The Risk Factors Associated with Delirium in Neonates Admitted to the Neonatal Intensive Care Unit

The Risk Factors Associated with Delirium in Neonates Admitted to the Neonatal Intensive Care Unit | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article The Risk Factors Associated with Delirium in Neonates Admitted to the Neonatal Intensive Care Unit Mona Alinejad-Naeini, Saleheh Tajalli, Roqayeh Aliyari, Farhad Abolhassan Choobdar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6241299/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Delirium is a critical neurological condition that can manifest abruptly in individuals of all ages, encompassing infants, children, and adolescents. Investigating the factors related to delirium is essential to identify at-risk populations and to offer fundamental data for developing intervention strategies for sick neonates and infants. The present study aimed was to investigate the risk factors associated with the development of delerium in neonates admitted to the neonatal intensive care unit (NICU) in Iran. This descriptive, cross-sectional study involved 243 infants with admitted to NICU at four hospitals. Data were collected using a demographic questionnaire, and the cornell assessment of pediatric delirium scale. The logestic regression model considering a 5% significance level were conducted to examination of study aim. Out of 243 infants who participated in this study, 40 percent of them had delirium and130 of them were male. Birth weight and gestational age of infants were 2801.8 ± 670.9 grams and 35.87 ± 2.34 weeks respectively. stay at isolation room was related with hospitalization at isolation room (PV < 0.001).The mean The apgar first minuts was assocted with delirium (PV = 0.004). The no feeding bas neen increased the odds of delrium 10.87 times rather than gavage feeding (OR: 10.87 (1.53, 76.9)), PV = 0.017). The diagnosis and treatment of neonates with delirium is a new area in neonatal medicine and there is limited information on assessment tools, best practice and potential side effects of treatment. However, clinicians should be aware that untreated delirium in this population has potential developmental consequences and consider intervention when appropriate. Therefore, screening of infants in the NICU with a focus on risk factors is recommended. Health sciences/Health care Health sciences/Risk factors Delirium Infant Sick neonate Risk factor Neonatal inensive care unit Figures Figure 1 Figure 2 Introduction Delirium is a serious neurological disorder that occurs acutely in all age groups, including infants, children and adolescents [ 1 ]. The prevalence of paediatric delirium in paediatric intensive care units has been reported to vary widely in different studies, ranging from 15.9–65.6% [ 2 – 4 ]. Paediatric delirium is influenced by factors such as age, developmental delay, severity of illness, use of mechanical ventilation, type of admission, use of physical restraints, severity of agitation and sedation, oxygen requirements, nutritional status, presence of familiar objects and administration of sedatives [ 5 , 6 ]. Early identification of delirium in children is now a medical emergency, as identifying and treating the underlying causes can minimise the long-term consequences [ 7 ]. Neonates and infants show considerable developmental differences compared to older children [ 8 ]. The incidence of delirium in neonates and infants in intensive care has not been definitively established and is not well understood, so no conclusions can be drawn about the incidence of paediatric delirium [ 9 ]. Symptoms of neonatal delirium include insensitivity to escalating doses of sedatives, lack of responsiveness to calming measures, increasing and decreasing motor agitation with distrupted sleep-wake cycles and deficits in awareness, cognition and arousal [ 1 , 10 ]. Delirium in sick neonates and infants has different characteristics compared to paediatric delirium. However, the differences are not clearly defined [ 9 ]. Delirium is rarely discussed in the NICU [ 11 – 13 ]. However, the sick infant is likely to be at significant risk due to the combination of severe illness, prolonged stay in a highly medical environment and the use of multiple medications [ 14 ]. The need for close monitoring of neonates at risk of delirium is an essential part of routine care in the neonatal intensive care unit, as symptoms in neonates can be more subtle and developmentally variable. Early recognition of delirium is crucial because delirium in children may indicate ongoing damage to the fragile, developing brain. Delirium symptoms can also be attributed to a number of other health conditions, putting the child with delirium at risk of unnecessary investigations, poorer neurodevelopmental outcomes and longer length of stay [ 15 , 16 ]. The nursing team is the ideal first-line care provider for assessing whether delirium is present or not. Awareness of the importance of delirium screening and the ability to perform an accurate, rapid and efficient assessment are critical to the care of the critically ill child. Early delirium screening and early intervention are key to reducing adverse outcomes in critically ill children and using non-pharmacologica strategies to prevent and treat delirium [ 17 ]. Therefore, an investigation of factors associated with delirium is needed to provide clues to delirium- prone populations or baseline data for intervention strategies for sick neonates and infants [ 8 ]. There is little literature describing delirium in the neonatal intensive care unit [ 11 , 12 , 18 ]. This knowledge gap is problematic because without routine screening, delirium often goes unrecognised and represents a missed opportunity for intervention [ 19 ]. Although neonates are likely to be at high risk of delirium [ 20 ], delirium is not considered a common complication of NICU stay [ 21 ]. The aim of present study was to identify risk factors associated with the development of delirium in neonates admitted to the neonatal intensive care unit in Iran. Material and methods This study is a prospective observational study conducted between November 2023 and January 2025 in three Level III NICUs affiliated with Iran university of Medical Sciences. The ethics committee of Iran University of medical sciences (code: IR.IUMS.REC.1402.725 ) at 2023.11.15, approved the research and confirmed that all research was performed in accordance with relevant guidelines/regulations. The inclusion criteria for this study were: Hospitalization in pediatric intensive care unit for at least 3 days, gestational age 37 weeks and above, postnatal age 3 to 28 days, birth weight 1500–4000 grams. Neonates with any of the following conditions were excluded: (i) administration of sedatives or anesthetics and muscle relaxants within four hours prior to intubation, (ii) administration of pain medication as prescribed, (iii) intracranial hemorrhage grade 2 and above, (v) emergency conditions such as cardiopulmonary resuscitation or seizures, (vi) infant with acute cardiac or respiratory disease, (vii) maternal drug use in the past. Ethical consideration The institutional ethics committee approved the study (code: