Julia Kearney

Cornell Assessment of Pediatric Delirium: A Valid, Rapid, Observational Tool for Screening Delirium in the PICU*

Objective:To determine validity and reliability of the Cornell Assessment of Pediatric Delirium, a rapid observational screening tool. Design:Double-blinded assessments were performed with the Cornell Assessment of Pediatric Delirium completed by nursing staff in the PICU. These ratings were compared with an assessment by consultation liaison child psychiatrist using the Diagnostic and Statistical Manual IV criteria as the “gold standard” for diagnosis of delirium. An initial series of duplicate Cornell Assessment of Pediatric Delirium assessments were performed in blinded fashion to assess interrater reliability. Nurses recorded the time required to complete the Cornell Assessment of Pediatric Delirium screen. Setting:Twenty-bed general PICU in a major urban academic medical center over a 10-week period, March–May 2012. Patients:One hundred eleven patients stratified over ages ranging from 0 to 21 years and across developmental levels. Intervention:Two hundred forty-eight paired assessments completed. Measurements and Main Results:The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8–98.8%) and specificity of 79.2% (95% CI, 73.5–84.9%). Overall Cronbach’s &agr; of 0.90 was observed, with a range of 0.87–0.90 for each of the eight items, indicating good internal consistency. A scoring cut point of 9 demonstrated good interrater reliability of the Cornell Assessment of Pediatric Delirium when comparing results of the screen between nurses (overall &kgr; = 0.94; item range &kgr; = 0.68–0.78). In patients without significant developmental delay, sensitivity was 92.0% (95% CI, 85.7–98.3%) and specificity was 86.5% (95% CI, 75.4–97.6%). In developmentally delayed children, the Cornell Assessment of Pediatric Delirium showed decreased specificity of 51.2% (95% CI, 24.7–77.8%) but sensitivity remained high at 96.2% (95% CI, 86.5–100%). The Cornell Assessment of Pediatric Delirium takes less than 2 minutes to complete. Conclusions:With an overall prevalence rate of 20.6% in our study population, delirium is a common problem in pediatric critical care. The Cornell Assessment of Pediatric Delirium is a valid, rapid, observational nursing screen that is urgently needed for the detection of delirium in PICU settings.

Pediatric delirium and associated risk factors: a single-center prospective observational study.

Objective: To describe a single-institution pilot study regarding prevalence and risk factors for delirium in critically ill children. Design: A prospective observational study, with secondary analysis of data collected during the validation of a pediatric delirium screening tool, the Cornell Assessment of Pediatric Delirium. Setting: This study took place in the PICU at an urban academic medical center. Patients: Ninety-nine consecutive patients, ages newborn to 21 years. Intervention: Subjects underwent a psychiatric evaluation for delirium based on the Diagnostic and Statistical Manual IV criteria. Measurements and Main Results: Prevalence of delirium in this sample was 21%. In multivariate analysis, risk factors associated with the diagnosis of delirium were presence of developmental delay, need for mechanical ventilation, and age 2–5 years. Conclusions: In our institution, pediatric delirium is a prevalent problem, with identifiable risk factors. Further large-scale prospective studies are required to explore multi-institutional prevalence, modifiable risk factors, therapeutic interventions, and effect on long-term outcomes.

Standards of Psychosocial Care for Parents of Children With Cancer

Parents and caregivers of children with cancer are both resilient and deeply affected by the childs cancer. A systematic review of published research since 1995 identified 138 studies of moderate quality indicating that parent distress increases around diagnosis, then returns to normal levels. Post‐traumatic symptoms are common. Distress may be impairing for vulnerable parents and may impact a childs coping and adjustment. Moderate quality evidence and expert consensus informed a strong recommendation for parents and caregivers to receive early and ongoing assessment of their mental health needs with access to appropriate interventions facilitated to optimize parent, child, and family well being. Pediatr Blood Cancer

