Fatigue resident survival guide (pediatrics): Difference between revisions

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{{familytree | | | | | | | | | | | | | A01 | | | A01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Physical Exam <br>
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* '''[[Temperature]]''' - Any recurrent or persistent fever should be documented.
* '''[[Temperature]]''' - Any recurrent or persistent [[fever]] should be documented.
* '''[[Pulse]]''': [[Anxiety]] and [[stress]] can be the most common causes of elevated [[pulse rate]] in the pediatrician office.  
* '''[[Pulse]]''': [[Anxiety]] and [[stress]] can be the most common causes of elevated [[pulse rate]] in the pediatrician office.  
*'''[[Respiratory |Respiratory Rate]]''': Abnormalities in respiratory rate can also be associated with cardiac, metabolic, or pulmonary disorders. Variation may also indicate [[drug abuse]] among the adolescent population
*'''[[Respiratory |Respiratory Rate]]''': Abnormalities in [[respiratory rate]] can also be associated with [[cardiac]], [[metabolic]], or [[pulmonary]] [[disorders]]. Variation may also indicate [[drug abuse]] among the [[adolescent]] [[population]].
* '''[[Blood Pressure]]''': Elevated Blood pressure may be due to metabolic conditions such as [[Cushing syndrome]], [[hyperaldosteronism]], [[hyperthyroidism]], and renal abnormalities. [[Orthostatic hypotension]] may also be associated with unexplained fatigue.
* '''[[Blood Pressure]]''': Elevated [[blood pressure]] may be due to [[metabolic]] conditions such as [[cushing syndrome]], [[hyperaldosteronism]], [[hyperthyroidism]], and [[renal]] abnormalities. [[Orthostatic hypotension]] may also be associated with unexplained [[fatigue]].
*'''[[Height]]''': Failure of reaching exponential [[height]] during growth years might hint at the possibility of an underlying disorder.
*'''[[Height]]''': Failure of reaching exponential [[height]] during [[growth]] years might hint at the possibility of an underlying [[disorder]].
*'''[[Weight]]''': Excessive weight gain or weight loss over time may also indicate a serious underlying systemic process.  
*'''[[Weight]]''': Excessive [[weight gain]] or [[weight loss]] over time may also indicate a serious underlying [[systemic]] process.  
*'''[[Dermatological lesions|Cutaneous signs]]''': [[Cyanosis]], [[pallor]] or generalized [[hyperpigmentation]] may be seen in [[congenital cardiac disorders]], [[iron deficiency anemia]], and [[Addison disease]] respectively.
*'''[[Dermatological lesions|Cutaneous signs]]''': [[Cyanosis]], [[pallor]] or generalized [[hyperpigmentation]] may be seen in congenital cardiac disorders, [[iron deficiency anemia]], and [[Addison disease]] respectively.
*'''Ocular & Oral Examination''': The presence of [[dry eyes]], allergic shiners, bluish discoloration under the eyes, may hint towards [[Sjogren syndrome]], [[chronic sinusitis]] respectively. Oral findings may help to rule out [[bulimia]], [[Addison disease]] (hyperpigmentation of gum), and other systemic disorders.
*'''[[Ocular]] & [[Oral]] Examination''': The presence of [[dry eyes]], [[allergic shiners]], bluish discoloration under the [[eyes]], may hint towards [[sjogren syndrome]], [[chronic sinusitis]] respectively. [[Oral]] findings may help to rule out [[bulimia]], [[Addison disease]] (hyperpigmentation of gum), and other [[systemic]] disorders.
*'''Musculoskeletal Signs''':  Muscular weakness and fatigue can also be associated with [[muscular dystrophy]], [[myasthenia gravis]], and [[juvenile rheumatoid arthritis]]. Chronic bone pain and fatigue might indicate [[malignancy]].  
*'''[[Musculoskeletal]] Signs''':  [[Muscular weakness]] and [[fatigue]] can also be associated with [[muscular dystrophy]], [[myasthenia gravis]], and [[juvenile rheumatoid arthritis]]. Chronic [[bone pain]] and [[fatigue]] might indicate [[malignancy]].  
* '''Neurological Signs''' : Chiari Malformation may be associated with neurological signs. Floppy palatal tissue might indicate [[obstructive sleep apnea]].<br> </div> }}
* '''[[Neurological]] Signs''' : Chiari Malformation may be associated with [[neurological]] signs. Floppy [[palatal]] [[tissue]] might indicate [[obstructive sleep apnea]].<br> </div> }}
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{{familytree | | | | | | | | | | | | | A01 | | | A01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Diagnostic Tests'''
{{familytree | | | | | | | | | | | | | A01 | | | A01=<div style="float: left; text-align: left; width: 30em; padding:1em;">'''Diagnostic Tests'''

Revision as of 15:52, 9 October 2020


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Usman Ali Akbar, M.B.B.S.[2]

Synonyms and keywords: Fatigue, Pediatric Fatigue, Approach to weakness, Approach to tiredness, Approach to lethargy, Approach to debility

Fatigue resident survival guide (pediatrics) Microchapters
Overview
Causes
Diagnosis
Treatment
Do's
Don'ts

Overview

Fatigue in chronic health conditions in childhood is pretty common and has been associated with poor quality of life. Fatigue, a subjective feeling of exhaustion is a state of being less active. It is usually a benign condition. Fatigue and weakness, both being ubiquitous complaints are sometimes difficult to define. Fatigue involves extreme and unusual tiredness with decreased performance and sometimes irritability. The differential diagnosis of fatigue in pediatrics is huge and encompasses different underlying systemic disorders. Emergent evaluation and treatment of fatigue is rarely required except in some selected conditions. Both non-pharmacological and pharmacological treatment options are utilized in the treatment of fatigue.

Causes


General Causes Behavorial/Psychological Infections Medication Induced Metabolic Chronic Conditions



Complete Diagnostic Approach

 
 
 
 
 
 
 
 
 
 
 
 
Patient presents with the complaint of new-onset fatigue
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
History
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical Exam
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Diagnostic Tests

Basic Screening Tests

Additional Tests

  ❑Indicated if fatigue persists, diagnosis remains uncertain, or symptoms of neurally mediated hypotension are present 
❑Abnormal pooling of blood in lower extremities
❑Automated oscillometer facilitates process
Tilt-table testing
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Cause Identified
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
YES
 
NO
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manage Accordingly
 
Unexplained Fatigue
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Pyscological Component likely?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

❑Lifestyle advice as appropriate ❑Behavorial Changes

❑Rule out and manage according to the Psychological cause

Treatment

Shown below is an algorithm summarizing the treatment of fatigue in children and adolescent population.

 
 
 
 
 
 
 
 
 
 
 
 
Treatment should be according to the cause of fatigue and should meet individual patient's requirements.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-Pharmacological Treatment
 
Pharmacological Treatment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Advice to the adolescent and teenager that get less sleep.
[5]

•Reduce the TV watching hours especially at bedtime
•Complete at least 8h per day of sleep time
•Schedule your sleep at the same time every night
•Avoid vigorous activity or exercise in the evening
•Avoid caffeinated drinks or products in the evening
•Avoid nap during the day.
•Consume light snacks during the day


 
❑Exercise plus leisure activities
❑Exercise plus psychosocial intervention
❑Healing touch
❑MassageAcupressure

Fluids:
❑Give 10 to 20 mL/kg of 0.9% Normal Saline , or other isotonic solution, administered as an IV bolus
❑Mild DKA – 10 mL/kg bolus
❑Moderate or severe DKA – 20 mL/kg bolus
Insulin : Begin a continuous insulin infusion at 0.1 units/kg per hour.◊ Mix 50 units of regular insulin in 50 mL of saline (0.45% or 0.9% NaCl).
Serum Electrolyte Correction

Fluids and electrolytes – Give a bolus of D5 normal saline (5% dextrose with 0.9% saline, without potassium), 20 mL/kg intravenously over one hour.
Glucocorticoids and mineralocorticoids
•0-3 years old – Hydrocortisone 25 mg IV
•3-12 years old – Hydrocortisone 50 mg IV
•12 years and older – Hydrocortisone 100 mg IV

Do's

Don'ts

References

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  2. Silva, Michele Cristina Miyauti da; Lopes Júnior, Luís Carlos; Nascimento, Lucila Castanheira; Lima, Regina Aparecida Garcia de (2016-08-29). "Fatigue in children and adolescents with cancer from the perspective of health professionals". Revista latino-americana de enfermagem. FapUNIFESP (SciELO). 24 (0). doi:10.1590/1518-8345.1159.2784. ISSN 0104-1169. PMC 5016058. PMID 27579937.
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  4. Bansal, Amolak S (2016-07-19). "Investigating unexplained fatigue in general practice with a particular focus on CFS/ME". BMC Family Practice. Springer Science and Business Media LLC. 17 (1). doi:10.1186/s12875-016-0493-0. ISSN 1471-2296. PMC 4950776. PMID 27436349.
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  6. Mendelson, Tamar; Tandon, S. Darius (2016). "Prevention of Depression in Childhood and Adolescence". Child and adolescent psychiatric clinics of North America. Elsevier BV. 25 (2): 201–218. doi:10.1016/j.chc.2015.11.005. ISSN 1056-4993. PMID 26980124.
  7. 7.0 7.1 Stewart, Julian M.; Boris, Jeffrey R.; Chelimsky, Gisela; Fischer, Phillip R.; Fortunato, John E.; Grubb, Blair P.; Heyer, Geoffrey L.; Jarjour, Imad T.; Medow, Marvin S.; Numan, Mohammed T.; Pianosi, Paolo T.; Singer, Wolfgang; Tarbell, Sally; Chelimsky, Thomas C. (2017-12-08). "Pediatric Disorders of Orthostatic Intolerance". Pediatrics. American Academy of Pediatrics (AAP). 141 (1): e20171673. doi:10.1542/peds.2017-1673. ISSN 0031-4005. PMC 5744271. PMID 29222399. Check date values in: |year= / |date= mismatch (help)
  8. Escalante, Carmen P.; Manzullo, Ellen F. (2009-10-18). "Cancer-Related Fatigue: The Approach and Treatment". Journal of general internal medicine. Springer Science and Business Media LLC. 24 (S2): 412–416. doi:10.1007/s11606-009-1056-z. ISSN 0884-8734. PMC 2763160. PMID 19838841.
  9. Nap-van der Vlist, Merel M; Dalmeijer, Geertje W; Grootenhuis, Martha A; van der Ent, Cornelis K; van den Heuvel-Eibrink, Marry M; Wulffraat, Nico M; Swart, Joost F; van Litsenburg, Raphaële R L; van de Putte, Elise M; Nijhof, Sanne L (2019-06-07). "Fatigue in childhood chronic disease". Archives of disease in childhood. BMJ. 104 (11): 1090–1095. doi:10.1136/archdischild-2019-316782. ISSN 0003-9888. PMID 31175124.
  10. Lopes, Clarice L.S.; Pinheiro, Paula Pitta; Barberena, Luzia S.; Eckert, Guilherme U. (2017). "Diabetic ketoacidosis in a pediatric intensive care unit". Jornal de pediatria. Elsevier BV. 93 (2): 179–184. doi:10.1016/j.jped.2016.05.008. ISSN 0021-7557. PMID 27770618.
  11. 11.0 11.1 Uçar, Ahmet; Baş, Firdevs; Saka, Nurçin (2016-04-08). "Diagnosis and management of pediatric adrenal insufficiency". World journal of pediatrics : WJP. Springer Science and Business Media LLC. 12 (3): 261–274. doi:10.1007/s12519-016-0018-x. ISSN 1708-8569. PMID 27059746.
  12. Gildas, Aymar Pierre; Zaharo, Fayçal Khalil; Missambou Mandilou, Steve Vassili; Kambourou, Judicaël; Letitia, Lombet; Yolaine Poathy, Jesse Pierre; Engoba, Moyen; Cyriaque Ndjobo, Mamadou Ildevert; Monabeka, Henri Germain; Moyen, Georges Marius (2018). "Acidocétose diabétique chez l'enfant: aspects épidémiologiques et pronostiques". The Pan African medical journal. Pan African Medical Journal. 31. doi:10.11604/pamj.2018.31.167.14415. ISSN 1937-8688. PMC 6488241. PMID 31086620.