Users Online: 3274
Home Print this page Email this page
Home About us Editorial board Search Browse articles Submit article Ahead of Print Instructions Subscribe Contacts Special issues Login 

Previous article Browse articles Next article 
Adv Biomed Res 2023,  12:25

Delirium in a child in pediatric intensive care unit

Department of Pediatrics, Imam Hossein Children Hospital; Child Growth and Development Research Center, Research Institute for Primordial Prevention of Non-Communicable Disease, Isfahan University of Medical Sciences, Isfahan, Iran

Date of Submission07-Jul-2021
Date of Acceptance18-Oct-2021
Date of Web Publication25-Feb-2023

Correspondence Address:
Dr. Nazanin Zibanejad
Department of Pediatrics, Imam Hossein Children Hospital, Isfahan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/abr.abr_196_21

Rights and Permissions

Delirium is a syndrome with an acute onset that is accompanied by fluctuation and is associated with behaviors that indicate impaired consciousness and cognition. It is common and costly and is associated with severe functional decline and distress in an adult. However, its detection and diagnosis are so challenging in children. Herein, we report a 2-year-old girl who was admitted in the pediatric intensive care unit (PICU) with pneumonia and was intubated because of respiratory failure. She needed a lot of benzodiazepine and opioid drugs to be sedated. During hospital course after extubation, she developed by agitation and restlessness and dissociation from environment. Electroencephalography was done and diffuse generalized slow wave was observed. Finally, by environmental factors' correction, benzodiazepine decreasing, and risperidone administering, she became well and discharged. Delirium should be considered as an important, underdiagnosed, and common condition in the PICU. It should be considered in altered cognition, consciousness, and circadian rhythm disturbance situation in children.

Keywords: Benzodiazepine, delirium, pediatric, pediatric intensive care unit

How to cite this article:
Zibanejad N. Delirium in a child in pediatric intensive care unit. Adv Biomed Res 2023;12:25

How to cite this URL:
Zibanejad N. Delirium in a child in pediatric intensive care unit. Adv Biomed Res [serial online] 2023 [cited 2023 Sep 25];12:25. Available from:

  Introduction Top

Delirium is a syndrome with an acute onset that is accompanied by fluctuation and is associated with behaviors that indicate impaired consciousness and cognition.[1],[2] It is common and costly and is associated with severe functional decline and distress and is a manifestation of acute encephalopathy.[3] However, its diagnosis is so challenging in children. Delirium is common in critically ill patients and is associated with increased intensive care unit (ICU) length of stay and long-term cognitive impairment.[4]

It is usually underdiagnosed.[5] Three hypoactive, hyperactive, and mixed subtypes commonly occur in severely malnourished children and adults, indicating global dysfunction due to the direct physiological impact of an underlying disease or its treatment. Delirium in children is strongly associated with a poor prognosis, including increased mortality, prolonged hospital and pediatric ICU (PICU) stay, and increased duration of mechanical ventilation and treatment costs.[1]

The care of delirium patients depends on the correct diagnosis and treatment of the underlying cause. Management of delirium patients is currently avoiding the aggravating and initiating factors of delirium and atypical antipsychotic drugs.[6] Delirium affects up to 80% of adults admitted to the ICU and up to 30% of children admitted to the PICU.[7],[8]

  Case Report Top

A 2-year-old girl (patient consent form has been obtained), previously known for protein malabsorption by a genetic test that used to receive amino acids and venofer weekly, had a fever 2 days before admission and she had difficulty breathing, so she brought to our hospital and was admitted.

At the beginning, she had tachypnea and tachycardia and severe respiratory distress, which she underwent the noninvasive ventilation (NIV). Due to the continuation of the respiratory distress and intolerance of the NIV, the patient was intubated and connected to the ventilator. Ceftriaxone and vancomycin were administered.

Chest-x-ray showed lobar pneumonia. She was anemic in the first laboratories as past. PCR and COVID-19 antibodies were sent and were negative. Bactec that was sent outpatient 2 days before admission reported positive. She had mechanically ventilated, so midazolam and fentanyl were started.

Under mechanical ventilation, due to the patient's alertness and fight, fentanyl and midazolam were fully dosed and dexmedetomidine and ketamine were added. She was still sometimes quite alert and looked at her mother and communicated with her, and sometimes needed doses of stat midazolam. An opioid rotation was performed and fentanyl was changed to morphine.

Finally, 11 days later, the patient underwent (spontaneous breathing trial) and extubation.

The patient's sedation and analgesics were continued with the previous level, but the stat doses were discontinued.

