. 2021 Oct-Dec;33(4):483–486. doi: 10.5935/0103-507X.20210070

Table 1.

Recommendations for the diagnosis, prevention and treatment of delirium in pediatric patients with COVID-19

Diagnosis^{(¹²,²¹,²²,²⁴)}	Evaluate the patient’s baseline mental state, obtaining information from a reliable informant. For pediatric patients, it is recommended that a single family member or other companion authorized by the parents remain with the child at all times. The companion must follow the norms of the unit and obey the recommended isolation measures (surgical mask, apron and frequent hand washing). Ideally, the companion should always be the same person. In the absence of a companion for the child, information about the child’s basic mental state can be obtained by telephone interview Use of a valid and reliable tool: psCAM-ICU, pCAM-ICU, CAPD or SOS-PD^*. The tool should be administered at some point during every 12-h shift
Identification of risk factors^{(³,²¹,²²)}	Identify and address risk factors, including pain and withdrawal syndrome Pay attention to bladder, fecaloma, hypoxemia, overlapping infections, dehydration, electrolyte disorders and polypharmacy (review prescriptions)
Nonpharmacological measures^{(¹,²⁵-³¹)}	Consider environmental changes: provide a calm and peaceful environment that is consistent and predictable; consider moving patients with hyperactive or mixed delirium to a bed in a quieter location and moving patients with hypoactive delirium to a bed in a location with greater interaction; verify the possibility of letting the child have an object that is familiar to him or her; use physical restraints as a last resort; provide glasses or hearing aids to children who use these devices; explore the use of electronic devices (smartphones or tablets) for communication with the family if the child is alone Adopt communication strategies: speak calmly and slowly using short and clear sentences, explaining to the child where he or she is and why he or she needs to stay there; identify oneself and describe what is being done; tell the child the time of day and day of the week; do not discuss visual or auditory hallucinations with child, and instead simply explain that their perceptions are different; when possible, talk to the child about real people and events Promote sleep: wake the child at the same time every morning; leave the bed in a chair-like position similar when possible according to the child’s age and tolerance; discourage daytime sleep, except for scheduled naps or periods of silent rest; use a weak night light to reduce the child’s misperceptions and fears at night; use masks to block light during sleep and earplugs or white noise for sound masking; avoid overstimulation, especially before scheduled sleep or rest times; try to concentrate team activities during the day to avoid sleep interruptions at night; make a calendar and clock available for identifying the date and time Encourage mobilization and cognitive stimulation activities: adopt consistent daily routines for hygiene, mobility, range of motion exercises, therapies, interventions and play Cluster care: concentrate interventions to be performed with the patient to minimize interruptions and noise during rest periods Behavioral therapies: directed relaxation techniques that use cognitive behavioral resources and can be applied by qualified professionals on the multidisciplinary team, such as psychological therapy, occupational therapy, music therapy, aromatherapy, pet therapy and play therapy Breastfeeding and non-nutritive sucking with oral solutions of sucrose and/or glucose in patients with an oral diet whose clinical condition allows it. These strategies can be used with neonates and infants undergoing mildly to moderately painful procedures alone or in combination with other pain relief strategies. Start 5 minutes before the painful procedure and, if possible, continue during the procedure Other non-pharmacological strategies, such as facilitated tucking (a technique that provides comfort and pain relief and that consists of keeping the extremities of the neonates or infants flexed and contained during a painful procedure), curling/swaddling (wrapping the body of the newborn or infant up to 6 months of age in a blanket/blankets, considering the clinical conditions, while keeping the arms close to the body to promote pain relief during painful procedures), and skin-to-skin contact and sensory stimulation (massage, caregiving) have been shown to be useful for reducing pain scores during short-term mildly to moderately painful procedures and should be used consistently

Diagnosis^{(¹²,²¹,²²,²⁴)}

Evaluate the patient’s baseline mental state, obtaining information from a reliable informant. For pediatric patients, it is recommended that a single family member or other companion authorized by the parents remain with the child at all times. The companion must follow the norms of the unit and obey the recommended isolation measures (surgical mask, apron and frequent hand washing). Ideally, the companion should always be the same person. In the absence of a companion for the child, information about the child’s basic mental state can be obtained by telephone interview Use of a valid and reliable tool: psCAM-ICU, pCAM-ICU, CAPD or SOS-PD^*. The tool should be administered at some point during every 12-h shift

Identification of risk factors^{(³,²¹,²²)}

Identify and address risk factors, including pain and withdrawal syndrome Pay attention to bladder, fecaloma, hypoxemia, overlapping infections, dehydration, electrolyte disorders and polypharmacy (review prescriptions)

Nonpharmacological measures^{(¹,²⁵-³¹)}

Consider environmental changes: provide a calm and peaceful environment that is consistent and predictable; consider moving patients with hyperactive or mixed delirium to a bed in a quieter location and moving patients with hypoactive delirium to a bed in a location with greater interaction; verify the possibility of letting the child have an object that is familiar to him or her; use physical restraints as a last resort; provide glasses or hearing aids to children who use these devices; explore the use of electronic devices (smartphones or tablets) for communication with the family if the child is alone Adopt communication strategies: speak calmly and slowly using short and clear sentences, explaining to the child where he or she is and why he or she needs to stay there; identify oneself and describe what is being done; tell the child the time of day and day of the week; do not discuss visual or auditory hallucinations with child, and instead simply explain that their perceptions are different; when possible, talk to the child about real people and events Promote sleep: wake the child at the same time every morning; leave the bed in a chair-like position similar when possible according to the child’s age and tolerance; discourage daytime sleep, except for scheduled naps or periods of silent rest; use a weak night light to reduce the child’s misperceptions and fears at night; use masks to block light during sleep and earplugs or white noise for sound masking; avoid overstimulation, especially before scheduled sleep or rest times; try to concentrate team activities during the day to avoid sleep interruptions at night; make a calendar and clock available for identifying the date and time Encourage mobilization and cognitive stimulation activities: adopt consistent daily routines for hygiene, mobility, range of motion exercises, therapies, interventions and play Cluster care: concentrate interventions to be performed with the patient to minimize interruptions and noise during rest periods Behavioral therapies: directed relaxation techniques that use cognitive behavioral resources and can be applied by qualified professionals on the multidisciplinary team, such as psychological therapy, occupational therapy, music therapy, aromatherapy, pet therapy and play therapy Breastfeeding and non-nutritive sucking with oral solutions of sucrose and/or glucose in patients with an oral diet whose clinical condition allows it. These strategies can be used with neonates and infants undergoing mildly to moderately painful procedures alone or in combination with other pain relief strategies. Start 5 minutes before the painful procedure and, if possible, continue during the procedure Other non-pharmacological strategies, such as facilitated tucking (a technique that provides comfort and pain relief and that consists of keeping the extremities of the neonates or infants flexed and contained during a painful procedure), curling/swaddling (wrapping the body of the newborn or infant up to 6 months of age in a blanket/blankets, considering the clinical conditions, while keeping the arms close to the body to promote pain relief during painful procedures), and skin-to-skin contact and sensory stimulation (massage, caregiving) have been shown to be useful for reducing pain scores during short-term mildly to moderately painful procedures and should be used consistently

psCAM -ICU - Preschool Confusion Assessment Method for the Intensive Care Unit; pCAM-ICU - Pediatric Confusion Assessment Method for the Intensive Care Unit; CAPD - Cornell Assessment of Pediatric Delirium; SOS-PD - Sophia Observation Withdrawal Symptoms - Pediatric Delirium Scale.

The pCAM-ICU tool has a version that has been translated and validated for Brazilian Portuguese. The CAPD and SOS-PD tools have only been translated (not yet validated).