly detected in children on invasive mechanical ventilation (67% vs 17%, P < .01) and those with underlying neurologic disorders (64% vs 13%, P < .01). A multivariate logistic regression revealed that neurologic disability and mechanical ventilation were both independently associated with a positive delirium screen (aOR: 12.3, CI: 4.5-33.6 and aOR: 9.3, CI: 2.5-34.6, respectively). CONCLUSIONS: Our results indicate that delirium likely occurs frequently in term-equivalent infants in the NICU. Further research is necessary to establish feasibility, validity, and interrater reliability of delirium screening in this population.

Delirium in Children Undergoing Hematopoietic Cell Transplantation: A Multi-Institutional Point Prevalence Study.

Introduction: Delirium occurs frequently in adults undergoing hematopoietic cell transplantation, with significant associated morbidity. Little is known about the burden of delirium in children in the peri-transplant period. This study was designed to determine delirium rates, define risk factors (demographic and treatment related), and establish feasibility of multi-institutional bedside screening for delirium in children undergoing hematopoietic cell transplant. Methods: This is a multi-institutional point prevalence study. All subjects were prospectively screened for delirium twice daily using the Cornell Assessment of Pediatric Delirium over a 10-day period. De-identified data, including basic demographics and daily characteristics, were extracted from the electronic medical record. Results: Eleven North American institutions were included, 106 children were enrolled, and 883 hospital days were captured. Delirium screening was successfully completed on more than 98% of the study days. Forty-eight children (45%) developed delirium over the course of the 10-day study. Children were diagnosed with delirium on 161/883 study days, for an overall delirium rate of 18% per day. Higher delirium rates were noted in children <5 years old (aOR 0.41 for children over 5 years), and in association with specific medications (melatonin, steroids, and tacrolimus). Conclusion: Delirium was a frequent occurrence in our study cohort, with identifiable risk factors. Delirium screening is highly feasible in the pediatric hematopoietic cell transplant patient population. A large-scale prospective longitudinal study following children throughout their transplant course is urgently needed to fully describe the epidemiology of pediatric delirium, explore the effects of delirium on patient outcomes, and establish guidelines to prevent and treat delirium in the peri-transplant period.

Association Between Pediatric Delirium and Quality of Life After Discharge.

OBJECTIVE: Delirium occurs frequently in critically ill children, with highest rates reported in children under 5 years old. The objective of this study was to measure the residual effect of delirium on quality of life at 1 and 3 months after hospital discharge. DESIGN: Prospective observational cohort study. SETTING: Urban academic PICU. PATIENTS: Children younger than five years of age at time of admission to the PICU. INTERVENTIONS: All children were screened for delirium (using the Cornell Assessment for Pediatric Delirium) throughout their stay in the PICU. Quality of life was measured using the Infant-Toddler Quality of Life questionnaire at three time points: baseline, 1 month, and 3 months after hospital discharge. Infant-Toddler Quality of Life scores were compared between children who did and did not develop delirium. MEASUREMENTS AND MAIN RESULTS: Two hundred seven children were enrolled. One hundred twenty-two completed the 1-month follow-up, and 117 completed the 3-month follow-up. Fifty-six children (27%) developed delirium during their PICU stay. At follow-up, Infant-Toddler Quality of Life scores for the PICU cohort overall were consistently lower than age-related norms. When analyzed by delirium status, children who had experienced delirium scored lower in every quality of life domain when compared with children who did not experience delirium. Even after controlling for severity of illness, delirious patients demonstrated an average 11-point lower general health score than nondelirious patients (p = 0.029). CONCLUSION: This pilot study shows an independent association between delirium and decreased quality of life after hospital discharge in young children.

Sleep in Hospitalized Children With Cancer: A Cross-Sectional Study.