IR.IUMS.REC.1402.725). written informed consent was obtained from parents/legal guardians after explaining the aim of the study. They have the right to refuse to participate or to withdraw from the study at any time. They were assured about the confidentiality of the collected data. Outcome measures The data were collected using an instrument consisting of two parts, the neonates demographic form, The Cornell Assessment of Pediatric Delirium (CAPD), The background information questionnaire (demographic information) included gestational age, Corrected age, sex, birth weight, apgar 1th minute, apgar 5th minute, delivery type, birth rank, isolation room, feeding, ventilation and disease. The CAPD is an observational tool for the assessment of delirium [ 22 , 23 ]. This scale was developed as a quick and easy-to-administer screening tool for nurses to identify critically ill children of all ages and developmental stages at risk of delirium [ 7 , 24 ]. It consists of eight items that correlate with the diagnostic domains of consciousness and cognition from the DSM-5, and also includes psychomotor symptoms [ 24 ]. The CAPD scale is a standard PD assessment scale suitable for a wide age range (neonates to 21 years), and we have recently validated the Japanese version in pediatric patients30. The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8–98.8%) and a specificity of 79.2% (95% CI, 73.5–84.9%). Overall, Cronbach's α was 0.90, with a range of 0.87–0.90 for each of the eight items, indicating good internal consistency [ 24 ]. This instrument was psychometrically evaluated in Iran by Navaeifar et al. and inter-rater agreement was assessed using the Kendall's test. The Kendall coefficient for the total score was 0.046, and no significant difference was found between ratrs on any of the 8 question items and also on the overall score of the Cornell instrument [ 25 ]. We used Cohen's K- test (SPSS software Version 23.0) https://grok.lsu.edu/article.aspx?articleid=17715 to ensure interrater reliability. Cohen's Kappa is used to compare the degree of agreement between raters (inspectors). Kappa takes values between 0 and 1. The minimum acceptable value of the kappa coefficient is above 0.6 and values above 0.8 are ideal for agreement between two raters [ 26 ]. To this end, 10 independent observations between 2 raters were conducted in this study and the kappa coefficient was found to be 0.97, indicating ideal reliability. Procedure : All neonates were screened with the Cornell Assessment of Pediatric Delirium (CAPD). First, the researcher visited the NICU of the desired neonates. She selected the neonates who met the inclusion criteria for the study. She obtained and recorded demographic data from the patient records. The researcher provided the parents of the newborns with sufficient information about the aims of the study and its significance. After obtaining written informed consent from the parents of the newborns, he observed the neonate for 8 hours during the requested shift and then assessed the newborn using the Cornell questionnaire. The nurses were provided with developmental anchor points for the key ages of the newborn, 4 weeks, 6 weeks, 8 weeks and 28 weeks, as a bedside reference. Also authors confirm that all experimental protocols in this study were approved by a was approved by the Ethic Committee of Iran University of Medical Sciences (code: IR.IUMS.REC.1402.725 ) at 2023.11.15. Statistical Analysis: The relationship between each variable and delirium was analysed using t-tests and chi-square tests. If necessary, we used the Fisher-exact test instead of the chi-square. Risk factors that had a significance level of less than 0.2 in the previous step were included in the logistic regression model, considering a 5% significance level. Results Out of 243 infants who participated in this study, 130 of them were male. The mean birth weight and gestational age of infants were 2801.8 ± 670.9 grams and 35.87 ± 2.34 weeks respectively. The demographic and clinical characteristics of the neonates can be found in Table 1 . Ninety eight of infant (40.32%) had delirium that 58 (59. 2%) of them were female and 40 (40.8%) were male. delirium showed the correlation with gender (P V = 0.001). The apgar first minuts was assocted with delirium (P V = 0.004). Out of 98 infants who had delirium all of them did not hospital stay at isolation room, and according to Fisher-exact test delirum statisticaly was related with hospitalization at isolation room (P V < 0.001). feeding type was assocated with delirum statisticaly (P V < 0.001).Other significant relationship can be found in Table 1 . Table 1 The relationship between some risk factors and delirium. Total Negative delirium Positive delirium P.V Sex Female 113 (46.5) 55 (37.9) 58 (59.2) 0.001 Male 130 (53.5) 90 (62.1) 40 (40.8) Apgar 1th minute 7 26 (10.7) 20 (13.8) 6 (6.1) 0.004 8 66 (27.2) 45 (31.0) 21 (21.4) 9 133 (54.7) 66 (45.5) 67 (68.4) 10 18 (7.4) 14 (9.7) 4 (4.1) Apgar 5th minute 8 6 (2.5) 4 (2.8) 2 (2.0) 0.180 9 75 (30.9) 51 (35.2) 24 (24.5) 10 162 (66.7) 90 (62.1) 72 (73.5) Delivery type NVD 80 (32.9) 50 (34.5) 30 (30.6) 0.529 CS 163 (67.1) 95 (65.5) 68 (69.4) Birth rank 1 138 (56.8) 85 (58.6) 53 (54.1) 0.513 2 72 (29.6) 39 (26.9) 33 (33.7) 3 33 (13.6) 21 (14.5) 12 (12.2) Isolation room Yes 31 (12.8) 31 (21.4) 0 (0) < 0.001 a No 212 (87.2) 114 (78.6) 98 (100.0) Feeding No 36 (14.8) 9 (6.2) 27 (27.6) < 0.001 BF 166 (68.3) 115 (79.3) 51 (52.0) Gavage 41 (16.9) 21 (14.5) 20 (20.4) Ventilation No 110 (45.3) 68 (47.2) 42 (42.4) < 0.001 Freeoxygen 105 (43.2) 69 (47.9) 36 (36.4) Hood 15 (6.2) 1 (0.7) 14 (14.1) Ventilator 2 (0.8) 1 (0.7) 1 (1.0) CPAP 11 (4.5)_ 5 (3.5) 6 (6.1) Disease Prematurity 42 (17.3) 31 (21.4) 11 (11.2) 0.002 Sepsis 82 (33.7) 38 (26.2) 44 (44.9) TTN 30 (12.3) 25 (17.2) 5 (5.1) Pnumonia 12 (4.9) 10 (6.9) 2 (2.0) Jundis 48 (19.8) 25 (17.2) 23 (23.5) RDS 16 (6.6) 8 (5.5) 8 (8.2) NEC 13 (5.3) 8 (5.5) 5 (5.1) GA (week) 35.87 ± 2.34 36.2 ± 1.94 35.37 ± 2.75 0.011 Corrected age (week) 39.54 ± 2.17 39.97 ± 1.54 38.90 ± 2.72 0.001 Birth weight 2801.8 ± 670.9 2894.5 ± 555.7 2664.6 ± 795.5 0.014 a: Fisher-exact test; BF:breast feeding; NVD:normal vaginal delivery, CS:cesarean section, GA:gestational age, TTN: Transient tachypnea of the newborn, RDS:respiratory distress syndrome, NEC:necrotizing enterocolitis. Among risk factors the sepsis disease increased the odds of delirum four times more than prematurity disease (OR: 4.99 (1.72, 14.57), PV = 0.003). The no feeding increased the odds of delrium 10.87 times rather than gavage feeding (OR: 10.87 (1.53, 76.9)), PV = 0.017), while there is not statisticaly difference between gavage and BF feeding (PV = 0.722). In addition the correccted age has negative relationship with delirum (OR: 0.96 (0.93, 0.99)), also hospitalization in solation room had a strong positive correlation with delirium (OR: 27.04 (2.95, 248.14), PV = 0.004), (Table 2 ). Table 2 The association between delirium and some risk factors using logistics regression OR(95% CI) P.V Sex (Ref: Female) Male 0.74 (0.35, 1.54) 0.416 Apgar 1th minute ( Ref: 10) 7 1.63 (0.20, 13.16) 0.645 8 2.97 (0.48, 18.59) 0.244 9 2.50 (0.44, 14.13) 0.300 Isolation a ( Ref: Yes) No 27.04 (2.95, 248.14) 0.004 Feeding ( Ref: gavage) No 10.87 (1.53, 76.9) 0.017 BF 1.25 (0.36, 4.40) 0.722 Ventilation (Ref: No) Yes 0.98 (0.44, 2.15) 0.958 Disease( Ref: prematurity) sepsis 4.99 (1.72, 14.57) 0.003 TTN 1.16(0.28, 4.85) 0.838 pnumonia 0.71 (0.11, 4.63) 0.719 jundis 1.67 (0.45, 6.13) 0.443 RDS 2.55 (0.58, 11.18) 0.216 NEC 2.30 (0.34, 15.64) 0.396 GA 0.99(0.96, 1.03) 0.708 Corrected age 0.96 (0.93, 0.99) 0.040 Birth weight 1.00 (0.99, 1.00) 0.240 a: There was not any isolated child with positive delirium; so we consume one child to model fitting, as can be seen 95% CI is very big due to low sample size. Discussion Delirium is increasingly recognized as a common syndrome in critically ill children, but it is rarely considered in the NICU [ 11 ]. Delirium can be a common complication of critical illness in neonates. It is the result of the underlying medical condition, the adverse effects of the medications used, and the medicalized environment in the NICU, which is highly unnatural for a newborn [ 20 ]. Routine screening for delirium has become the benchmark for prevention because it creates awareness and vigilance within the care team [ 10 ]. Although it is rational that newborns, as well as older children and adults, occasionally experience delirium, consideration of this important diagnosis is not yet part of the standard of care in the neonatal intensive car unit [ 11 ]. The present study investigated the prevalence and factors influencing neonatal delirium. There are several case reports of delirium in newborns [ 12 , 18 ], but only one study has reported on the prevalence and factors influencing delirium [ 10 ] in the neonatal period. In this study, a prevalence of 40.32% for delirium was found after screening in three neonatal intensive care units. These results reflect prevalence rates of 12–65% reported in the PICU and NICU [ 6 , 10 , 19 , 27 , 28 ]. Consistent with many other pediatric delirium studies, higher rates of delirium occurred in younger children (aOR 0.41 for children older than 5 years) [ 6 , 27 , 29 , 30 ]. In this study, we investigated the association between neonatal delirium and a number of contributing factors. The results showed a correlation between neonatal delirium and gender, with delirium occurring more frequently in girls. First minute Apgar score was associated with delirium, and of the 98 neonates who had delirium, none were admitted to an isolation room, and according to Fisher's exact test, delirium was statistically associated with admission to an isolation room. The type of feeding was statistically associated with delirium. Among the risk factors, sepsis increased the likelihood of delirium four times more than prematurity. Malnutrition increased the likelihood of delirium by 10.87 times compared to tube feeding. In addition, adjusted age was negatively associated with delirium, and admission to a bedroom was also strongly positively associated with delirium. To our knowledge, only one study [ 10 ] was found that examined factors affecting delirium, and this study also examined other factors. In this study a multivariate logistic regression revealed that neurologic disability and mechanical ventilation were both independently associated with a positive delirium screen. It is possible that if the neonatal team is more vigilant, delirium can be recognized in the NICU, allowing for tailored intervention. If we can shorten the duration of delirium, we may be able to improve the long-term health of vulnerable neonates [ 11 ]. Studies have shown that routine daily screening is needed to reliably detect delirium in hospitalized patients [ 31 ] This study has strengths and limitations. As it is a multicentre study, the results are generalizable as the admission and patient criteria in the NICUs are different. In addition, a team of professionals with extensive experience in the NICU was used to screen and administer the delirium instrument. A limitation of this study is that it is an observational study, so we only described the prevalence of delirium and associated factors and did not examine causality. We also only described the prevalence of delirium on selected days of the study. However, as delirium varies throughout the hospitalisation, examining the incidence on consecutive days would provide more accurate results. Our study evaluated only some of the potential risk factors for delirium, but there are many others that should be considered in future studies. Conclusion and Recommendations The diagnosis and treatment of infants with delirium is a new area in neonatal medicine and there is limited information on assessment tools, best practice and potential side effects of treatment. However, clinicians should be aware that untreated delirium in this population has potential developmental consequences and consider intervention when appropriate. Therefore, screening of infants in the NICU with a focus on risk factors is recommended [ 13 ]. It is also recommended that multicenter and longitudinal studies be conducted to identify modifiable risk factors, prevalence, long-term outcomes, and financial impact. Further research is needed to identify evidence-based pharmacologic and nonpharmacologic prevention and treatment strategies for delirium in infants. Declarations Acknowledgments The authors wish to acknowledge all neonatal parents for their time and effort contributed to this study. They also want to thank the NICU nurses who collaborated in this research. Funding This work was supported by the Iran University of Medical Sciences under Grant number (1402-1-3-25858). Conflict of interest Authors declare no conflict of interest. Authors’ contribution ST: Data curation, Investigation and Methodology; MA: Conceptualized the study, Methodology supervisor, Developed an analytical framework, Validation and Funding acquisition; RA: Data collection supervisor, Supervision, Validation and Visualization; FCH: Software, Formal analysis, Writing – review & editing. All authors agree to be accountable for the research presented. References Porter, S., Holly, C. & Echevarria, M. 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The preschool confusion assessment method for the ICU: valid and reliable delirium monitoring for critically ill infants and children. Crit. Care Med. 44 , 592–600 (2016). Ely, E. W., Siegel, M. D. & Inouye, S. K. Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction. In Seminars in respiratory and critical care medicine . Copyright© 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New … 5–126. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6241299","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":484748416,"identity":"d21baac5-a455-4ccf-b454-55ddc180a055","order_by":0,"name":"Mona Alinejad-Naeini","email":"","orcid":"","institution":"Iran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mona","middleName":"","lastName":"Alinejad-Naeini","suffix":""},{"id":484748417,"identity":"b29f8a38-db2b-444d-9497-eb9372300e5d","order_by":1,"name":"Saleheh Tajalli","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Saleheh","middleName":"","lastName":"Tajalli","suffix":""},{"id":484748418,"identity":"ce9e65d1-c297-40a2-9681-f7459ec1cdd8","order_by":2,"name":"Roqayeh Aliyari","email":"","orcid":"","institution":"Shahroud University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Roqayeh","middleName":"","lastName":"Aliyari","suffix":""},{"id":484748419,"identity":"e78cd992-cfee-492e-a9da-97b379d83abd","order_by":3,"name":"Farhad Abolhassan Choobdar","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYDACCQYGZgY2Bgb2BhDJxiYHEjzwgBgtPAfAWviMwVoSSNAil9gAEsWnhX9288HHBWV2+TzsZ589+FFmlj4/7PBDoC12croNOCy5cyzZeMa5ZMsennRzw55zabkbb6cZALUkG5sdwK7FQCLHTJq3jdnAniGNTYK37VjuxtkJIC0HErfh11JvwMP/jE3yb9v/dMPZ6R+I0XLYgEcijQ3IYEuQl87Bb4vEjTSQX44DtTxjk5Y5x2a4QTqn4ECCAW6/8M9IBoVYNdBhaWySb8rY5OVnp2/+8KHCTg6XFixOBas0IFY5CMg3kKJ6FIyCUTAKRgIAAPtOWT5eZ+FDAAAAAElFTkSuQmCC","orcid":"","institution":"Iran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Farhad","middleName":"Abolhassan","lastName":"Choobdar","suffix":""}],"badges":[],"createdAt":"2025-03-17 05:53:26","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6241299/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6241299/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":86786254,"identity":"1c6f80b4-8167-46a6-a20a-13e68d623b2c","added_by":"auto","created_at":"2025-07-15 14:09:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":99018,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCAPD. A rapid bedside delirium screening tool\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6241299/v1/9fa257dbaaa2a3379f33a16c.png"},{"id":86786224,"identity":"fa54e7a4-25ec-4b7b-bd89-67cd22f5e4ed","added_by":"auto","created_at":"2025-07-15 14:09:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":20457,"visible":true,"origin":"","legend":"\u003cp\u003eAssociation between neonatal disease and ventilation with delirium during this study\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6241299/v1/dc5ec5803f2b4768f45d54f9.png"},{"id":94672147,"identity":"1852d944-fe58-4d5f-b30b-590c4b6f2fa9","added_by":"auto","created_at":"2025-10-29 13:39:30","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":793411,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6241299/v1/6855b431-3d93-4fb8-9633-7d83823bbb9e.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Risk Factors Associated with Delirium in Neonates Admitted to the Neonatal Intensive Care Unit","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDelirium is a serious neurological disorder that occurs acutely in all age groups, including infants, children and adolescents [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The prevalence of paediatric delirium in paediatric intensive care units has been reported to vary widely in different studies, ranging from 15.9\u0026ndash;65.6% [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Paediatric delirium is influenced by factors such as age, developmental delay, severity of illness, use of mechanical ventilation, type of admission, use of physical restraints, severity of agitation and sedation, oxygen requirements, nutritional status, presence of familiar objects and administration of sedatives [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Early identification of delirium in children is now a medical emergency, as identifying and treating the underlying causes can minimise the long-term consequences [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eNeonates and infants show considerable developmental differences compared to older children [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The incidence of delirium in neonates and infants in intensive care has not been definitively established and is not well understood, so no conclusions can be drawn about the incidence of paediatric delirium [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Symptoms of neonatal delirium include insensitivity to escalating doses of sedatives, lack of responsiveness to calming measures, increasing and decreasing motor agitation with distrupted sleep-wake cycles and deficits in awareness, cognition and arousal [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Delirium in sick neonates and infants has different characteristics compared to paediatric delirium. However, the differences are not clearly defined [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Delirium is rarely discussed in the NICU [\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, the sick infant is likely to be at significant risk due to the combination of severe illness, prolonged stay in a highly medical environment and the use of multiple medications [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The need for close monitoring of neonates at risk of delirium is an essential part of routine care in the neonatal intensive care unit, as symptoms in neonates can be more subtle and developmentally variable. Early recognition of delirium is crucial because delirium in children may indicate ongoing damage to the fragile, developing brain. Delirium symptoms can also be attributed to a number of other health conditions, putting the child with delirium at risk of unnecessary investigations, poorer neurodevelopmental outcomes and longer length of stay [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The nursing team is the ideal first-line care provider for assessing whether delirium is present or not. Awareness of the importance of delirium screening and the ability to perform an accurate, rapid and efficient assessment are critical to the care of the critically ill child. Early delirium screening and early intervention are key to reducing adverse outcomes in critically ill children and using non-pharmacologica strategies to prevent and treat delirium [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTherefore, an investigation of factors associated with delirium is needed to provide clues to delirium- prone populations or baseline data for intervention strategies for sick neonates and infants [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. There is little literature describing delirium in the neonatal intensive care unit [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. This knowledge gap is problematic because without routine screening, delirium often goes unrecognised and represents a missed opportunity for intervention [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Although neonates are likely to be at high risk of delirium [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], delirium is not considered a common complication of NICU stay [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The aim of present study was to identify risk factors associated with the development of delirium in neonates admitted to the neonatal intensive care unit in Iran.\u003c/p\u003e"},{"header":"Material and methods","content":"\u003cp\u003eThis study is a prospective observational study conducted between November 2023 and January 2025 in three Level III NICUs affiliated with Iran university of Medical Sciences. The ethics committee of Iran University of medical sciences (code: IR.IUMS.REC.1402.725 ) at 2023.11.15, approved the research and confirmed that all research was performed in accordance with relevant guidelines/regulations. The inclusion criteria for this study were: Hospitalization in pediatric intensive care unit for at least 3 days, gestational age 37 weeks and above, postnatal age 3 to 28 days, birth weight 1500\u0026ndash;4000 grams. Neonates with any of the following conditions were excluded: (i) administration of sedatives or anesthetics and muscle relaxants within four hours prior to intubation, (ii) administration of pain medication as prescribed, (iii) intracranial hemorrhage grade 2 and above, (v) emergency conditions such as cardiopulmonary resuscitation or seizures, (vi) infant with acute cardiac or respiratory disease, (vii) maternal drug use in the past.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eEthical consideration\u003c/h2\u003e\u003cp\u003e The institutional ethics committee approved the study (code: IR.IUMS.REC.1402.725). written informed consent was obtained from parents/legal guardians after explaining the aim of the study. They have the right to refuse to participate or to withdraw from the study at any time. They were assured about the confidentiality of the collected data.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cp\u003eThe data were collected using an instrument consisting of two parts, the neonates demographic form, The Cornell Assessment of Pediatric Delirium (CAPD), The background information questionnaire (demographic information) included gestational age, Corrected age, sex, birth weight, apgar 1th minute, apgar 5th minute, delivery type, birth rank, isolation room, feeding, ventilation and disease.\u003c/p\u003e\u003cp\u003eThe CAPD is an observational tool for the assessment of delirium [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This scale was developed as a quick and easy-to-administer screening tool for nurses to identify critically ill children of all ages and developmental stages at risk of delirium [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. It consists of eight items that correlate with the diagnostic domains of consciousness and cognition from the DSM-5, and also includes psychomotor symptoms [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The CAPD scale is a standard PD assessment scale suitable for a wide age range (neonates to 21 years), and we have recently validated the Japanese version in pediatric patients30. The Cornell Assessment of Pediatric Delirium had an overall sensitivity of 94.1% (95% CI, 83.8\u0026ndash;98.8%) and a specificity of 79.2% (95% CI, 73.5\u0026ndash;84.9%). Overall, Cronbach's α was 0.90, with a range of 0.87\u0026ndash;0.90 for each of the eight items, indicating good internal consistency [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This instrument was psychometrically evaluated in Iran by Navaeifar et al. and inter-rater agreement was assessed using the Kendall's test. The Kendall coefficient for the total score was 0.046, and no significant difference was found between ratrs on any of the 8 question items and also on the overall score of the Cornell instrument [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWe used Cohen's K- test (SPSS software Version 23.0) \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://grok.lsu.edu/article.aspx?articleid=17715\u003c/span\u003e\u003cspan address=\"https://grok.lsu.edu/article.aspx?articleid=17715\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e to ensure interrater reliability. Cohen's Kappa is used to compare the degree of agreement between raters (inspectors). Kappa takes values between 0 and 1. The minimum acceptable value of the kappa coefficient is above 0.6 and values above 0.8 are ideal for agreement between two raters [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. To this end, 10 independent observations between 2 raters were conducted in this study and the kappa coefficient was found to be 0.97, indicating ideal reliability.\u003c/p\u003e\n\u003cdiv class=\"Heading\"\u003e\u003cb\u003eProcedure\u003c/b\u003e:\u003c/div\u003e\u003cp\u003eAll neonates were screened with the Cornell Assessment of Pediatric Delirium (CAPD). First, the researcher visited the NICU of the desired neonates. She selected the neonates who met the inclusion criteria for the study. She obtained and recorded demographic data from the patient records. The researcher provided the parents of the newborns with sufficient information about the aims of the study and its significance. After obtaining written informed consent from the parents of the newborns, he observed the neonate for 8 hours during the requested shift and then assessed the newborn using the Cornell questionnaire. The nurses were provided with developmental anchor points for the key ages of the newborn, 4 weeks, 6 weeks, 8 weeks and 28 weeks, as a bedside reference. Also authors confirm that all experimental protocols in this study were approved by a was approved by the Ethic Committee of Iran University of Medical Sciences (code: IR.IUMS.REC.1402.725 ) at 2023.11.15.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis:\u003c/h2\u003e\u003cp\u003eThe relationship between each variable and delirium was analysed using t-tests and chi-square tests. If necessary, we used the Fisher-exact test instead of the chi-square. Risk factors that had a significance level of less than 0.2 in the previous step were included in the logistic regression model, considering a 5% significance level.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOut of 243 infants who participated in this study, 130 of them were male. The mean birth weight and gestational age of infants were 2801.8\u0026thinsp;\u0026plusmn;\u0026thinsp;670.9 grams and 35.87\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34 weeks respectively. The demographic and clinical characteristics of the neonates can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Ninety eight of infant (40.32%) had delirium that 58 (59. 2%) of them were female and 40 (40.8%) were male. delirium showed the correlation with gender (P\u003csub\u003eV\u003c/sub\u003e = 0.001). The apgar first minuts was assocted with delirium (P\u003csub\u003eV\u003c/sub\u003e= 0.004). Out of 98 infants who had delirium all of them did not hospital stay at isolation room, and according to Fisher-exact test delirum statisticaly was related with hospitalization at isolation room (P\u003csub\u003eV\u003c/sub\u003e \u0026lt; 0.001). feeding type was assocated with delirum statisticaly (P\u003csub\u003eV\u003c/sub\u003e \u0026lt; 0.001).Other significant relationship can be found in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe relationship between some risk factors and delirium.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNegative delirium\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePositive delirium\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eP.V\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e113 (46.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e55 (37.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e58 (59.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e130 (53.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90 (62.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40 (40.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApgar 1th minute\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (10.