Pediatric ICU delirium: new findings and persistent evidence gaps in the post-guideline era - an expert opinion

Pediatric Delirium (PD) is a frequent manifestation of acute brain dysfunction in critically ill children and is associated with increased morbidity, prolonged hospitalization, higher healthcare costs, and potential short- and long-term sequelae. Reported prevalence varies widely depending on patient population and assessment tools, reflecting both methodological heterogeneity and ongoing challenges in recognition. Although awareness has increased and international guidelines have been published, important uncertainties remain regarding risk stratification, prevention strategies, pharmacological management, and long-term outcomes. In this expert narrative review, we synthesized studies published between 2020 and 2025 to provide an updated overview of Pediatric Intensive Care Unit (PICU) delirium in the post-guideline era. Mechanical ventilation, benzodiazepine exposure, transfusions, and environmental stressors continue to be associated with increased delirium risk, while emerging approaches including models and biomarker research, aim to improve risk identification and early detection. Validated bedside screening tools are widely available; however, variability in implementation and adherence persists across settings, particularly among children with developmental disabilities and in neonatal intensive care units. Multicomponent non-pharmacological bundles are increasingly adopted as preventive strategies, although heterogeneity in design and reporting limits comparability across studies. Evidence supporting pharmacological treatment remains limited and largely retrospective, and current recommendations discourage routine antipsychotic use for prevention. Delirium has been associated with adverse short-term outcomes and may negatively affect post-discharge quality of life and family well-being, although long-term data remain incomplete. Further prospective, multicenter research with standardized outcome measures is needed to clarify optimal management and long-term implications.