Abstract
Aim:
Pediatric delirium remains understudied among oncology patients. This study aimed to evaluate the prevalence of delirium and associated factors among children admitted to the pediatric intensive care unit (PICU) in Jordan.
Methods:
A cross-sectional study was conducted over 6 months, including 165 pediatric oncology patients aged 1 month to 18 years. Delirium was assessed twice daily using the Cornell Assessment of Pediatric Delirium (CAPD). Demographic and clinical variables were analyzed for associations with delirium.
Results:
Delirium occurred in 29% of patients. Younger age (<5 years), prolonged PICU stay (>7 days), and higher night-shift acuity scores were significantly associated with delirium (P < .05). Delirium was also more frequent among patients receiving low-flow oxygen therapy, likely reflecting greater illness severity.
Conclusion:
Delirium was common among critically ill pediatric oncology patients admitted to the PICU. These findings highlight the importance of routine delirium screening using validated tools in this population.
Introduction
Delirium is a neurocognitive syndrome characterized by an acute and fluctuating disturbance in attention, awareness, and cognition that represents a change from baseline and is attributable to an underlying medical condition or its treatment. 1 In pediatric patients, delirium is increasingly recognized as a serious yet potentially reversible complication of critical illness, particularly in intensive care unit (ICU) settings. 2 When unrecognized or untreated, delirium has been associated with prolonged hospitalization, increased healthcare utilization, higher mortality, and long-term neurocognitive impairment. 3
The prevalence of delirium in pediatric intensive care units (PICUs) has been reported to range between 20% and 40%, with higher rates observed among children with greater illness severity and exposure to complex medical interventions.3 -5 Pediatric oncology patients represent a particularly vulnerable subgroup due to the combined effects of malignancy, intensive treatments such as chemotherapy and surgery, frequent exposure to sedatives and analgesics, immune suppression, metabolic disturbances, and repeated ICU admissions.6 -8 In addition, environmental stressors inherent to the PICU such as sleep disruption, frequent procedures, and separation from familiar surroundings may further increase delirium risk. 9
While delirium has been extensively studied in adult ICU and oncology populations, evidence among pediatric patients remains limited, particularly in children with cancer admitted to the PICU. 2 Existing pediatric studies have largely focused on heterogeneous PICU cohorts or postoperative cardiac populations, with relatively few investigations targeting pediatric oncology patients specifically.4,10 Moreover, most available data originate from high-income countries, leaving a significant gap in knowledge regarding delirium prevalence and associated factors in resource-limited and middle-income settings. 11
Early identification of delirium is essential, as timely recognition may allow for supportive interventions and mitigation of adverse outcomes. 3 The development of validated pediatric delirium screening tools, such as the Cornell Assessment of Pediatric Delirium (CAPD), has enabled routine bedside assessment by nursing staff. 12 However, despite the availability of validated tools, delirium remains under-recognized in many PICUs due to competing clinical priorities and limited awareness of its clinical significance. 7
In Jordan and the broader Middle East region, data on pediatric delirium particularly among critically ill oncologypatients are scarce. Therefore, this study aimed to assess the prevalence of delirium among pediatric oncology patients admitted to the PICU at a specialized cancer center in Jordan and to examine its association with selected demographic and clinical variables.
Aim
This study aims to fill the gap in the literature by assessing the prevalence of delirium among pediatric cancer patients admitted to the PICU a specialized cancer center in Jordan, and examining its relationship with various demographic and clinical variables. By identifying key risk factors associated with delirium development, the research provides insights to guide future care interventions. Early detection of delirium is crucial in preventing long-term negative outcomes, such as prolonged hospitalization, higher mortality rates, and irreversible cognitive damage. The study emphasizes the importance of routine delirium assessments using validated tools like the Cornell Assessment of Pediatric Delirium (CAPD) to enable early identification and timely intervention, particularly in resource-limited settings. The findings aim to improve patient outcomes by equipping healthcare providers with the knowledge to better detect and manage delirium in this vulnerable population.
Methods
Design and Setting
This study followed a descriptive, cross-sectional design. It was conducted over 6 months, from March to August 2022 in the PICU of a specialized oncology hospital in Jordan, a specialized oncology hospital in Jordan. The hospital is the only center in the country that provides care for pediatric oncology patients, making it an ideal setting for this study.
Population and Sample
Pediatric cancer patients aged 1 month to 18 years who were admitted to the PICU during the study period met the inclusion criteria. Patients under neuromuscular blockade, deeply sedated patients according to a comfort scale, and unconscious patients were excluded, as were any patients whose parents or guardians requested to withdraw from the study at any time.
