Fatigue resident survival guide (pediatrics)

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, a subjective feeling of exhaustion is a state of being less active.Fatigue in childhood has been associated with poor quality of life, and is usually a benign condition. Fatigue and weakness, are sometimes difficult to define. Fatigue involves extreme and unusual tiredness with decreased performance and sometimes irritability. The differential diagnosis of fatigue in pediatrics 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

• The causes of fatigue in the pediatric population are enormous but can be divided mainly into the following categories:

General Causes	Behavorial/Psychological	Infections	Medication Induced	Metabolic	Chronic Conditions
Overexertion Deconditioning Puberty	Insufficient sleep Sleep disorders Boredom Depression Anxiety Insecurity School phobia Normal quiet personality	Acute viral illnesses Adenovirus Epstein-Barr virus Influenza Lyme disease Parvovirus	Alcohol Antidepressants Antihistamines	Anemia Abnormal diet or malnutrition Hypoglycemia Hyperammonemia	Congenital heart disease Acquired heart disease e.g. endocarditis Diabetes Hypothyroidism Hyperthyroidism Addison disease Cushing’s syndrome Crohn’s disease Ulcerative colitis Hepatitis or liver failure Renal – renal insult or failure Neurological/Genetic: Myasthenia gravis Muscle weakness Chronic fatigue syndrome Heavy metal intoxication Pain, e.g. Fibromyalgia Malignancy

Complete Diagnostic Approach

• A complete diagnostic approach should be carried out after proper evaluation and following the initiation of any urgent intervention:

Patient presents with the complaint of new-onset fatigue

History Clarify what is meant by fatigue Impact on everyday's life and function Family's concern and ideas Onset, duration, severity Associated symptoms - somatic and psychological Birth history Pediatric milestones history Medication history

Physical Exam 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. 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. 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. 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. 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.

Diagnostic Tests Basic Screening Tests Complete blood count with differential ESR Serum electrolyte panel Liver enzymes, protein, and albumin Thyroxin, TSH Morning cortisol versus ACTH stimulation test Epstein-Barr virus viral capsid antigen immunoglobulin (Ig)M and IgG Human parvovirus B19 IgM titers Antinuclear antibody, rheumatoid factor, C3 and C4 complement, creatine phosphokinase Urinalysis, urine culture and sensitivity Additional Tests Orthostatic blood pressure measurements ❑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 Sinus films Human immunodeficiency virus testing, Lyme titers Chest radiograph, purified protein derivative Toxicology screen Magnetic resonance imaging of brain for chiari malformation Cytomegalovirus and toxoplasma titers

Cause Identified

YES

NO

Manage Accordingly

Unexplained fatigue

Psychological component likely?

❑Lifestyle advice as appropriate ❑Behavioral 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

Advise extra rest Limited and carefully paced exercise Referral to a physiotherapist Gradual returning to school life Psychotherapy with family therapy Graded exercise therapy]] Cognitive Behavioral Therapy seems to be effective. Advice the adolescent and teenager to get less sleep. •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

Pain management with acetaminophen or NSAIDs for arthralgias, headaches or myalgias. Start pharmacotherapy according to the cause of fatigue. Depression should be treated with appropriate anti-depressants such as amitriptyline or fluoxetine at a low dose of 10-20mg at bedtime. Orthostatic hypotension should be treated with intravascular fluids (at least 2L/day). Cancer-related fatigue is usually treated with the following interventions: ❑Exercise plus leisure activities ❑Exercise plus psychosocial intervention ❑Healing touch ❑Massage ❑Acupressure Chronic Fatigue Syndrome: Behavorial and Lifestyle Changes. