Benzodiazepines and Development of Delirium in Critically Ill Children: Estimating the Causal Effect
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OBJECTIVES: Benzodiazepine use may be associated with delirium in critically ill children. However, benzodiazepines remain the first-line sedative choice in PICUs. Objectives were to determine the temporal relationship between administration of benzodiazepines and delirium development, control for time-varying covariates such as mechanical ventilation and opiates, and evaluate the association between dosage of benzodiazepines and subsequent delirium. DESIGN: Retrospective observational study. SETTING: Academic tertiary care PICU. PATIENTS: All consecutive admissions from January 2015 to June 2015. INTERVENTIONS: Retrospective assessment of benzodiazepine exposure in a population that had been prospectively screened for delirium. MEASUREMENTS AND MAIN RESULTS: All subjects were prospectively screened for delirium throughout their stay, using the Cornell Assessment for Pediatric Delirium, with daily cognitive status assigned as follows: delirium, coma, or normal. Multivariable mixed effects modeling determined predictors of delirium overall, followed by subgroup analysis to assess effect of benzodiazepines on subsequent development of delirium. Marginal structural modeling was used to create a pseudorandomized sample and control for time-dependent variables, obtaining an unbiased estimate of the relationship between benzodiazepines and next day delirium. The cumulative daily dosage of benzodiazepines was calculated to test for a dose-response relationship. Benzodiazepines were strongly associated with transition from normal cognitive status to delirium, more than quadrupling delirium rates (odds ratio, 4.4; CI, 1.7-11.1; p < 0.002). Marginal structural modeling demonstrated odds ratio 3.3 (CI, 1.4-7.8), after controlling for time-dependent confounding of cognitive status, mechanical ventilation, and opiates. With every one log increase in benzodiazepine dosage administered, there was a 43% increase in risk for delirium development. CONCLUSIONS: Benzodiazepines are an independent and modifiable risk factor for development of delirium in critically ill children, even after carefully controlling for time-dependent covariates, with a dose-response effect. This temporal relationship suggests causality between benzodiazepine exposure and pediatric delirium and supports limiting the use of benzodiazepines in critically ill children.
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Anticholinergic drugs, benzodiazepines, opioids, immobilization, and restraints are among the modifiable risk factors for delirium.
“Anticholinergic drugs, benzodiazepines, opioids, immobilization, and restraints are among the modifiable risk factors for delirium [61,63,67,69].”
From Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness (2022) · cites this paper as [69]
The Results (Predictors of Delirium; page unavailable) identify benzodiazepines, opiates, and restraints as bivariate predictors in critically ill children, but opiates were not independently associated with delirium. The Discussion (page unavailable) says anticholinergics were not studied, and the paper does not establish immobilization as a risk factor. Its conclusion specifically identifies benzodiazepines as a modifiable risk factor. (LLM, conf=0.87)
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Psychological and Psychiatric Comorbidities in Youth with Serious Physical Illness
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“Anticholinergic drugs, benzodiazepines, opioids, immobilization, and restraints are among the modifiable risk factors for delirium [61,63,67,69].”
BackgroundPharmacological principles for safe benzodiazepine and Z-drug dose reduction
Horowitz, M., Lamberson, N., Brandt, J., Framer, A., Shapiro, B., Sørensen, A., Cadogan, C., Ritvo, A., & Taylor, D. (2026) · Psychological Medicine · doi:10.1017/s0033291726104887
“…occur between benzodiazepine dose and saccadic slowing/sedation (Hommer et al., 1986), zolpidem ’ s effects on sleep (Merlotti et al., 1989) (Figure 3d), diazepam ’ s impact on cortisol and growth hormone (Hommer et al., 1986) and delirium risk in critically ill children (Mody et al., 2018).”
- Authors
- Mody, K., Kaur, S., Mauer, E. A., Gerber, L. M., Greenwald, B. M., Silver, G., & Traube, C.
- Affiliations
- Icahn School of Medicine at Mount Sinai (US)
- Weill Cornell Medicine (US)
- Venue
- Critical Care Medicine
- Published
- 2018-09
- Volume
- 46
- Issue
- 9
- Pages
- 1486-1491
- ISSN
- 0090-3493 (ISSN-L)
- PMC
- PMC6095819
- OpenAlex
- W2917758789
- Cited by
- 161
- References
- 26
- Citations by year
- 2026: 14 · 2025: 12 · 2024: 23 · 2023: 19 · 2022: 31 · 2021: 23 · 2020: 21 · 2019: 12 · 2018: 5
- FWCI
- 12.78
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Critical Care Medicine (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institutes of Health (UL1TR000457, UL1TR002384)
- National Center for Advancing Translational Sciences
- Topics
- Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Intensive Care Unit Cognitive Disorders
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Anesthesia and Sedative Agents
- Health Sciences › Nursing › Nutrition and Dietetics › Clinical Nutrition and Gastroenterology
- Keywords
- benzodiazepines, delirium, pediatric intensive care, critically ill children, sedation, dose-response relationship, causal effects, time-varying confounding, mechanical ventilation, opioid use, cognitive status
- MeSH terms
- Adolescent, Benzodiazepines, Child, Child, Preschool, Delirium, Female, Humans, Infant, Male, Retrospective Studies, Time Factors, Critical Illness
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