Infant Delirium in Pediatric Critical Care Settings

Pediatric delirium is a common though underrecognized and understudied phenomenon in pediatric critical care. The unique combination of the vulnerability and resiliency of children’s developing brains makes it imperative that research on prevention, evaluation, treatment, and follow-up of this complication of pediatric medical illness and treatment be vigorously pursued. Although antipsychotics are rarely used for treatment, a small but growing body of research supports the effi cacy and short-term safety of using both conventional and atypical antipsychotics. Further understanding of the complex neurophysiology of delirium may lead to more refi ned treatments. Developmentally valid screening tools will make the assessment and treatment of pediatric delirium more feasible when expert consultation is not available.

Impact of Caregiving for a Child With Cancer on Parental Health Behaviors, Relationship Quality, and Spiritual Faith Do Lone Parents Fare Worse?

Caregiving stress has been associated with changes in the psychological and physical health of parents of children with cancer, including both partnered and single parents. While parents who indicate “single” on a demographic checklist are typically designated as single parents, a parent can be legally single and still have considerable support caring for an ill child. Correspondingly, an individual can be married/partnered and feel alone when caring for a child with serious illness. In the current study, we report the results from our exploratory analyses of parent self-reports of behavior changes during their child’s treatment. Parents (N = 263) of children diagnosed with cancer were enrolled at 10 cancer centers. Parents reported significant worsening of all their own health behaviors surveyed, including poorer diet and nutrition, decreased physical activity, and less time spent engaged in enjoyable activities 6 to 18 months following their child’s diagnosis. More partnered parents found support from friends increased or stayed the same since their child’s diagnosis, whereas a higher proportion of lone parents reported relationships with friends getting worse. More lone parents reported that the quality of their relationship with the ill child’s siblings had gotten worse since their child’s diagnosis. Spiritual faith increased for all parents.

Olanzapine for chemotherapy-induced nausea: Lessons learned from child and adolescent psychiatry

1Department of PsychosocialOncology andPalliativeCare, Dana–FarberCancer Institute, Boston,Massachusetts 2Department of Psychiatry, BostonChildrensHospital, Boston,Massachusetts 3HarvardMedical School, Boston,Massachusetts 4Department of Psychiatry andBehavioral Sciences,Memorial SloanKetteringCancerCenter, NewYorkCity, NewYork 5Department of Psychiatry andPediatrics, University of KentuckyCollege ofMedicine, Lexington, Kentucky 6KentuckyChildrensHospital, Lexington, Kentucky 7Department of Pediatric Psychosocial Oncology,MassachusettsGeneral Hospital, Boston,Massachusetts 8Department of Psychiatry andPalliativeCare, University of California SanDiego School ofMedicine, SanDiego, California Correspondence ChaseSamsel,DepartmentofPsychosocialOncologyandPalliativeCare,Dana–FarberCancer Institute, SW360A,450BrooklineAvenue,Boston,MA,02115. Email: chase_samsel@dfci.harvard.edu

Psychiatric Issues in Pediatric Oncology: Diagnosis and Management

Psychiatric issues in pediatric oncology describe the role of the consultation-liaison child psychiatrist in psycho-oncology. The chapter begins with general considerations for psychiatric diagnosis, treatment planning, and psychopharmacology in medically complex children and adolescents with cancer. The authors discuss specific psychiatric disorders and symptoms including depression, suicidal ideation, anxiety, posttraumatic symptoms, delirium and drug withdrawal syndromes, neurocognitive impairment, and other cancer treatment-related psychiatric symptoms. The evidence base for psychopharmacology in this population, efficacy and safety data, and cancer-specific prescribing concerns are reviewed in detail including commonly seen side effects, oncology-specific uses of certain drugs, and recommended monitoring practices in medically ill patients. Clinical cases demonstrate common presentations and treatment issues. The chapter highlights the critical importance of the recognition, diagnosis, and management of psychiatric comorbidities for patient safety, relief of suffering, and optimal quality of life through cancer treatment and describes the specialized role of the child psychiatrist consultant as an expert who collaborates in the multimodal, integrated care of the child and family.

