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Delirium frequent among noncritically ill children with cancer
Delirium diagnoses occurred among 18.8% of hospitalized children with cancer appeared associated with longer hospital stays, according to a study published in The Journal of Pediatrics.
“The incidence of delirium in children with cancer that is reported in the literature is quite low and that’s not because children with cancer don’t get delirious,” Chani Traube, MD, associate professor of clinical pediatrics in the division of pediatric critical care medicine at Weill Cornell Medicine and pediatric intensivist at NewYork-Presbyterian Komansky Children’s Hospital, told HemOnc Today. “It’s because delirium is often not recognized unless it’s at its most extreme.”
Delirium can present as severe agitation or more commonly as hypoactivity, in which children act withdrawn, apathetic and are not able to think clearly, according to Traube.
“Delirium in oncology patients has been shown to decrease effectiveness of pain management, and increase psychological distress [among] patients, families and medical providers,” Traube and colleagues wrote. “Early recognition of delirium in adults with cancer has been shown to be key to successful treatment. Although delirium in hospitalized adults with cancer is widely recognized, little is known about the incidence of delirium in pediatric oncology.”
The researchers studied 319 consecutive admissions of 186 patients — equaling 2,731 hospital days — to a pediatric cancer service over 3 months. Patients received screening for delirium twice daily by his or her nurse using the Cornell Assessment of Pediatric Delirium.
“The availability of an easy-to-use bedside delirium screening tool — suitable for children of all ages and all stages of development — allows us to routinely monitor children for delirium,” Traube told HemOnc Today. “The tool we used in our study takes less than 2 minutes for the bedside nurse to complete and reliably diagnoses delirium and trends its trajectory.”
Study results showed 18.8% (n = 35) of children were diagnosed with delirium for a median duration of 2 days.
For comparison, delirium occurs among 25% of critically ill children, according to the researchers.
“What is so notable about this paper is that the cohort is not the traditional ICU cohort, but children who are hospitalized for cancer treatments or complications; it’s a noncritically ill cohort of children with cancer,” Traube said. “We showed pretty significant delirium rates in those noncritically ill children. The rates were not as high as in critically ill children, but they were a lot higher than you would find in the general pediatric ward.”
Independent delirium risk factors included age less than 5 years (OR = 2.6; P = .026), postoperative status (OR = 3.3; P =.014), receipt of benzodiazepines (OR = 3.7; P < .001) and brain tumor diagnosis (OR = 4.7; P = .026).
Median length of hospital stay was 10 days among delirious children compared with 5 days among those without delirium (P < .001).
The mortality rate for the entire cohort was 1.6% (n = 3); however, it was significantly higher among children with delirium (8.6% vs. 0%; P = .006).
It is standard of care to screen for delirium in adults with cancer, but not yet in children with cancer.
“A similar kind of change needs to take place within pediatric oncology as it has already in pediatric critical care and in adult oncology,” Traube said. “Delirium detected early is much more amendable to treatment. You can shorten its duration which is a lot better for the patient.
“We owe it to these children to screen them for delirium,” she added. “We don’t have any excuses. There are easy screening tools available to use at the bedside. Delirium happens commonly and it’s treatable and it’s preventable. We can no longer avoid recognizing and addressing this problem [for] children with cancer.”
Further research is needed on the long-term effects of delirium among children and the role of benzodiazepines in delirium development.
“We should probably limit benzodiazepine. A study looking at a different way to approach medication choices to decrease delirium rates is probably the most important next step,” Traube said. – by Cassie Homer
For more information:
Chani Traube, MD, can be reached at Pediatric Critical Care Medicine, 525 East 68th St., M-508,New York, NY 10065.
Disclosures: The authors report no relevant financial disclosures.