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20 (13.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6 (6.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66 (27.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45 (31.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21 (21.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e133 (54.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66 (45.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e67 (68.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18 (7.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e14 (9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4 (4.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApgar 5th minute\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (2.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4 (2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.180\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75 (30.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e51 (35.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e24 (24.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e162 (66.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e90 (62.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e72 (73.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDelivery type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNVD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80 (32.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50 (34.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30 (30.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e0.529\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e163 (67.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e95 (65.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e68 (69.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth rank\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e138 (56.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85 (58.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e53 (54.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.513\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72 (29.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39 (26.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e33 (33.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (13.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (14.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e12 (12.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIsolation room\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (12.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e31 (21.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0 (0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e212 (87.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e114 (78.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e98 (100.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeeding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (14.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9 (6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27 (27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e166 (68.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e115 (79.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51 (52.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGavage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41 (16.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21 (14.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e20 (20.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVentilation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e110 (45.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68 (47.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e42 (42.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFreeoxygen\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105 (43.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69 (47.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36 (36.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHood\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (6.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1 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colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSepsis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82 (33.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38 (26.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44 (44.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTTN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e30 (12.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (17.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (5.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePnumonia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 (6.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2 (2.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJundis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (19.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25 (17.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23 (23.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRDS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e16 (6.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8 (8.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNEC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5 (5.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGA (week)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e35.87\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e35.37\u0026thinsp;\u0026plusmn;\u0026thinsp;2.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.011\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCorrected age (week)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e39.54\u0026thinsp;\u0026plusmn;\u0026thinsp;2.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e39.97\u0026thinsp;\u0026plusmn;\u0026thinsp;1.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e38.90\u0026thinsp;\u0026plusmn;\u0026thinsp;2.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth weight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003e2801.8\u0026thinsp;\u0026plusmn;\u0026thinsp;670.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2894.5\u0026thinsp;\u0026plusmn;\u0026thinsp;555.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2664.6\u0026thinsp;\u0026plusmn;\u0026thinsp;795.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003ea: Fisher-exact test; BF:breast feeding; NVD:normal vaginal delivery, CS:cesarean section, GA:gestational age, TTN: Transient tachypnea of the newborn, RDS:respiratory distress syndrome, NEC:necrotizing enterocolitis.