Pediatric Delirium in the Emergency Department: An Underrecognized Sixth Vital Sign
Year: 2025
Type: article
Abstract: Delirium in critically ill children is a serious complication (1). It is increasingly understood as an early sign of acute brain dysfunction—one that predicts worse outcomes, including prolonged mechanical ventilation, higher mortality risk, and long-term neurocognitive impairment (1,2). Yet, in practice, pediatric delirium (PD) remains underdiagnosed and undertreated in the PICU (3,4). Now, in this issue of Pediatric Critical Care Medicine (PCCM), there is a research report from a single center carried out 2022 to 2023 that adds an important and provocative dimension to the evolving clinical picture of PICU-associated PD. It appears that there is a potential role of emergency department (ED) exposures in the development of PD within the first 24 hours of PICU admission (5). The authors found that of 138 pediatric patients screened, 37% met criteria for PD within 24 hours of PICU admission according to the Cornell Assessment of Pediatric Delirium (CAPD). Two ED-based interventions—intermittent urinary catheterization and mechanical ventilation—were associated with a more than three-fold greater odds of developing PD. One of the notable strengths of the study is its focus on the ED-to-PICU transition inpatient care. Although most PICU-based research into PD begins at the time of PICU admission, this new study started by asking whether exposures in the ED may initiate or contribute to early delirium risk. In doing so, the authors draw attention to a critical period of vulnerability that is often overlooked in both research and practice. And we agree: “Delirium Yes or No” (6) should be considered the “Next (Sixth) Vital Sign” (7) in combination with level of consciousness, respiratory pattern and rate, blood pressure, pulse rate, and body temperature. SCREENING WITHOUT DIAGNOSIS Another strength of the new study (5) is its structural implementation of CAPD screening in the PICU. The authors had twice-daily CAPD assessments integrated into their clinical practice, which is a step that many institutions still struggle to operationalize. This approach enhances the generalizability of the findings, and models how structured delirium monitoring can be sustained outside of research protocols. Although the 64% compliance rate suggests ongoing barriers, the study shows that routine screening is feasible and informative, even if imperfect. However, the study used only a single CAPD threshold score of greater than or equal to 9 as a surrogate for diagnosing PD—without clinical validation or psychiatric consultation. As the authors acknowledge, this single assessment raises the risk of false-positives, particularly in younger patients or those with neurodevelopmental conditions in which behavioral dysregulation may mimic the symptoms of PD. That is, the absence of diagnostic confirmation also means that delirium subtypes and a fluctuating course was not fully explored. This limited assessment—the use of structured screening tools in the absence of a validated diagnostic framework—is a known weakness of (many) research studies in PD. A CAPD score greater than or equal to 9 is a probable indicator of delirium, but not diagnostic confirmation (8). In the PICU, there is no consensus on clinical adjudication using the phenomenology and Diagnostic and Statistical Manual of Mental Disorders or International Classification of Diseases (ICD-10) criteria of PD (2). Even so, the new PCCM study illustrates screening without diagnosis introduces new clinical dilemmas. A high CAPD score may lead to labeling and treatment (e.g., antipsychotic use) in the absence of true PD. Conversely, the absence of a clinical framework may lead to dismissing valid screen-positive cases. This process may lead to patients who are both over treated and under treated depending on the clinical context. TYPE SPECIFYING The authors were also careful with records specifying PD type; after all, both types of PD are fundamentally different. In the 2022 to 2023 cohort, 53% of 51 PD cases were hypoactive and 31% were mixed. These numbers align with earlier reviews and comments on hypoactive and mixed delirium subtypes predominating during pediatric critical illness, yet they are the most easily missed (9,10). These children are quiet, disengaged, and often sedated. Without structured screening, they are unlikely to be recognized. This study also shows that even with routine CAPD screening in the PICU, compliance was only 64%. This incomplete adherence suggests logistical challenges, which could have had a role in the near-total absence of screening or recognition in the ED. Not one patient in the study had an ICD-10 delirium code assigned during their ED stay. Whether this reflects true absence of symptoms or simply a lack of clinical awareness is unclear—but in either case, it highlights a critical blind spot. RISK FACTORS Perhaps the study’s most clinically actionable contribution is its identification of specific and modifiable PD risk factors originating in the ED. The association between intermittent urinary catheterization and PD is unexpected but important. Although the underlying mechanism is unclear—ranging from discomfort and pain to sleep disruption or iatrogenic stress—it highlights a procedure that could potentially be avoided or replaced by alternative strategies in non-critical cases. Similarly, mechanical ventilation, although often life saving, brings with it a cascade of interventions (e.g., sedatives, immobilization) that compound neurologic-psychiatric risks like the onset of emergence delirium. The study’s emphasis on these interventions—rather than on nonmodifiable factors like age or severity of illness—provides a logical starting point for PD prevention strategies. It invites clinicians to ask: if this child requires intubation or catheterization, what measures can we add or put in place immediately to minimize their delirium risk? The answer may lie in early environmental supports and reduced sedation. TOWARD A MORE INTEGRATED APPROACH The disconnect between clinical documentation and structured CAPD screening results reflects broader challenges in how PD is recognized, or more often missed, in the PICU. Therefore, the new report in PCCM (5) should be a call to action for both clinicians and researchers. PD must not only be seen as a condition that emerges only in the later stages of critical illness. Instead, it must be seen as a dynamic process—one that begins early in the ED, fluctuates frequently, and is shaped by the multifactorial model of illness, environment, and interventions. To do so, we need to: 1) raise awareness of PD originating in the ED, 2) validate diagnostic frameworks for PD and multidisciplinary clinical consensus, 3) screen routinely with CAPD, ideally starting when the child enters the hospital, and 4) include research that incorporates both screening and clinical diagnosis. In conclusion, PD is a serious complication not only in the PICU, but also in patients transitioning from the ED where there is an opportunity to mitigate etiological factors.
Source: Pediatric Critical Care Medicine
Language: English
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4414609509