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New guidelines address pain, anxiety, delirium in critically ill children

August 1, 2022

Pain, anxiety and delirium in the intensive care unit (ICU) affect the well-being and recovery of children during critical illness and long beyond hospitalization.

For decades, pediatric ICU practitioners have worked to refine the recognition and standardize the assessment of pain and anxiety. Recently, delirium has emerged as an underrecognized problem in the pediatric ICU. Challenges to assessment of pain, anxiety and delirium include the child’s developmental stage as well as complex ICU interventions.

Historically, the approach to treatment of pain, anxiety and delirium varied by ICU depending on practitioner experience and institutional preference. In recent years, many pediatric institutions have developed protocols to guide sedation, analgesia and neuromuscular blockade to standardize care and improve outcomes.

New guidelines from the Society of Critical Care Medicine (SCCM) represent the first coordinated effort by pediatric intensive care practitioners to streamline the approach to the management of pain, anxiety and delirium in critically ill children. The 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility (PANDEM) are available at

A taskforce of 29 multidisciplinary experts collaborated over a decade to develop the evidence-based recommendations. The guidelines consist of 14 strong recommendations and 30 conditional recommendations based on the quality of evidence using the GRADE methodology. Five good practice statements reflect indirect evidence that support benefit with no or minimal risk.

Key considerations include careful assessment of pain, agitation and withdrawal; adequate treatment of pain; thoughtful use of sedative medications to treat agitation and anxiety; use of protocols to guide practice; assessment and management of delirium; the role of nonpharmacological interventions; promotion of early mobility; and family involvement.

Assessing pain

The guidelines highlight the importance of using self-reported scales to assess pain in children older than 6 years and observational rating scales in children who are uncommunicative. They acknowledge the challenges of accurate pain assessment in children who are deeply sedated with neuromuscular blockade.

Serial assessment of pain is vital to guide analgesia titration to maximize relief while minimizing dependence and withdrawal.

Treating pain adequately

Opioids are recommended as the mainstay of pain management in the ICU, with the addition of acetaminophen and/or nonsteroidal anti-inflammatory agents for opioid-sparing in the post-operative period.


Sedation assessment is best achieved through the use of validated scoring tools. Protocol-guided sedation to a target depth of sedation and frequent reassessment are emphasized. The guidelines discourage the use of sedation interruptions or drug holidays. Specific to the peri-extubation period in the ICU, a bundled approach is suggested to minimize adverse events.

An important change is a shift from benzodiazepines to alpha-agonist agents to optimize sedation while minimizing the risk of delirium and other side effects. The guidelines also clarify the use of propofol and ketamine in the ICU.

Neuromuscular blockade

Neuromuscular blockade is best managed through train-of-four monitoring and ideally by administering the lowest dose needed to achieve desired clinical effects. Though the evidence is uncertain, electroencephalogram monitoring while under neuromuscular blockade may be a useful adjunct for assessment. Attention to eye care to prevent corneal abrasions is emphasized.


Besides routine use of validated pediatric delirium screening tools, the guidelines recommend minimizing benzodiazepine infusions and discourage the routine use of antipsychotic agents to prevent or reduce delirium duration.

Nonpharmacological interventions

The guidelines recognize the key role of nonpharmacological interventions such as music, occupational, physical and child life therapy together with the promotion of sleep hygiene and early mobility to reduce pain, agitation and delirium.

Families’ role

The guidelines acknowledge the role of family-centered care as recommended by the AAP and seek to involve the family when possible in the care of their child. These interventions are especially important during the COVID-19 pandemic due to numerous disruptions and modifications of protocols to care for critically ill children.

Finally, the guidelines outline gaps in knowledge and list areas for research to enhance the approach to pain, anxiety and delirium in the critically ill child.

Dr. Srinivasan is a co-author and task force member of the PANDEM guidelines and chair-elect of the AAP Section on Critical Care Executive Committee.

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