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAmong risk factors the sepsis disease increased the odds of delirum four times more than prematurity disease (OR: 4.99 (1.72, 14.57), PV\u0026thinsp;=\u0026thinsp;0.003). The no feeding increased the odds of delrium 10.87 times rather than gavage feeding (OR: 10.87 (1.53, 76.9)), PV\u0026thinsp;=\u0026thinsp;0.017), while there is not statisticaly difference between gavage and BF feeding (PV\u0026thinsp;=\u0026thinsp;0.722). In addition the correccted age has negative relationship with delirum (OR: 0.96 (0.93, 0.99)), also hospitalization in solation room had a strong positive correlation with delirium (OR: 27.04 (2.95, 248.14), PV\u0026thinsp;=\u0026thinsp;0.004), (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eThe association between delirium and some risk factors using logistics regression\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eOR(95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP.V\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex (Ref: Female)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.74 (0.35, 1.54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.416\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eApgar 1th minute ( Ref: 10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1.63 (0.20, 13.16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.645\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e2.97 (0.48, 18.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.244\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e2.50 (0.44, 14.13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.300\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIsolation\u003csup\u003ea\u003c/sup\u003e ( Ref: Yes)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e27.04 (2.95, 248.14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.004\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeeding ( Ref: gavage)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e10.87 (1.53, 76.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.017\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBF\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1.25 (0.36, 4.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.722\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVentilation (Ref: No)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.98 (0.44, 2.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.958\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisease( Ref: prematurity)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003esepsis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e4.99 (1.72, 14.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.003\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTTN\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1.16(0.28, 4.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.838\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003epnumonia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.71 (0.11, 4.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.719\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ejundis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e1.67 (0.45, 6.13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.443\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRDS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e2.55 (0.58, 11.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.216\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNEC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e2.30 (0.34, 15.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.396\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eGA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.99(0.96, 1.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.708\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCorrected age\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e\u003cb\u003e0.96 (0.93, 0.99)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.040\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eBirth weight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.00 (0.99, 1.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003e0.240\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003ea: There was not any isolated child with positive delirium; so we consume one child to model fitting, as can be seen 95% CI is very big due to low sample size.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eDelirium is increasingly recognized as a common syndrome in critically ill children, but it is rarely considered in the NICU [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Delirium can be a common complication of critical illness in neonates. It is the result of the underlying medical condition, the adverse effects of the medications used, and the medicalized environment in the NICU, which is highly unnatural for a newborn [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Routine screening for delirium has become the benchmark for prevention because it creates awareness and vigilance within the care team [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Although it is rational that newborns, as well as older children and adults, occasionally experience delirium, consideration of this important diagnosis is not yet part of the standard of care in the neonatal intensive car unit [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe present study investigated the prevalence and factors influencing neonatal delirium. There are several case reports of delirium in newborns [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], but only one study has reported on the prevalence and factors influencing delirium [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] in the neonatal period. In this study, a prevalence of 40.32% for delirium was found after screening in three neonatal intensive care units. These results reflect prevalence rates of 12\u0026ndash;65% reported in the PICU and NICU [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Consistent with many other pediatric delirium studies, higher rates of delirium occurred in younger children (aOR 0.41 for children older than 5 years) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this study, we investigated the association between neonatal delirium and a number of contributing factors. The results showed a correlation between neonatal delirium and gender, with delirium occurring more frequently in girls. First minute Apgar score was associated with delirium, and of the 98 neonates who had delirium, none were admitted to an isolation room, and according to Fisher's exact test, delirium was statistically associated with admission to an isolation room. The type of feeding was statistically associated with delirium. Among the risk factors, sepsis increased the likelihood of delirium four times more than prematurity. Malnutrition increased the likelihood of delirium by 10.87 times compared to tube feeding. In addition, adjusted age was negatively associated with delirium, and admission to a bedroom was also strongly positively associated with delirium. To our knowledge, only one study [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] was found that examined factors affecting delirium, and this study also examined other factors. In this study a multivariate logistic regression revealed that neurologic disability and mechanical ventilation were both independently associated with a positive delirium screen.