A total of 165 pediatric cancer patients admitted to the PICU were recruited, adhering to these specific inclusion and exclusion criteria. The population consisted of a mix of oncology diagnoses and was representative of the typical patient demographic at the hospital. The sample was stratified by age and disease severity to account for different delirium risk factors.
Instruments
CAPD, an observational tool used to assess patients’ status during nursing shifts, was implemented as part of routine care every 12 hours at the end of each shift (06:00 AM and 06:00 PM). A CAPD score of ≥9 was considered positive for delirium, and scores were recorded for each patient. The CAPD tool was used to assess the prevalence of delirium following its integration into a mixed-method, patient-centered improvement project.
Data Collection Procedures
Data collection was conducted by trained research team members (nurses) for each eligible patient using a standardized data collection sheet. Collected data included information on admission and discharge dates, diagnosis, reason for admission, length of stay, CAPD scores, and other demographic and clinical variables, such as illness severity. Acuity scores (ranging from 1 to 4, with higher scores indicating greater workload) were assessed during both the day and night shifts. All data were stored securely in a special file managed by the research team.
In addition to CAPD assessments, non-pharmacological interventions were routinely employed by the nursing staff to help prevent delirium and manage early symptoms. These interventions included reorientation techniques, promoting sleep hygiene (eg, reducing noise and light during nighttime), minimizing environmental stressors, ensuring hydration and nutrition, and engaging patients in simple cognitive activities when appropriate. Nurses were trained to apply these strategies as part of their routine care for all patients at risk of delirium, which was particularly important in the pediatric ICU setting.
Delirium assessments were conducted twice daily for each patient until discharged. Upon discharge, all data were entered into a secure database, accessible only to the data collection team. The principal investigator (PI) reviewed all collected data for completeness. In cases of missing data, the PI worked with the assigned nurse to complete the required information. All team members received training on database usage to ensure data accuracy.
Instrument
CAPD consists of 8 items addressing the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) domains of delirium: consciousness, cognition, orientation, psychomotor activity, and affect/distress. These items are scored on a scale of never, rarely, sometimes, often, or always. The scores are summed to provide a total score, with a cutoff of 9 indicating a positive delirium screening. The CAPD tool has demonstrated high reliability (k = 0.94), sensitivity (94.1%), specificity (79.2%), and internal consistency (Cronbach’s α = .90).
Sample Size Estimation and Sampling Strategy
The sample size was calculated using the Cochrane formula with a 5% margin of error, a confidence level of 95%, and an estimated delirium prevalence of 23% based on previous studies. The required sample size was 272; however, after adjusting for the population size (367), the final sample size was 165 participants.
Recruitment Strategy
At the start of each nursing shift, research team members screened patients for eligibility based on the inclusion and exclusion criteria. If eligible, the purpose of the study was explained to both the patient (child) and the parent. Verbal consent was obtained from the parents, as approved by the Institutional Review Board (IRB), which waived the need for written consent for minors in accordance with IRB regulations.
Once consent was obtained, trained nurses collected data twice daily using standardized data collection sheets. This data included demographic and clinical information such as admission and discharge dates, diagnosis, reasons for admission, length of stay, CAPD scores, and acuity scores. CAPD was used to assess delirium at the end of each nursing shift (06:00 AM and 06:00 PM), and a CAPD score was recorded for each patient during every shift until discharge. All collected data were entered into a secure, password-protected database accessible only to the research team. The principal investigator reviewed the data regularly for completeness, and any missing information was retrieved by consulting the patient’s assigned nurse.
Ethical Approval and Informed Consent
Ethical approval for this study was obtained from the Institutional Review Board (IRB) of the study hospital (IRB approval number: 22 KHCC 99). The study was reviewed and approved as an expedited study. At the start of each nursing shift, eligible patients were identified based on the inclusion and exclusion criteria. The purpose of the study was explained to both the child and the parent or legally authorized representative. Verbal informed consent was obtained from the parents or legally authorized representatives, as approved by the IRB, which waived the requirement for written informed consent due to the observational nature of the study and the inclusion of minors, in accordance with institutional and IRB regulations.
Data Analysis
Data was analyzed using SPSS version 24.0. Continuous variables were reported as means and standard deviations (SD), while nominal variables were presented as percentages. The prevalence of delirium was calculated as a percentage of the total sample (ie, number of patients with delirium divided by the total number of participants). Statistical differences between delirium and demographic or clinical variables were assessed using t-tests and chi-square tests. A significant level of P < .05 was applied.
