Severe Alcohol Withdrawal in a Pediatric Patient

Introduction: Alcohol remains the most common drug of use and abuse by children and adolescents. While alcohol withdrawal in the pediatric population remains rare, it is well known that “transitional” patients (ages 18-21) are making up an increasing percentage of overall pediatric hospital admissions. Alcohol Withdrawal Assessment tools have been shown to significantly improve the quality of care of patients undergoing withdrawal at adult hospitals. Despite this, there is no standardized approach to the care of young adults presenting with alcohol withdrawal to pediatric hospitals.

Case Description: We present a case of a 20 year old male with alcohol use disorder who presented to the pediatric emergency department for alcohol withdrawal. He had been drinking a pint a day for one year, and presented four hours after his last drink. Family history was notable for multiple family members with alcohol use disorder necessitating ICU admission for withdrawal.
On presentation, he endorsed chills, anxiety, fatigue, and was hypertensive, tremulous and diaphoretic. He was initially admitted to the general pediatric service for management of his alcohol withdrawal. Within the first 24 hours of his hospitalization, he required > 30 mg of lorazepam and one dose of haloperidol for hallucinations. Based on his high benzodiazepine requirement, he required ICU level care for further monitoring and treatment. Upon attempted transfer to the pediatric ICU, the transferring team was notified that the clinical staff in the ICU had not been trained in the assessment and treatment of severe alcohol withdrawal. The admission was declined, and the adult critical care team was notified. The patient developed worsening hallucinations, autonomic instability, and altered mentation. A rapid response was called in order to initiate phenobarbital loading, a mainstay of therapy for patients with refractory alcohol withdrawal. The adult critical care fellow assessed the patient and he was ultimately admitted to the adult ICU for further management.

Discussion: This case illustrates the importance of a standardized approach for the treatment of patients with severe alcohol withdrawal admitted to a pediatric hospital. Given the geography of our adult and pediatric hospitals, as well as the overall acuity and high census of the adult hospital, this transfer occurred over the span of multiple hours resulting in a long delay of care at a time when the patient was at high risk for decompensation. As such, we recommend the implementation of an alcohol withdrawal assessment tool at pediatric hospitals. We also recommend that pediatric clinicians (including resident and attending physicians, nursing, pharmacy and social work) be trained in the assessment and therapeutics of mild, moderate, and severe alcohol withdrawal.

Conclusion: The implementation of guidelines and education surrounding severe alcohol withdrawal management may improve the care of patients at pediatric hospitals.