\u003c/p\u003e\u003cp\u003eIt is possible that if the neonatal team is more vigilant, delirium can be recognized in the NICU, allowing for tailored intervention. If we can shorten the duration of delirium, we may be able to improve the long-term health of vulnerable neonates [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Studies have shown that routine daily screening is needed to reliably detect delirium in hospitalized patients [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]\u003c/p\u003e\u003cp\u003eThis study has strengths and limitations. As it is a multicentre study, the results are generalizable as the admission and patient criteria in the NICUs are different. In addition, a team of professionals with extensive experience in the NICU was used to screen and administer the delirium instrument. A limitation of this study is that it is an observational study, so we only described the prevalence of delirium and associated factors and did not examine causality. We also only described the prevalence of delirium on selected days of the study. However, as delirium varies throughout the hospitalisation, examining the incidence on consecutive days would provide more accurate results. Our study evaluated only some of the potential risk factors for delirium, but there are many others that should be considered in future studies.\u003c/p\u003e"},{"header":"Conclusion and Recommendations","content":"\u003cp\u003eThe diagnosis and treatment of infants with delirium is a new area in neonatal medicine and there is limited information on assessment tools, best practice and potential side effects of treatment. However, clinicians should be aware that untreated delirium in this population has potential developmental consequences and consider intervention when appropriate. Therefore, screening of infants in the NICU with a focus on risk factors is recommended [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. It is also recommended that multicenter and longitudinal studies be conducted to identify modifiable risk factors, prevalence, long-term outcomes, and financial impact. Further research is needed to identify evidence-based pharmacologic and nonpharmacologic prevention and treatment strategies for delirium in infants.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to acknowledge all neonatal parents for their time and effort contributed to this study.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003eThey also want to thank the NICU nurses who collaborated in this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Iran University of Medical Sciences under Grant number (1402-1-3-25858).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors declare no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eST: Data curation, Investigation and Methodology; MA: Conceptualized the study, Methodology supervisor, Developed an analytical framework, Validation and Funding acquisition; RA: Data collection supervisor, Supervision, Validation and Visualization; FCH: Software, Formal analysis, Writing \u0026ndash; review \u0026amp; editing. All authors agree to be accountable for the research presented.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003ePorter, S., Holly, C. \u0026amp; Echevarria, M. Infants with delirium: a primer on prevention, recognition, and management. \u003cem\u003ePediatr. Nurs.\u003c/em\u003e \u003cb\u003e42\u003c/b\u003e, 223 (2016).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKalvas, L. B. \u0026amp; Harrison, T. M. State of the science in pediatric ICU delirium: an integrative review. \u003cem\u003eRes. Nurs. Health\u003c/em\u003e. \u003cb\u003e43\u003c/b\u003e, 341\u0026ndash;355 (2020).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKim, H. J., Kim, D. H., Kim, H. J. \u0026amp; Kim, D. H. Factors associated with pediatric delirium in the pediatric intensive care unit. \u003cem\u003eChild. Health Nurs. 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Care Med.\u003c/em\u003e \u003cb\u003e44\u003c/b\u003e, 592\u0026ndash;600 (2016).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEly, E. W., Siegel, M. D. \u0026amp; Inouye, S. K. Delirium in the intensive care unit: an under-recognized syndrome of organ dysfunction. In \u003cem\u003eSeminars in respiratory and critical care medicine\u003c/em\u003e. Copyright\u0026copy; 2001 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New \u0026hellip; 5\u0026ndash;126.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Delirium, Infant, Sick neonate, Risk factor, Neonatal inensive care unit","lastPublishedDoi":"10.21203/rs.3.rs-6241299/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6241299/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDelirium is a critical neurological condition that can manifest abruptly in individuals of all ages, encompassing infants, children, and adolescents. Investigating the factors related to delirium is essential to identify at-risk populations and to offer fundamental data for developing intervention strategies for sick neonates and infants. The present study aimed was to investigate the risk factors associated with the development of delerium in neonates admitted to the neonatal intensive care unit (NICU) in Iran. This descriptive, cross-sectional study involved 243 infants with admitted to NICU at four hospitals. Data were collected using a demographic questionnaire, and the cornell assessment of pediatric delirium scale. The logestic regression model considering a 5% significance level were conducted to examination of study aim. Out of 243 infants who participated in this study, 40 percent of them had delirium and130 of them were male. Birth weight and gestational age of infants were 2801.8\u0026thinsp;\u0026plusmn;\u0026thinsp;670.9 grams and 35.87\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34 weeks respectively. stay at isolation room was related with hospitalization at isolation room (PV\u0026thinsp;\u0026lt;\u0026thinsp;0.001).The mean The apgar first minuts was assocted with delirium (PV\u0026thinsp;=\u0026thinsp;0.004). The no feeding bas neen increased the odds of delrium 10.87 times rather than gavage feeding (OR: 10.87 (1.53, 76.9)), PV\u0026thinsp;=\u0026thinsp;0.017). The diagnosis and treatment of neonates with delirium is a new area in neonatal medicine and there is limited information on assessment tools, best practice and potential side effects of treatment. However, clinicians should be aware that untreated delirium in this population has potential developmental consequences and consider intervention when appropriate. Therefore, screening of infants in the NICU with a focus on risk factors is recommended.\u003c/p\u003e","manuscriptTitle":"The Risk Factors Associated with Delirium in Neonates Admitted to the Neonatal Intensive Care Unit","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 14:08:23","doi":"10.21203/rs.3.rs-6241299/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9c768d88-d9aa-448e-b30d-4db4a55323a6","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":51458555,"name":"Health sciences/Health care"},{"id":51458556,"name":"Health sciences/Risk factors"}],"tags":[],"updatedAt":"2025-10-29T09:23:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-15 14:08:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6241299","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6241299","identity":"rs-6241299","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}