The Pharmacologic Management of Delirium in Children and Adolescents

Abstract

Delirium is a serious and common problem in severely medically ill patients of all ages. It has been less addressed in children and adolescents. Treatment of delirium is predicated on addressing its underlying cause. The management of its symptoms depends on the off-label use of antipsychotics, while avoiding agents that precipitate or worsen delirium. Olanzapine, quetiapine, and risperidone are presently considered first-line drugs, usually replacing haloperidol. Other agents have shown promise, including melatonin to address the sleep disturbance characteristic of delirium, and dexmedetomidine, an α2-agonist, that may facilitate lower doses of benzodiazepines and opioids that may worsen delirium.

Delirium in Children: Identification, Prevention, and Management

“…17,18 Prevention and management of delirium in children may benefit from a holistic, interprofessional approach that first focuses on identifying, modifying, and, when possible, correcting a patient's underlying medical conditions that may be contributing to the delirium. 7,[19][20][21] Because of the complexity of a critically ill child's condition and the required management, completely modifying or correcting the underlying condition is not always possible, so equal attention must be paid to minimizing the risk for the development of delirium and modifying the PICU environment to better support a delirious patient. 4,7,[19][20][21][22] Finally, providing psychosocial support to a delirious child and the child's family is essential.…”

“…2,[19][20][21]27,41 Pharmacological intervention may be necessary when a child's psychomotor symptoms interfere with the child's safety, especially when the medical condition causing or contributing to the delirium cannot be immediately remedied. 2,16,17,19,21,23,27,28 In these situations, medications to help manage the signs of delirium may be appropriate to enhance the child's safety and to support brain function. 7,17,21 Additional reasons for administering medications to manage or decrease the behavioral expression of delirium include limiting the time the patient is in a delirious state, decreasing any associated physical or emotional trauma and distress, and reducing the hospital length of stay.…”

“…2 Haloperidol may be beneficial for children who cannot tolerate oral medications and whose agitation has not changed in response to the nonpharmacological interventions previously described. 4,16,19 Haloperidol Have the child out of bed when awake as much as tolerated…”

“…Use a room with windows with an outside view to cue time of day 11,34,36 Have a calendar and clock for date and time identification 23 Alternate a picture of the sun during the day and the moon at night 19,38 Post a picture identifying what meal is coming next 21,39 Have parents, visitors, and staff actively reorient child to person, place, time, and reason for being in the hospital 14,31,32 Explain where the child is and why he or she is there.…”

“…22 Antipsychotic medications are sedating, particularly quetiapine, so administering these medications at bedtime may promote sleep. 19,34 Pharmacological treatment of delirium requires reassessment and ongoing drug titration once the child's clinical status improves. 4,19 The unfavorable and potentially permanent side effects of antipsychotic medications can be mitigated with dose progression of the drugs, administration of anticholinergic medications, and careful monitoring by bedside nurses.…”