Reply to: Comment on: Olanzapine for chemotherapy-induced nausea: Lessons learned from child and adolescent psychiatry

To the Editor: We thankDrsDupuis et al for their letter and for enhancing the discussion regarding the use of Olanzapine for refractory chemotherapyinduced nausea and vomiting (CINV).1 The intent of our commentary was to foster collaboration among pediatric oncology, pharmacy, and psychiatry in the novel use of this medication.2 We applaud the development of guidelines to provide effective relief of CINV in children and adolescents and are encouraged by the role that olanzapine can play. There are important distinctions between the long-term use of antipsychotic medications in the treatment of acute and chronic psychiatric illness and the short-term targeted use of olanzapine for refractory CINV. Our commentary is meant to contribute additional information to concurrently reduce risk and allay concerns, and we do not intend to create barriers to the use of potentially effective antiemetic therapy. We are especially enthusiastic about the use of olanzapine for children and adolescents with comorbid CINV and psychiatric symptoms such as severe anxiety, mood instability, or delirium. We agree the existing pediatric and psychiatric consensus guidelines regarding metabolic and waist circumference monitoring in long-term use of atypical antipsychotics may not be applicable for short-term use in pediatric oncology.3,4 It is important background information to have should prolonged treatment be considered or become necessary, as olanzapine has the strongest metabolic effects of its class.5,6 We agree that severe QTc prolongation is not an acute risk with olanzapine monotherapy in children without other cardiac risk factors or QTc prolonging polypharmacy. However, in clinical oncology practice, many children are on concomitant QTc prolonging medications and may need a reference electrocardiogram, often available from their baseline medical work-up.7 In terms of dosing, we agree that 0.1 mg/kg/dose (max: 10 mg/dose) is a reasonable rule of thumb, though dosage forms of oral and disintegrating tablets may limit the increments for dosing. Doses of greater than 5 mg may be too sedating and should only be considered for older children or adolescents who do not respond to lower doses. Intramuscular administration is only used for acute psychiatric emergencies. We are hopeful that prospective research can be done regarding the efficacy and side effects of olanzapine for refractory CINV in children and adolescents.8 Some of our own institutions are rolling out evidence-based guidelines based on those developed by Pediatric Oncology Group of Ontario and endorsed by The Childrens Oncology Group,9,10 with olanzapine as a treatment for refractory CINV. We appreciate the multidisciplinary efforts that can contribute to supportive care and symptom relief for our young patients with cancer,

Delirium in Hospitalized Children with Cancer: Incidence and Associated Risk Factors

Objective To assess the incidence of delirium and its risk factors in hospitalized children with cancer. Study design In this cohort study, all consecutive admissions to a pediatric cancer service over a 3‐month period were prospectively screened for delirium twice daily throughout their hospitalization. Demographic and treatment‐related data were collected from the medical record after discharge. Results A total of 319 consecutive admissions, including 186 patients and 2731 hospital days, were included. Delirium was diagnosed in 35 patients, for an incidence of 18.8%. Risk factors independently associated with the development of delirium included age <5 years (OR = 2.6, P = .026), brain tumor (OR = 4.7, P = .026); postoperative status (OR = 3.3, P = .014), and receipt of benzodiazepines (OR = 3.7,P < .001). Delirium was associated with increased hospital length of stay, with median length of stay for delirious patients of 10 days compared with 5 days for patients who were not delirious during their hospitalization (P < .001). Conclusions In this cohort, delirium was a frequent complication during admissions for childhood cancer, and was associated with increased hospital length of stay. Multi‐institutional prospective studies are warranted to further characterize delirium in this high‐risk population and identify modifiable risk factors to improve the care provided to hospitalized children with cancer.