OBJECTIVES: Many children with cancer have repeated and prolonged hospitalizations, and in-hospital sleep disruption may negatively affect outcomes. Our objective for this study was to characterize sleep quality and quantity in hospitalized children with cancer by using parental surveys and actigraphy, to evaluate the association between subjective and objective sleep measures, and to describe hospital-associated risk factors related to poor sleep. METHODS: Cross-sectional study of children aged 0 to 18 years old admitted to a pediatric oncology ward. Parents completed a baseline sleep questionnaire describing their child's sleep at home before hospitalization, followed by daily questionnaires describing their child's sleep for up to 3 nights while in the hospital. A subgroup of children aged 5 to 18 years wore actigraphs during the same time period. Demographic and clinical data were extracted from the electronic medical record. The primary outcome was inadequate sleep, defined by the total sleep duration adjusted for age. RESULTS: Among 56 participants over 135 hospital nights, 66% (n = 37) reported inadequate sleep. Actigraphy was completed on 39 nights (29%), with a median total sleep time of 477 (interquartile range 407-557) minutes. There was a strong correlation between subjective questionnaire measures and actigraphic measures (r = 0.76). No patient-specific demographic factors were related to inadequate sleep. A multivariable model indicated the following hospital-related factors were associated with inadequate sleep: noise (adjusted odds ratio [aOR] 3.0; confidence interval [CI] 1.2-7.7), alarms (aOR 3.1; CI 1.2-8.3), child's worries (aOR 2.8; CI 1.1-7.2), and receipt of benzodiazepines (aOR 2.9; CI 1.2-7.5). CONCLUSIONS: A majority of children experienced inadequate sleep during hospitalization. Subjective report of sleep duration correlated well with objective measures of sleep by actigraphy. Several potentially modifiable factors were independently associated with poor sleep. Further interventional studies are required to test approaches to optimize sleep in hospitalized children with cancer.

Delirium and Developmental Disability: Improving Specificity of a Pediatric Delirium Screen.

OBJECTIVES: Children with developmental disabilities are at high risk for developing delirium when critically ill. However, existing pediatric delirium screening tools were designed for children with typical development. The objective of this study was to improve the specificity of the Cornell Assessment for Pediatric Delirium, to allow for accurate detection of delirium in developmentally delayed children admitted to the PICU. We hypothesized that the Cornell Assessment for Pediatric Delirium, when combined with fluctuation in level of awareness as measured by the Richmond Agitation-Sedation Scale, would be valid and reliable for the diagnosis of delirium in developmentally delayed children. DESIGN: Prospective observational double-blind cohort study. SETTING: Tertiary care academic PICU. PATIENTS: Children with moderate to severe developmental delay. INTERVENTIONS: Each child was evaluated by the bedside nurse with the Cornell Assessment for Pediatric Delirium once every 12 hours and the Richmond Agitation-Sedation Scale every 4 hours. Cornell Assessment for Pediatric Delirium (score ≥ 9) + Richmond Agitation-Sedation Scale fluctuation (change in Richmond Agitation-Sedation Scale score of at least 2 points during a 24-hr period) was compared with the criterion standard psychiatric evaluation for diagnosis of delirium. MEASUREMENTS AND MAIN RESULTS: Forty children participated; 94 independent paired assessments were completed. The psychiatrists' diagnostic evaluations were compared with the detection of delirium by the Cornell Assessment for Pediatric Delirium and Richmond Agitation-Sedation Scale. Specificity of the Cornell Assessment for Pediatric Delirium + Richmond Agitation-Sedation Scale fluctuation was 97% (CI, 90-100%), positive predictive value of Cornell Assessment for Pediatric Delirium + Richmond Agitation-Sedation Scale fluctuation was 89% (CI, 65-99%); and negative predictive value remained acceptable at 87% (95% CI, 77-94%). In addition, to confirm interrater reliability of the criterion standard, 11 assessments were performed by two or more psychiatrists in a blinded fashion. There was perfect agreement (κ = 1), indicating reliability in psychiatric diagnosis of delirium in developmentally delayed children. CONCLUSION: When used in conjunction with Richmond Agitation-Sedation Scale score fluctuation, the Cornell Assessment for Pediatric Delirium is a sensitive and specific tool for the detection of delirium in children with developmental delay. This allows for reliable delirium screening in this hard-to-assess population.

The Validity and Reliability of the Japanese Version of the Cornell Assessment of Pediatric Delirium.