Ethical Consideration
The study was reviewed and approved by the Institutional Review Board (IRB) of the hospital. Patients’ confidentiality was maintained throughout the study by assigning unique codes to each participant. Data protection followed research guidelines and was securely stored. No personally identifiable information was disclosed or accessible to anyone outside the research team. Verbal Informed consent was obtained from all participants in accordance with IRB requirements, and all methods were performed in accordance with relevant guidelines and regulations.
Results
Eligibility, Screening, and Consent
During the 6-month study period, all pediatric oncology patients admitted to the PICU were screened for eligibility. Patients who were deeply sedated, under neuromuscular blockade, or unconscious were excluded. All eligible patients were included in the study (n = 165), and verbal consent was obtained in accordance with institutional review board approval.
Sample Characteristics
The mean age of participants was 8.38 years (SD = 5.61; range 2-20 years), and 60% were male (n = 99). The average PICU length of stay was 5.01 days (SD = 2.91). Mean acuity scores were 2.77 during the day shift and 2.85 during the night shift. Patients underwent an average of 4.8 delirium assessments (SD = 2.9).
The most common diagnoses were brain or spinal cord tumors (22.4%), leukemia (21.2%), and other malignancies (37.6%). Postoperative admissions accounted for 44.8% of cases. Sedation or analgesia was administered to 32.7% of patients, invasive mechanical ventilation was used in 4.2%, and 30.3% received low-flow nasal cannula oxygen therapy (Table 1).
Demographic and Clinical Characteristics of the Sample.
Prevalence of Delirium
Delirium was identified in 29% of patients (n = 48). Delirium assessments were conducted twice daily throughout the PICU stay.
Factors Associated with Delirium
Patients who screened positive for delirium were younger than those without delirium (mean age 4.67 years vs 8.27 years, P < .001). Delirium-positive patients also had longer PICU stays (5.94 days vs 4.62 days, P = .008) and higher mean night-shift acuity scores (3.02 vs 2.78, P = .015). Receipt of low-flow oxygen therapy was significantly associated with delirium occurrence (P = .016) (Table 2).
Distribution of Delirium Cases Based on Different Demographic and Clinical Variables.
Difference is significant at the .05 level (two-tailed).
Difference is significant at the .01 level (two-tailed).
No significant associations were observed between delirium and gender, type of companion, use of sedation or analgesia, mechanical ventilation, high-flow oxygen therapy, bedridden status, or reason for PICU admission (Table 2).
Discussion
Delirium is a common and clinically significant complication among critically ill pediatric patients, including those with oncologic diagnoses. In this study, 29% of pediatric oncology patients admitted to the PICU developed delirium, which aligns with prevalence rates reported in other international cohorts. 13 The use of structured and validated assessment tools, such as the Cornell Assessment of Pediatric Delirium (CAPD), enhances early detection, as unrecognized delirium is associated with prolonged hospitalization, increased healthcare costs, higher mortality, and long-term neurocognitive impairment.2,11,13
Pediatric oncology patients are particularly vulnerable due to the cumulative effects of malignancy, intensive chemotherapy, surgery, exposure to sedatives and analgesics, and frequent ICU admissions, which may complicate delirium management.6 -8 Environmental stressors inherent to the PICU, such as continuous noise, frequent interventions, sleep disruption, and separation from familiar surroundings, further contribute to delirium risk.9,14,15 These findings underscore the multifactorial nature of delirium, arising from interactions among patient-specific vulnerabilities, environmental factors, and medical interventions.
Age is an important determinant of pediatric delirium risk. Younger children, particularly those between 2 and 5 years, are more susceptible due to dependence on consistent environmental cues and increased sensitivity to disruptions in sleep-wake cycles.4,6,16 Older children and adolescents may also experience delirium in the context of severe illness and complex interventions.6,16 In this study, delirium-positive patients were significantly younger than those without delirium, supporting the role of developmental stage in susceptibility.
In this cohort, delirium was significantly associated with younger age, prolonged PICU length of stay, higher night-shift acuity scores, and receipt of low-flow oxygen therapy, highlighting that intensive care measures may precipitate acute neurocognitive dysfunction.17 -19 Adequate oxygenation appears protective, whereas hypoxia and impaired cerebral perfusion have been implicated in delirium pathogenesis.17,20,21 Other interventions commonly implicated in delirium development in prior studies, such as vasopressor use and blood transfusions, were not significantly associated in our cohort, which may reflect differences in population characteristics or sample size limitations.
