From Neighborhood to Bedside: Addressing Macro-Level Disparities to Reduce Delirium and Post-Intensive Care Syndrome in Critically Ill Children

Neighborhood-level factors and the need for critical care are deeply intertwined. Children from disparate neighborhoods have higher severity of illness, need for critical care interventions such as mechanical ventilation, and mortality when admitted to a PICU (1,2). This higher severity of illness could be related to delays in presentation secondary to reduced access to care. Furthermore, children with geospatial disparities have an increased risk of emergent readmissions within the first year after PICU admission, indicating that even after their ICU admission, these children continue to experience high burden of illness (3). Increased severity of illness is associated with higher rates of delirium in critically ill children (4,5). Necessary life-saving critical care interventions such as mechanical ventilation are also associated with higher delirium rates, with potential development as early as 72 hours within a PICU admission (4,5). Delirium not only complicates the acute course of care but is also linked to longer lengths of stay, greater resource use, and long-term neurocognitive and psychosocial consequences, underscoring the importance of early recognition, prevention, and mitigation strategies in the pediatric critical care setting (5). In this issue of Pediatric Critical Care Medicine, Madden et al (6) used geospatial analysis in conjunction with the Child Opportunity Index (COI) to assess for an association between delirium and a child’s surrounding environment. COI is a neighborhood-level index used to understand environmental influence on child health and wellness. Their key findings indicate that children from lower opportunity, and subsequently lower resourced, neighborhoods are more likely to develop delirium (6). Specifically, lower COI was associated with a 150% increase in odds of delirium even after controlling for well-established delirium risk factors (6). COI reflects broader social and environmental influences such as education, neighborhood conditions, health, and household finance that shape a child’s overall health and well-being (2). Negative exposures within these domains—such as limited educational opportunities, overcrowded housing, low household income, neighborhood violence, environmental toxins, and inadequate access to healthcare—can lead to increased illness severity and contribute to the development of delirium during an intensive care stay. In their cohort, delirium was higher among children with public insurance compared with private insurance (6). Race and ethnicity, language preference, and insurance status were also associated with COI grouping (6). This aligns with prior literature demonstrating that children residing in areas of low opportunity are disproportionately from racial and ethnic minority backgrounds and more likely to be publicly insured (1,2). Structural barriers negatively impact vulnerable populations and are now being recognized as key drivers of adverse outcomes during an acute care hospitalization, including a heightened risk of delirium. These downstream consequences of neighborhood-level disparities can be attributed to historic implications of redlining on continued systemic racism and discrimination (2,7). Therefore, social risks need to be properly screened for, identified, and addressed to further explore potential protective factors that could reduce harm to children during their critical care stay (7). Higher family presence at the bedside has been shown to be protective against delirium for children (8). However, families from lower COI neighborhoods often have additional socioeconomic strain that renders them unable to be present with regularity for their children. As indicated by Madden et al (6), these caregivers are balancing many factors when it comes to their child in the ICU—being present at the bedside, for other family members at home, or at work to maintain employment (6). This balance leads to stress and strain on caregivers and can give rise to an increase in anxiety, depression, and post-traumatic stress disorder (PTSD) for caregivers with children who had ICU-related delirium (9). This balance, while difficult to achieve for all families, places additional burden on families facing significant financial stressors. Additionally, children with lower COI and higher odds of delirium were more likely to be deeply sedated during their ICU stay (6). A qualitative study of recently hospitalized children found that when families and caregivers were present at the bedside, children felt safe, heard, and as if their needs were met (10). A reduction in family presence due to social and environmental constraints could be a significant contributing factor to higher sedation utilization and ultimately higher rates delirium among the lower COI cohort. Provision of support to families from lower COI neighborhoods could allow them an augmented presence at the bedside and overall lead to a reduction in pediatric delirium and subsequent morbidity. Delirium can lead to consequences even after an ICU stay. Pediatric patients experienced sleep disturbances and lower quality of life while their caregivers experienced higher anxiety, depression, and PTSD symptoms months after their ICU stay (8). These findings indicate how delirium and post-ICU sequelae have long-term ramifications to both patients and their families. Given the repeated stresses that are seen during a PICU admission and the variety of post-discharge morbidities a child can have, a strong emphasis on post-intensive care syndrome in pediatrics (PICS-P) is being greatly researched (10). The PICS-P framework identifies how the ramifications of an ICU stay—ranging across social, psychologic, cognitive, and physical domains—occurs at a time of developmental growth and maturation for a child (11). This framework recognizes the strain that an ICU admission has not only on the admitted child but on their family as well. Social determinants of health have also been shown to affect a child’s ability to seek care even after their ICU stay—particularly relating to rehabilitation services for reduction of morbidity developed during acute injury and critical illness (12). Therefore, children and families from lower COI backgrounds not only have higher risk of morbidity before and during their hospitalization, but this risk can be extrapolated to continued long after their ICU stay. Addressing key social determinants that cause delirium and subsequent morbidities can not only curtail the long term effects of PICS-P, but also the functional deficit that children experience after their critical hospitalization. Madden et al (6) did not find an association between language preference and delirium (6). However, in their cohort, 85% of the patients had primary English language preference. A low percentage of patients with a non-English language preference could skew the findings to not document an association that truly exists, and is a limitation of this single-center cohort. The relationship between language preference other than English and delirium has been well documented in the older aged individuals (13). In the pediatric population, non-English language preference users have been shown to experience significant obstacles when navigating healthcare services through lack of interpreter services, lack of written materials in a language other than English, and hurdles related to living in a rural area (12). Therefore, further investigation is necessary to know if children with differential language preference, and living in a lower opportunity neighborhood, are at higher risk of delirium or not. The association between delirium and COI only continues to emphasize how structural barriers need to be addressed to improve care for children with high social risk factors. Our focus, while on the individual patient, cannot be isolated from the environment in which these children are fostered. Pediatric intensivists are uniquely positioned to recognize neighborhood-level disparities, as the most critically ill children face some of the greatest macro-level barriers to healthcare. Now we see that these same patients are at high risk of morbidity during their ICU stay, including delirium. Incorporating neighborhood-level indices such as COI in a prospective manner could be critical to recognizing at-risk populations, reducing barriers to care, and attenuating delirium for children from lower opportunity neighborhoods. Ultimately, by addressing these upstream factors, we may not only improve acute outcomes but also lessen long-term morbidity and adverse consequences following an ICU stay.