OBJECTIVES: To examine validity and reliability of the Japanese version of the Cornell Assessment of Pediatric Delirium. DESIGN: Prospective double-blinded observational cohort study. SETTING: Eight-bed mixed PICU (post-surgical and internal medicine) from May 2017 to June 2018. PATIENTS: All children between the ages of 0-13 years who were admitted to the PICU for at least 24 hours were eligible for inclusion, as long as the child was arousable to verbal stimulation. INTERVENTIONS: Two nurses simultaneously and independently assessed each patient for pediatric delirium with the Japanese version of the Cornell Assessment of Pediatric Delirium; this was compared to the gold standard of psychiatric diagnosis based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition standards. MEASUREMENTS AND MAIN RESULTS: Forty-one children were enrolled and 92 assessments (ranging from one to four per subject) were completed. Congenital heart disease patients accounted for 73 enrollees (79%). Forty-three percent of observations were performed in children on invasive mechanical ventilation. Pediatric delirium prevalence (as determined by psychiatric diagnosis) was 53%. The Japanese version of the Cornell Assessment of Pediatric Delirium demonstrated an optimal scoring cutpoint of 9. Overall, area under the curve was 92%, sensitivity 90% (95% CI, 79-97%), specificity 88% (95% CI, 75-96%), positive predictive value of 90% (95% CI, 79-97%), negative predictive value of 91% (95% CI, 80-97%), and a Cohen's κ of 0.89 (95% CI, 0.8-0.98). In children on invasive mechanical ventilation, the Japanese version of the Cornell Assessment of Pediatric Delirium maintained an area under the curve 87%, sensitivity 97%, and specificity 64%. CONCLUSIONS: The Japanese version of the Cornell Assessment of Pediatric Delirium is a valid and reliable tool for use in Japanese PICUs. This will allow for detection of delirium in real-time and may lead to better identification of the population and risk factors for appropriate management and therapeutic and preventative interventions.

A Clinical Pathway to Standardize Care of Children With Delirium in Pediatric Inpatient Settings.

Pediatric delirium is an important comorbidity of medical illness in inpatient pediatric care that has lacked a consistent approach for detection and management. A clinical pathway (CP) was developed to address this need. Pediatric delirium contributes significantly to morbidity, mortality, and costs of inpatient care of medically ill children and adolescents. Screening for delirium in hospital settings with validated tools is feasible and effective in reducing delirium and improving outcomes; however, multidisciplinary coordination is required for implementation. The workgroup, composed of international experts in child and adolescent consultation psychiatry, reviewed the literature and developed a flowchart for feasible screening and management of pediatric delirium. When evidence was lacking, expert consensus was reached; stakeholder feedback was included to create the final pathway. A CP expert collaborated with the workgroup. Two sequential CPs were created: (1) "Prevention and Identification of Pediatric Delirium" emphasizes the need for systematic preventive measures and screening, and (2) "Diagnosis and Management of Pediatric Delirium" recommends an urgent and ongoing search for the underlying causes to reverse the syndrome while providing symptomatic management focused on comfort and safety. Detailed accompanying documents explain the supporting literature and the rationale for recommendations and provide resources such as screening tools and implementation guides. Additionally, the role of the child and adolescent consultation-liaison psychiatrist as a resource for collaborative care of patients with delirium is discussed.

Erratum: This Article Corrects: "Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry".

[This corrects the article on p. 409 in vol. 20, PMID: 30881565.].

Cornell Assessment of Pediatric Delirium: Italian cultural validation and preliminary testing.

INTRODUCTION: Paediatric delirium is associated with a longer duration of hospitalization in paediatric intensive care units, the emergence of post-traumatic symptoms and possible neurocognitive dysfunction after discharge. In preschool children, the diagnosis of delirium appears rather challenging: their pre-verbal status and the presence of cognitive skills still in development make accurate diagnosis difficult. Recently, a pediatric delirium screening tool suitable for critical preschool children has also been developed and identified in international literature, with excellent results also in critical infants under 2 years of age: the Cornell Assessment of Pediatric Delirium (CAPD). The CAPD, using a Likert scale, bases the assessment of paediatric delirium within the context of child development. This scale follows the development of the infant by comparing the detection of specific items on the scale as the anchor points that characterize the development of infants by age groups. OBJECTIVE: Culturally and linguistically validation in Italian language and prior testing of the Cornell Assessment of Pediatric Delirium. METHOD: Translation and Cultural Validation of the Cornell Assessment of Pediatric Delirium (CAPD) for the Evaluation/Diagnosis of Pediatric Delirium within Pediatric Intensive Care. The translation and adaptation of this instrument followed the phases of the model proposed by the World Health Organization. Prior testings, such as item descriptive analysis, item-total correlation and Cronbach's alpha, were conducted. RESULTS: All phases of the cultural-linguistic validation process were carried out in a satisfactory manner. For the prior testing, the scale was administered to a sample of 42 children, with age ranged 0-5 years old (66.6%), with a higher prevalence of the male gender. All items were normally distributed and there was no excessive Skeweness and Kurtosis. Each item contributed to the scale fairly well and all coefficients of item total correlation (rjx) were higher than the recommended level of 0.30. The composite reliability index was 0.94 and Cronbach's alpha was 0.96. CONCLUSIONS: The process has meticulously followed the recommendations in international literature. The final version was approved by the authors of the original instrument.

