Fatigue in children
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief:
Synonyms and keywords: Fatigue in kids
Overview
Fatigue is a symptom defined by a subjective sense of increased more than average tiredness and exhaustion after a routine task that impairs one’s physical and mental capabilities[1]. The chronic fatigue syndrome is defined as severe persistent debilitating fatigue for six months or more along with somatic symptoms like myalgia, headache, joint pain and sore throat[2]. The incidence of fatigue is high in children particularly in adolescence due to high education and psychosocial stress[3]. It can have severe debilating adverse effects on children and negatively impact their academic and social life.The fatigue can also be a symptom of an underlying disease. Hence, a thorough clinical evaluation and relevant investigations should be performed to rule out any underlying pathology.
Classification
Pathophysiology
- The pathogenesis of fatigue in children is unknown and it depends upon the underlying disease.
- It is characterized by impaired humoral and cellular immunity with a reduced response by natural killer cells and lymphocytes in response to various viral infections[4].
- A reduced level of the total immunoglobulins G and its various subclasses have also been documented.
Causes
Fatigue may be caused by
- Anemia
- Congestive heart failure[5]
- Cancer[6]
- Cardiac septal defect
- Diabetes
- Obesity
- Cushing's syndrome[5]
- Inflammatory bowel disease[1]
- Multiple sclerosis[7]
- Reduced physical fitness
- Anxiety [8]
- Fibromyalgia
- Juvenile rheumatoid arthritis
- Intussusception
- Depression[8]
- Obstructive sleep apnea
- Cystic fibrosis
- Strained family relations
Differentiating fatigue from other Diseases
Chronic fatigue in children should be differentiated from other symptoms that result in extreme tiredness like sleeplessness and muscle weakness[5]. These symptoms can be differentiated by thorough examination of the patient. The symptoms of tiredness due to sleeplessness are alleviated by adequate sleep and adjusting sleep wake cycle[9]. The muscle weakness is mainly due to underlying pathogy at the neuromuscular junction. It is tested by detailed neurological examination assessing muscle motor strength testing[5].
Epidemiology and Demographics
The prevalence of fatigue in children is approximately 59,000 to 386,000 per 100,000 individuals in terminal cancer.
Age
- The prevalence of fatigue increases with age. The fatigue commonly affects children during childhood, school, and adolescent years[10].
- The peak age of prevalence is 15 years. The prevalence than decreases exponentially in boys while it remains high in girls till 18 years of age[10]..
Gender
Girls are more commonly affected by fatigue than boys. The female to male ratio is approximately 1.3 to 1.[3]
Race
There is no racial predilection for fatigue in children.
Risk Factors
- Common risk factors in the development of fatigue in children are family history of fatigue, known history of asthma, mood disorder like anxiety, depression, patient belonging to upper-middle class socioeconomic group[11][12][13].
Natural History, Complications and Prognosis
- Early clinical features include headache, myalgia, joint pain, increased body temperature, more tiredness thn normal after doing physical exertion[14].
- If left untreated, 20.5% of patients with fatigue in children may progress to develop depression, mood disorders, increase absence from school, and poor academic performance[15].
- Prognosis is generally good with the resolution of symptoms in 46.6% of patients after four to six months[13].
Diagnosis
Diagnostic Criteria
- The diagnosis of chronic fatigue syndrome is based on the Centers for Disease Control and Prevention criteria[2].
- The diagnosis of chronic fatigue syndrome is made when at least four of the following eight diagnostic criteria are met and symptoms are present for more than 6 months:
- Impaired memory or concentration
- Sore throat
- Painful cervical or axillary lymph nodes
- Myalgia
- Polyarthralgia
- New onset of headache
- Unrefreshing sleep
- Malaise after exertion
- Any underlying medical or psychiatric illness has been ruled out.
Symptoms
- Extreme tiredness more than normal for more than one month.
- Onset of fatigue along with exacerbating factors should be inquired.
- A detailed medical and psychiatric history should be asked to look for underlying disease or psychiatric illness.
- Systematic symptoms like breathlessness, new-onset headache, muscle aches, and joint pains.
- Substance abuse, alcohol or use of over-the-counter medications should be asked particularly from adolescent and teenager patients.
Physical Examination
- Physical examination may be remarkable for[2]:
- Conjunctival pallor in anemia
- Petechia and purpura in leukemia patients
- A thorough examination to rule out psychiatric or neurologic disease
- Tenderness in multiple joints and muscle in fibromyalgia and juvenile idiopathic arthritis
- Tenderness in the cervical or axillary lymph nodes
Laboratory Findings
- Laboratory findings consistent with the diagnosis of fatigue in children due to underlying diseases include[2]:
- Complete blood count with differential leukocyte count (to rule out anemia or leukemia)
- Erythrocyte sedimentation rate to rule out inflammatory disease.
- Alanine transaminase, aspartate transaminase, total albumin, globulin level and total protein levels to assess liver function.
- urine analysis, serum creatinine, blood urea nitrogen, serum calcium, phosphate and electrolytes to look for underlying renal disease.
- Serum Thyroid-stimulating hormone level to rule out thyroid disease.
- Fasting blood glucose levels to rule out diabetes.
- Specific neuroimaging and viral serologies like HBV, HCV, EBV should be done in patients with particular risk factors.
Electrocardiogram
There are no ECG findings associated with fatigue in children.
X-ray
There are no x-ray findings associated with fatigue in children.
Echocardiography or Ultrasound
There are no echocardiography/ultrasound findings associated with fatigue in children.
CT scan
There are no CT scan findings associated with fatigue in children.
MRI
There are no MRI findings associated with fatigue in children.
Other Imaging Findings
There are no other imaging findings associated with fatigue in children.
Other Diagnostic Studies
- Pediatric Quality of Life Inventory (PedsQL)
- Multidimensional Fatigue Scale (MFS)
- Fatigue Scale-Child [FS-C]
- Fatigue Scale-Adolescent [FS-A]
Treatment
Medical Therapy
- There is no proven treatment for fatigue in children; the mainstay of therapy is supportive care.
- Cognitive-behavioral therapy and graded exercise therapy do not have proven efficacy for the treatment of fatigue in children. Several randomized controlled trials have shown benefit in the symptoms of fatigue[21]. Graded exercise therapy particularly aerobic exercises have shown improvement in depression and energy levels in adolescent patients with chronic fatigue syndrome[22].
- Children with chronic fatigue have disrupted sleep with daytime drowsiness resulting in disturbed cortisol levels. Patients should be advised on activity management and behavioral modification with regular sleep patterns avoiding prolonged sleep hours and daytime naps. Regular sleep pattern will improve diurnal cortisol levels [23].
- The patients complaining of pain should be referred to specialized pain clinics and adequate treatment should be administered. Amitriptyline is administered in gradually increased doses for the management of pain with low doses given initially. The physicians should avoid prescribing opiates due to the high incidence of adverse reactions[21].
- Impaired cognition in patients can be improved with strategies implemented to improve attention span in children. These include a conducive school environment to improve the child’s attention, frequent revisions, reducing the amount of new information a child learns in a day, and use of visual tools in learning[24][25].
- Dizziness and headache should be treated by increasing physical activity, increase fluid intake with average of 2-3 liters per day, and high consumption of salt in some cases[24].
Surgery
Prevention
- There are no primary preventive measures available for fatigue.
References
- ↑ 1.0 1.1 van Langenberg DR, Gibson PR (2010). "Systematic review: fatigue in inflammatory bowel disease". Aliment Pharmacol Ther. 32 (2): 131–43. doi:10.1111/j.1365-2036.2010.04347.x. PMID 20456309.
- ↑ 2.0 2.1 2.2 2.3 2.4 Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A (1994). "The chronic fatigue syndrome: a comprehensive approach to its definition and study. International Chronic Fatigue Syndrome Study Group". Ann Intern Med. 121 (12): 953–9. doi:10.7326/0003-4819-121-12-199412150-00009. PMID 7978722.
- ↑ 3.0 3.1 ter Wolbeek M, van Doornen LJ, Kavelaars A, Heijnen CJ (2006). "Severe fatigue in adolescents: a common phenomenon?". Pediatrics. 117 (6): e1078–86. doi:10.1542/peds.2005-2575. PMID 16740810.
- ↑ Lloyd AR, Wakefield D, Hickie I (1993). "Immunity and the pathophysiology of chronic fatigue syndrome". Ciba Found Symp. 173: 176–87, discussion 187-92. doi:10.1002/9780470514382.ch11. PMID 8491097.
- ↑ 5.0 5.1 5.2 5.3 Nutini M, Karczewski M, Capoor J (2009). "Fatigue in children with neurologic impairments". Phys Med Rehabil Clin N Am. 20 (2): 339–46. doi:10.1016/j.pmr.2008.12.004. PMID 19389615.
- ↑ Wolfe J, Grier HE, Klar N, Levin SB, Ellenbogen JM, Salem-Schatz S; et al. (2000). "Symptoms and suffering at the end of life in children with cancer". N Engl J Med. 342 (5): 326–33. doi:10.1056/NEJM200002033420506. PMID 10655532.
- ↑ Amato MP, Goretti B, Ghezzi A, Lori S, Zipoli V, Portaccio E; et al. (2008). "Cognitive and psychosocial features of childhood and juvenile MS". Neurology. 70 (20): 1891–7. doi:10.1212/01.wnl.0000312276.23177.fa. PMID 18474844.
- ↑ 8.0 8.1 Van de Vijver E, Van Gils A, Beckers L, Van Driessche Y, Moes ND, van Rheenen PF (2019). "Fatigue in children and adolescents with inflammatory bowel disease". World J Gastroenterol. 25 (5): 632–643. doi:10.3748/wjg.v25.i5.632. PMC 6371006. PMID 30774277.
- ↑ Shen J, Barbera J, Shapiro CM (2006). "Distinguishing sleepiness and fatigue: focus on definition and measurement". Sleep Med Rev. 10 (1): 63–76. doi:10.1016/j.smrv.2005.05.004. PMID 16376590.
- ↑ 10.0 10.1 Haines LC, Saidi G, Cooke RW (2005). "Prevalence of severe fatigue in primary care". Arch Dis Child. 90 (4): 367–8. doi:10.1136/adc.2003.039917. PMC 1720362. PMID 15781924.
- ↑ Carter BD, Marshall GS (1995). "New developments: diagnosis and management of chronic fatigue in children and adolescents". Curr Probl Pediatr. 25 (9): 281–93. doi:10.1016/s0045-9380(06)80057-5. PMID 8582157.
- ↑ Bell KM, Cookfair D, Bell DS, Reese P, Cooper L (1991). "Risk factors associated with chronic fatigue syndrome in a cluster of pediatric cases". Rev Infect Dis. 13 Suppl 1: S32–8. doi:10.1093/clinids/13.supplement_1.s32. PMID 2020801.
- ↑ 13.0 13.1 Rimes KA, Goodman R, Hotopf M, Wessely S, Meltzer H, Chalder T (2007). "Incidence, prognosis, and risk factors for fatigue and chronic fatigue syndrome in adolescents: a prospective community study". Pediatrics. 119 (3): e603–9. doi:10.1542/peds.2006-2231. PMID 17332180.
- ↑ Mears CJ, Taylor RR, Jordan KM, Binns HJ, Pediatric Practice Research Group (2004). "Sociodemographic and symptom correlates of fatigue in an adolescent primary care sample". J Adolesc Health. 35 (6): 528e.21–6. doi:10.1016/j.jadohealth.2004.02.012. PMID 15581533.
- ↑ Carter BD, Edwards JF, Kronenberger WG, Michalczyk L, Marshall GS (1995). "Case control study of chronic fatigue in pediatric patients". Pediatrics. 95 (2): 179–86. PMID 7838632.
- ↑ Crichton A, Knight S, Oakley E, Babl FE, Anderson V (2015). "Fatigue in child chronic health conditions: a systematic review of assessment instruments". Pediatrics. 135 (4): e1015–31. doi:10.1542/peds.2014-2440. PMID 25802352.
- ↑ Varni JW, Burwinkle TM, Szer IS (2004). "The PedsQL Multidimensional Fatigue Scale in pediatric rheumatology: reliability and validity". J Rheumatol. 31 (12): 2494–500. PMID 15570657.
- ↑ Varni JW, Limbers CA, Bryant WP, Wilson DP (2009). "The PedsQL Multidimensional Fatigue Scale in type 1 diabetes: feasibility, reliability, and validity". Pediatr Diabetes. 10 (5): 321–8. doi:10.1111/j.1399-5448.2008.00482.x. PMID 19067887.
- ↑ Hockenberry MJ, Hinds PS, Barrera P, Bryant R, Adams-McNeill J, Hooke C; et al. (2003). "Three instruments to assess fatigue in children with cancer: the child, parent and staff perspectives". J Pain Symptom Manage. 25 (4): 319–28. doi:10.1016/s0885-3924(02)00680-2. PMID 12691683.
- ↑ Chiang YC, Hinds PS, Yeh CH, Yang CP (2008). "Development and psychometric testing of a Chinese version of the Fatigue Scale-Children in Taiwan". J Clin Nurs. 17 (9): 1201–10. doi:10.1111/j.1365-2702.2007.02138.x. PMID 18416796.
- ↑ 21.0 21.1 Crawley E (2017). "Pediatric chronic fatigue syndrome: current perspectives". Pediatric Health Med Ther. 9: 27–33. doi:10.2147/PHMT.S126253. PMC 5919160. PMID 29722371.
- ↑ Gordon BA, Knapman LM, Lubitz L (2010). "Graduated exercise training and progressive resistance training in adolescents with chronic fatigue syndrome: a randomized controlled pilot study". Clin Rehabil. 24 (12): 1072–9. doi:10.1177/0269215510371429. PMID 20605858.
- ↑ Segal TY, Hindmarsh PC, Viner RM (2005). "Disturbed adrenal function in adolescents with chronic fatigue syndrome". J Pediatr Endocrinol Metab. 18 (3): 295–301. doi:10.1515/jpem.2005.18.3.295. PMID 15813608.
- ↑ 24.0 24.1 Rowe PC, Underhill RA, Friedman KJ, Gurwitt A, Medow MS, Schwartz MS; et al. (2017). "Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Diagnosis and Management in Young People: A Primer". Front Pediatr. 5: 121. doi:10.3389/fped.2017.00121. PMC 5474682. PMID 28674681.
- ↑ Tucker P, Haig-Ferguson A, Eaton N, Crawley E (2011). "What to do about attention and memory problems in children with CFS/ME: a neuropsychological approach". Clin Child Psychol Psychiatry. 16 (2): 215–23. doi:10.1177/1359104511403585. PMID 21571764.