Delirium in Neonatal Intensive Care: Unveiling the Hidden Challenge in Infants with Severe Bronchopulmonary Dysplasia
Delirium, a neuropsychiatric syndrome characterized by acute disturbances in attention, cognition, and consciousness, has long been recognized in adult and pediatric intensive care units. However, its emergence as a critical diagnosis within neonatal intensive care units (NICUs) is garnering increased attention, particularly concerning vulnerable populations such as infants with grade 3 bronchopulmonary dysplasia (BPD). Recent research highlights the intricate clinical landscape in which delirium operates among these fragile patients, shaped by prolonged mechanical ventilation, severe critical illness, and the complexity of polypharmacy regimes that often include multiple neurosedatives.
Grade 3 bronchopulmonary dysplasia represents the most severe form of this chronic lung disease, commonly affecting premature infants with significant respiratory distress and requiring extensive respiratory support. The pathophysiology underlying BPD involves arrested lung development, inflammation, and fibrosis, necessitating aggressive therapeutic interventions that, while lifesaving, introduce a spectrum of iatrogenic risks. Among these, neurodevelopmental complications such as delirium have been under-recognized until recent clinical discourse began to expose their prevalence and implications.
The clinical manifestations of delirium in neonates diverge substantially from those observed in adults, presenting a diagnostic challenge compounded by the infants’ limited expressive capacities. Fluctuating levels of responsiveness, unexpected agitation, or even apathy, coupled with disrupted sleep-wake cycles, form a constellation of potential delirium indicators. In infants with grade 3 BPD, these signs may be easily misattributed to underlying respiratory distress or sedation effects, thereby complicating timely identification and intervention.
A vital aspect increasing the risk for delirium in these infants is the extended duration of mechanical ventilation. Intubation, alongside the constant barrage of noxious stimuli in the NICU environment, fosters an atmosphere rife with stress and sensory overload. The mechanical ventilation itself, essential for survival in BPD infants, can precipitate neuroinflammation and disrupt cerebral autoregulation, further predisposing these patients to neurocognitive disturbances.
In addition to physical interventions, the pharmacological landscape in managing grade 3 BPD substantially contributes to delirium risk. Polypharmacy, particularly regimens involving benzodiazepines, opioids, and other neurosedatives, while indispensable for pain and anxiety control, carry intrinsic neurotoxic potential. These agents modulate neurotransmitter systems pivotal in maintaining cognitive homeostasis, rendering the developing neonatal brain exquisitely sensitive to their adverse effects.
The recent national survey conducted by Munoz-Blanco, Makker, McKinney, and colleagues offers unprecedented insights into clinician knowledge, attitudes, and perceptions regarding delirium in this high-risk group. The study reveals a spectrum of awareness levels, with a substantial portion of NICU healthcare professionals acknowledging the existence of neonatal delirium but expressing uncertainty about optimal screening and management strategies. These findings underscore a pressing need for standardized protocols and targeted educational initiatives within NICUs to mitigate underdiagnosis.
Importantly, this survey sheds light on the diagnostic tools currently in use, or lack thereof, for delirium detection in neonates. Unlike adult patients, where validated delirium scales are commonplace, neonatal delirium screening remains embryonic, with limited consensus on assessment frameworks. Developing and incorporating objective, reliable, and age-appropriate diagnostic instruments could transform clinical practice, enabling earlier recognition and intervention.
Furthermore, the study contextualizes clinician perspectives on the implications of delirium for long-term neurodevelopmental outcomes. There is growing concern that delirium episodes may contribute to enduring cognitive deficits, delayed motor development, and behavioral disorders. This prognostic implication heightens the urgency for focused research aimed at delineating mechanistic pathways and exploring therapeutic avenues.
A multidisciplinary approach emerges as essential in addressing the complexities involved. Integrating neonatologists, neurologists, pharmacists, nursing staff, and developmental specialists fosters a holistic framework that can confront delirium from multiple angles – prevention, detection, treatment, and follow-up. Within such a model, optimizing sedation protocols to minimize neurotoxicity and instituting environmental modifications to reduce sensory stress may collectively attenuate the incidence and severity of delirium.
The impact of delirium on family dynamics also warrants attention, as parents navigating the NICU experience grapple with uncertainty and distress exacerbated by fluctuations in their infant’s condition. Improved communication and support systems, informed by heightened clinician awareness, can enhance parental involvement and potentially contribute to better clinical trajectories through gentle, family-centered care practices.
Emerging neuroimaging and biomarker research hold promise in unraveling the pathophysiological underpinnings of neonatal delirium. Insights into neuroinflammatory markers, cerebral perfusion changes, and neurotransmitter imbalances could yield novel diagnostic and therapeutic targets. Such advances could, in time, redefine clinical paradigms, transitioning from reactive management to proactive neuroprotective strategies.
Despite these developments, significant gaps remain in the literature regarding the epidemiology, risk stratification, and long-term consequences of delirium in neonates with severe BPD. Large-scale, multicenter longitudinal studies are imperative to generate robust data that can inform clinical guidelines and policy decisions. Establishing registries and fostering international collaborations will accelerate this process, enabling evidence-based care that optimally balances life-saving interventions with neurodevelopmental preservation.
In sum, delirium represents a critical yet underappreciated challenge in the care of infants with grade 3 bronchopulmonary dysplasia within NICUs. Its multifactorial etiology, compounded by diagnostic ambiguities and therapeutic dilemmas, necessitates concerted efforts to enhance clinician education, develop validated screening tools, and implement individualized management strategies. As our understanding deepens, the neonatal community stands poised to improve outcomes not only in terms of survival but also neurocognitive integrity and quality of life for these most vulnerable patients.
The enlightening findings of Munoz-Blanco et al. mark a significant step toward recognizing and addressing neonatal delirium in the context of severe pulmonary disease. Their work galvanizes the medical community to elevate delirium from a peripheral consideration to a central component of neonatal critical care, inspiring future research and clinical innovation that can transform the NICU experience worldwide.
Subject of Research: Clinician knowledge, attitudes, and perceptions of delirium in patients with grade 3 bronchopulmonary dysplasia.
Article Title: Clinician knowledge, attitudes, and perceptions of delirium in patients with grade 3 bronchopulmonary dysplasia: A national survey.
Article References:
Munoz-Blanco, S., Makker, K., McKinney, R.L. et al. Clinician knowledge, attitudes, and perceptions of delirium in patients with grade 3 bronchopulmonary dysplasia: A national survey. J Perinatol (2025). https://doi.org/10.1038/s41372-025-02546-0
Image Credits: AI Generated
DOI: 19 December 2025