Erratum: This Article Corrects: "Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry".

[This corrects the article on p. 409 in vol. 20, PMID: 30881565.].

Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry.

INTRODUCTION: Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. METHODS: Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED. RESULTS: Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use. CONCLUSION: These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.

A systematic approach to family engagement: Feasibility pilot of a pediatric delirium management and prevention toolkit.

OBJECTIVE: Delirium is a frequent and severe complication of serious pediatric illness. Development of a nonpharmacologic approach to prevent pediatric delirium may improve short- and long-term outcomes in children and their families. In this brief report, we describe the development of a quality improvement project designed to methodically promote the family member's engagement, comforting, and orienting activities with their critically ill child to decrease delirium rates. METHOD: We created a developmentally specific Delirium Prevention Toolkit for families. In a feasibility pilot, March through June 2016, we offered the kit to 15 patients and their families. On discharge, families were asked to describe use of the toolkit and whether or not it was helpful for them. RESULTS: Twelve of 15 patients and families used various elements of the toolkit, particularly the headphones, music, and games; no one regularly used the blank journal. All reported that it was easy and helpful to have as support for their stay in the pediatric intensive care unit.Significance of resultsThis pilot demonstrated practicality of a nonpharmacologic delirium prevention toolkit in the pediatric intensive care unit, and satisfaction from patients and families.

Risk Factors for the Development of Postoperative Delirium in Pediatric Intensive Care Patients.

OBJECTIVES: To determine and quantify risk factors for postoperative pediatric delirium. DESIGN: Single-center prospective cohort study. SETTING: Twenty-two bed PICU in a tertiary care academic medical center in Germany. PATIENTS: All children admitted after major elective surgery (n = 93; 0-17 yr). INTERVENTIONS: After awakening, children were screened for delirium using the Cornell Assessment of Pediatric Delirium bid over a period of 5 days. Demographic and clinical data were collected from the initiation of general anesthesia. MEASUREMENTS AND MAIN RESULTS: A total of 61 patients (66%) were delirious. Younger children developed delirium more frequently, and the symptoms were more pronounced. The number of preceding operations did not influence the risk of delirium. Total IV anesthesia had a lower risk than inhalational anesthesia (p < 0.05). Duration of anesthesia was similar in all groups. Patients with delirium had a longer duration of mechanical ventilation in the PICU (p < 0.001). Significant differences in cumulative doses of various medications (e.g., sedatives, analgesics, and anticholinergics) were noted between groups; these differences were independent of disease severity. Invasive catheters and respiratory devices (p < 0.01) as well as infections (p < 0.001) increased risk of delirium. CONCLUSIONS: A high prevalence of delirium was noted in the PICU, and several perioperative risk factors were identified. Our data may be a base for development of strategies to prevent and treat postoperative delirium in children.

Benzodiazepines and Development of Delirium in Critically Ill Children: Estimating the Causal Effect.

OBJECTIVES: Benzodiazepine use may be associated with delirium in critically ill children. However, benzodiazepines remain the first-line sedative choice in PICUs. Objectives were to determine the temporal relationship between administration of benzodiazepines and delirium development, control for time-varying covariates such as mechanical ventilation and opiates, and evaluate the association between dosage of benzodiazepines and subsequent delirium. DESIGN: Retrospective observational study. SETTING: Academic tertiary care PICU. PATIENTS: All consecutive admissions from January 2015 to June 2015. INTERVENTIONS: Retrospective assessment of benzodiazepine exposure in a population that had been prospectively screened for delirium. MEASUREMENTS AND MAIN RESULTS: All subjects were prospectively screened for delirium throughout their stay, using the Cornell Assessment for Pediatric Delirium, with daily cognitive status assigned as follows: delirium, coma, or normal. Multivariable mixed effects modeling determined predictors of delirium overall, followed by subgroup analysis to assess effect of benzodiazepines on subsequent development of delirium. Marginal structural modeling was used to create a pseudorandomized sample and control for time-dependent variables, obtaining an unbiased estimate of the relationship between benzodiazepines and next day delirium. The cumulative daily dosage of benzodiazepines was calculated to test for a dose-response relationship. Benzodiazepines were strongly associated with transition from normal cognitive status to delirium, more than quadrupling delirium rates (odds ratio, 4.4; CI, 1.7-11.1; p < 0.002). Marginal structural modeling demonstrated odds ratio 3.3 (CI, 1.4-7.8), after controlling for time-dependent confounding of cognitive status, mechanical ventilation, and opiates. With every one log increase in benzodiazepine dosage administered, there was a 43% increase in risk for delirium development. CONCLUSIONS: Benzodiazepines are an independent and modifiable risk factor for development of delirium in critically ill children, even after carefully controlling for time-dependent covariates, with a dose-response effect. This temporal relationship suggests causality between benzodiazepine exposure and pediatric delirium and supports limiting the use of benzodiazepines in critically ill children.

Delirium is a Common and Early Finding in Patients in the Pediatric Cardiac Intensive Care Unit.

OBJECTIVE: To determine incidence, associated risk factors, and characteristics of delirium in a pediatric cardiac intensive care unit (CICU). Delirium is a frequent and serious complication in adults after cardiac surgery, but there is limited understanding of its impact in children with critical cardiac disease. STUDY DESIGN: Single-center prospective observational study of CICU patients ≤21 years old. All were screened for delirium using the Cornell Assessment for Pediatric Delirium each 12-hour shift. RESULTS: Ninety-nine patients were included. Incidence of delirium was 57%. Median time to development of delirium was 1 day (95% CI 0, 1 days). Children with delirium were younger (geometric mean age 4 vs 46 months; P < .001), had longer periods of mechanical ventilation (mean 35.9 vs 8.8 hours; P = .002) and had longer cardiopulmonary bypass times (geometric mean 126 vs 81 minutes; P = .001). Delirious patients had longer length of CICU stay than those without delirium (median 3 (IQR 2, 12.5) vs 1 (IQR1, 2) days; P < .0001). A multivariable generalized linear mixed model showed a significant association between delirium and younger age (OR 0.35 for each additional month, 95% CI 0.19, 0.64), need for mechanical ventilation (OR 4.1, 95% CI 1.7, 9.89), and receipt of benzodiazepines (OR 3.78, 95% CI 1.46, 9.79). CONCLUSIONS: Delirium is common in patients in the pediatric CICU and is associated with longer length of stay. There may be opportunities for prevention of delirium by targeting modifiable risk factors, such as use of benzodiazepines.

Provider Beliefs Regarding Early Mobilization in the Pediatric Intensive Care Unit.

PURPOSE: Critically ill patients are at risk for short and long term morbidity. Early mobilization (EM) of critically ill adults is safe and feasible, with improvement in outcomes. There are limited studies evaluating EM in pediatric critical care patients. Provider beliefs and concerns must be evaluated prior to EM implementation in the pediatric intensive care unit (PICU). DESIGN AND METHODS: A survey was distributed to PICU providers assessing beliefs and concerns with regards to EM of PICU patients. RESULTS: Seventy-one providers responded. Most staff believed EM would be beneficial. The largest perceived benefits were decreased length of both stay and mechanical ventilation. The largest perceived concerns were risk of both endotracheal tube and central venous catheter dislodgement. Surveyed clinicians felt significantly more comfortable mobilizing the oldest as compared to the youngest patients (p<0.0001). Clinicians also felt significantly more comfortable mobilizing patients receiving invasive mechanical ventilation in the oldest as compared to the youngest patients (p<0.0001). CONCLUSION: There is clear benefit to the EM of adult ICU patients, with evidence supporting its safety and feasibility. As pediatric patients pose different challenges, it is imperative to understand provider concerns prior to the implementation of EM. Our research demonstrates similar concerns between adult and pediatric programs, with the addition of significant concern surrounding EM in very young children. PRACTICE IMPLICATIONS: Understanding pediatric specific concerns with regards to EM will allow for the proper development and implementation of pediatric EM programs, allowing us to assess safety, feasibility, and ultimately outcomes.