The day after the extubation, we noticed that the patient did not communicate with her mother. She was awake but did not have a meaningful look and did not pay attention to her surroundings. Vital signs and laboratory tests were stable and suspicious movement of seizure was not evident. The mother stated that she had been fully awake the night before and had not slept at all. Suspicious of delirium, midazolam and ketamine were discontinued, and the dose of dexmedetomidine was increased and continued with morphine drip. Because of withdrawal symptoms, tablet diazepam was started.

The patient gradually became more restless, screaming, and still not communicating. Cornell Assessment of Pediatric Delirium score was 24. Single dose of haloperidol was tried but did not seem to have much effect.

The patient was transferred to a single PICU room and the ambient noise was controlled. When sleeping at night, the room light was low and the day was exposed to light. The mother was given the necessary training to be present and communicate with her and create a familiar environment for her. Periods of restlessness continued. She did not sleep all night. The mother said that she is not my previous child at all. Electroencephalography (EEG) was taken, and generalized slow wave compatible with encephalopathy was reported. Finally, risperidone 0.25 mg per day was started for the patient, which was given at night. Thyroid tests were sent. Due to Withdrawal Assessment Tool score and withdrawal symptoms, the morphine dose was increased, and finally, diazepam tablets had to be prescribed every 12 hours. Then, gradually, over the next few days, the patient's cognition improved and his restlessness and sleep at night completely improved. With the onset of recovery, diazepam was gradually reduced daily, then morphine was reduced, and finally, dexmedetomidine was discontinued. The patient was discharged in good general condition with oral morphine with tapering plan.

  Discussion Top

Delirium is defined in the Fifth Edition Diagnostic and Statistical Manual of Mental Disorders as a disorder of attention and consciousness that can no longer be well explained despite previous or evolving dementia. This disorder develops in a short time and tends to fluctuate throughout the day. Moreover, the direct result is another medical problem such as toxicity or withdrawal or infection or electrolyte disturbances and various other etiologies.[9] Therefore, delirium may occur in different cases.[10] Determining the cause is very important because it is associated with high mortality.[11] In our case, there were predisposing factors such as ICU admission, invasive devices, invasive procedures such as repeated sampling, intubation and mechanical ventilation, and multiple drug therapy. All of which can act as delirium triggers or aggravating factors.[10],[12]

The need for many high-dose sedatives and analgesics, especially benzodiazepines in this patient, was one of the main factors in causing delirium. In a case report of a 7-year-old girl with an asthma attack, even administration of ranitidine was identified as the main cause of delirium in her, and many drugs have been identified as causative agents, such as h2 blockers due to their anticholinergic effect.[13],[14],[15]

In references, age under 2 years and previous growth retardation have been cited as predisposing factors.[1],[10],[12] Other factors include electrolyte, metabolic disorders, hypoxia, shock, anemia, hypothermia or fever, severe acute illness, surgery, physical restraints, and hypnotic sedatives such as benzodiazepines, opioids, and infections.[12],[16] Many of these factors were present in our patient: fever, anemia, severe acute illness, physical inhibition, infection, especially the use of high doses of sedatives, especially benzodiazepines such as midazolam.

EEG diffuse slow wave was reported. Generalized slowing in the EEG is strongly associated with delirium and its severity. In addition, generalized slowing in EEG causes concerns about the prognosis of delirium patients by changing mental status.

In patients with cognitive changes in references, EEG monitoring is recommended if there is a concern about seizures. Moreover, if there is no concern about seizures, EEG can help as a useful diagnostic tool in situation of changing the mental state. A normal EEG is against the diagnosis of delirium in adult patients,[17],[18]

Prevention is the most effective way to reduce the incidence of delirium. It is important to know the risk factors because they can be controlled and treated to some extent.

The main strategies include correction of environmental, iatrogenic, and disease-related factors. Treatment depends on prevention of risk factors, timely diagnosis, clinical monitoring, and elimination of the underlying disease.[19],[20]

Symptoms usually improve with the onset of the underlying disease, but drug therapy is recommended as an alternative treatment in cases where nondrug therapy is insufficient.[20],[21] Antipsychotic drugs such as risperidone and haloperidol are considered as the first-line appropriate treatment options. The action of risperidone is to decrease dopaminergic and serotonergic pathway activity in the brain, therefore decreasing symptoms of schizophrenia and delirium. We used risperidone for treatment and it was very effective.[22]