Mechanical ventilation and sedation also contribute to delirium risk, although their impact is often influenced by underlying illness severity and sedative practices.19,22 Delirium frequently develops early in the PICU stay, often within the first 1 to 3 days postoperatively, consistent with findings in pediatric cardiac surgery populations.10,15,16 Extended hospitalization may predispose patients to delirium and, conversely, delirium may prolong hospitalization, creating a bidirectional relationship that increases patient morbidity and healthcare utilization.3,22
Overall, these findings reinforce the multifactorial etiology of pediatric delirium, involving interactions among age, illness severity, environmental stressors, and intensive care interventions. The study highlights the critical need for routine delirium screening, proactive monitoring, and multidisciplinary interventions to mitigate risk in high-acuity pediatric oncology patients. Importantly, our study provides context-specific evidence from a resource-limited setting, emphasizing that early detection and targeted strategies are essential to improving patient outcomes and reducing the burden of this under-recognized complication.
Limitation
Delirium was a common condition among critically ill pediatric oncology patients admitted to the pediatric intensive care unit, with several patient- and treatment-related factors associated with its occurrence. These findings support the importance of routine delirium screening using validated tools in pediatric oncology critical care settings. However, given the observational design, exclusion of deeply sedated and mechanically ventilated patients, and the inability of the CAPD to differentiate delirium subtypes, the results should be interpreted with caution. While this study does not establish causal relationships or evaluate the impact of delirium prevention or management strategies, it provides valuable descriptive data in a specialized population with limited existing evidence. Future multicenter investigations with larger sample sizes, inclusion of ventilated and sedated patients, and instruments capable of distinguishing delirium subtypes are warranted to more fully characterize risk profiles and inform targeted prevention and management approaches in pediatric oncology critical care.
Recommendations for Future Research
Future interventional studies are warranted to assess both pharmacological and non-pharmacological treatment and preventive strategies in high-risk populations. These should include interventions such as early mobilization, adequate hydration, sleep cycle regulation, hygiene maintenance, and family interaction to better understand their effectiveness in preventing delirium. Additionally, longitudinal studies are necessary to investigate the long-term impact of delirium on outcomes in survivors of childhood cancer. Such research could provide crucial insights into optimizing care strategies to improve both short-term and long-term outcomes for these vulnerable patients.
Conclusion
Delirium was a common condition among critically ill pediatric oncology patients admitted to the pediatric intensive care unit, with several patient- and treatment-related factors associated with its occurrence. These findings emphasize the importance of routine delirium screening using validated tools in pediatric oncology critical care settings. However, given the observational design, exclusion of deeply sedated and mechanically ventilated patients, and the inability of the Cornell Assessment of Pediatric Delirium to differentiate delirium subtypes, the results should be interpreted with caution. While this study does not establish causal relationships or evaluate the impact of delirium prevention or management strategies on clinical outcomes, it provides valuable descriptive data in a specialized population with limited existing evidence. Future multicenter studies with larger sample sizes, inclusion of ventilated and sedated patients, and assessment tools capable of distinguishing delirium subtypes are warranted to better characterize delirium risk and inform targeted prevention and management strategies in pediatric oncology critical care.
Footnotes
Acknowledgements
We express sincere gratitude to the nursing staff of the PICU for their support of the study. Furthermore, our appreciation extends to the Nursing Research Unit for its comprehensive support and oversight of this project.
Ethical Considerations
Ethical approval was obtained from the Institutional Review Board of the study hospital, (IRB approval number: 22 KHCC 99). Verbal informed consent was obtained from parents or legally authorized representatives, and the IRB waived the requirement for written consent due to the observational nature of the study.
Consent to Participate
Verbal informed consent was obtained from parents or legally authorized representatives, and the IRB waived the requirement for written consent due to the observational nature of the study.
Consent for Publication
Participants provided informed consent for the publication of anonymized data
Author Contributions
1. Najah Hasan, RN: Conception and design of the work, wrote the main manuscript text (Corresponding Author).
2. Mohamed Khader, RN: Validate the data.
3. Mays Mohammed Basha, Conception and design of the work, wrote the main manuscript text.
4. Duaa Abu Shalanfah, RN: Analyze the data.
5. Farah Ayyad, RN: Collect the data.
6. Rahaf Aljabali, RN: Validate the data.
7. Noor Ulhuda Ghouri, RN: Collect the data.
8. Abed Alhameed Alnatsheh, RN: Analyze the data.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Data Availability Statement
The datasets generated during the current study are available from the corresponding author on reasonable request.