Recommendations for a Pediatric Catatonia Clinical Pathway in Acute Medical Care Settings: A Delphi Consensus Study

Objective: Pediatric catatonia research has increased recently. However, there is a lack of guidance and consensus o n best practices for assessment and management in acute care and hospital settings. This study presents a pediatric catatonia expert consensus clinical pathway to address this gap. Methods: A group of 15 child and adolescent psychiatrists representing 14 institutions in the United States and Canada performed four rounds of iterative Delphi surveys, supplemented by group meetings, to arrive at consensus statements informing the development of a pediatric catatonia clinical pathway. This study highlights areas of consensus (over 70% agreement) and lack of consensus throughout the care continuum. Results: The pediatric catatonia pathway should begin as soon as possible, in the most suitable setting, given local circumstances, once catatonia is suspected. It should utilize evidence-based rating scales for initial diagnosis and iterative assessment with management. The pathway should include suggestions about potential psychiatric, neurodevelopmental, and medical causes, a separate arm addressing autoimmune encephalitis, and standardized laboratory and imaging work-up, which may expand based on clinical circumstances. Lorazepam is the first line treatment for pediatric catatonia, followed by use of electroconvulsive therapy for youth with partial or no response to lorazepam, regardless of electroconvulsive therapy accessibility. There is no maximum dose for lorazepam. Clinicians should continue treatment until side effects occur or sufficient symptom improvement is achieved. Other agents may also be considered for managing catatonia when there is partial or no response to lorazepam until electroconvulsive therapy can be secured. However, their use should not delay pursuit of electroconvulsive therapy. Conclusions: Expert consensus exists for multiple important aspects of a pediatric catatonia clinical pathway including pathway initiation, assessment, diagnostic evaluation, clinical monitoring, setting of care, ongoing care delivery, and treatment. Findings balance minimum standards of care for this population while allowing reasonable variability in practice depending upon system resources making this study widely generalizable. The study also elucidates areas requiring further exploration and research.