  Conclusion Top

In this article we reviewed the definition, prognosis and management of delirium. With emphasizing that delirium is common in intensive care unit and should be highly sensitive for its detection and treatment. This case had many predisposing factors for presenting delirium. Despite the risk factors and severe form of delirium the patient improved by correcting environmental and disease related factors and at last drug treatment. Finally she was discharged with good general condition and proper consciousness.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Patel AK, Bell MJ, Traube C. Delirium in pediatric critical care. Pediatr Clin North Am 2017;64:1117-32.  Back to cited text no. 1
Rogers M, Shaffner D, Nichols D, Argent A, Arnold J, Biagas K, et al. Rogers Textbook of Pediatric Intensive Care. 5th ed. Netherlands: Wolters Kluwer; 2015. p. 416.  Back to cited text no. 2
Mattison M. Delirium. Ann Intern Med 2020;173:ITC49-64.  Back to cited text no. 3
Slooter AJ, Van De Leur RR, Zaal IJ. Delirium in critically ill patients. Handb Clin Neurol 2017;141:449-66.  Back to cited text no. 4
Setters B, Solberg LM. Delirium. Prim Care 2017;44:541-59.  Back to cited text no. 5
Turkel SB. Pediatric delirium: Recognition, management, and outcome. Curr Psychiatry Rep 2017;19:101.  Back to cited text no. 6
Hübscher A, Isenmann S. Delirium: Concepts, etiology, and clinical management. Fortschr Neurol Psychiatr 2016;84:233-44.  Back to cited text no. 7
8. California: Assessment and Management of Delirium across the Life Span. Available from: [Last updated on 2018 Oct 01].  Back to cited text no. 8
Arlington VA. Diagnostic and Statistical Manual of Mental Disorders American Psychiatric Association. 5th ed. Washington, D.C: American Psychiatric Publishing; 2013.  Back to cited text no. 9
Maldonado J. Delirium. Neurobiology, Characteristics and Management. In: Psychiatric Care of the Medical Patient. Oxford: Oxford university press. 2015. p. 823-907.  Back to cited text no. 10
Brahmbhatt K, Whitgob E. Diagnosis and management of delirium in critically ill infants: Case report and review. Pediatrics 2016;137:E20151940.  Back to cited text no. 11
Page V, Ely E. Delirium in Critical Care. 2nd ed. Cambridge: Cambridge University Press; 2015.  Back to cited text no. 12
Rudolph JL, Salow MJ, Angelini MC, McGlinchey RE. The anticholinergic risk scale and anticholinergic adverse effects in older persons. Arch Intern Med 2008;168:508-13.  Back to cited text no. 13
Field RH, Gossen A, Cunningham C. Prior pathology in the basal forebrain cholinergic system predisposes to inflammation-induced working memory deficits: Reconciling inflammatory and cholinergic hypotheses of delirium. J Neurosci 2012;32:6288-94.  Back to cited text no. 14
Madden K, Burns MM, Tasker RC. Differentiating delirium from sedative/hypnotic-related iatrogenic withdrawal syndrome: Lack of specificity in pediatric critical care assessment tools. Pediatr Crit Care Med 2017;18:580-8.  Back to cited text no. 15
Reveiz L, Guerrero-Lozano R, Camacho A, Yara L, Mosquera PA. Stress ulcer, gastritis, and gastrointestinal bleeding prophylaxis in critically ill pediatric patients: A systematic review. Pediatr Crit Care Med 2010;11:124-32.  Back to cited text no. 16
Chop.Edu. Philadelphia: PICU Clinical Pathway for Screening/Treatment of Children with Delirium, Updated 2017 June, 2019 March. Available from: [Last accessed on 2021 Dec 28].  Back to cited text no. 17
Kimchi EY, Neelagiri A, Whitt W, Sagi AR, Ryan SL, Gadbois G, et al. Clinical EEG slowing correlates with delirium severity and predicts poor clinical outcomes. Neurology 2019;93:e1260-71.  Back to cited text no. 18
Faria R, Moreno R. Delirium in intensive care: An under-diagnosed reality. Rev Bras Ter Intensiva 2013;25:137-47.  Back to cited text no. 19
Kotfis K, Marra A, Ely EW. ICU delirium-A diagnostic and therapeutic challenge in the intensive care unit. Anaesthesiol Intensive Ther 2018;50:160-7.  Back to cited text no. 20
Thom RP, Mock CK, Teslyar P. Delirium in hospitalized patients: Risks and benefits of antipsychotics. Cleve Clin J Med 2017;84:616-22.  Back to cited text no. 21
Chop.Edu. Philadelphia: PICU Clinical Pathway for Screening/Treatment of Children with Delirium, Updated 2017 June, 2019 March. . Available from: [Last accessed on 2021 Dec 27].  Back to cited text no. 22


Previous article  Next article
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Case Report

 Article Access Statistics
    PDF Downloaded59    
    Comments [Add]    

Recommend this journal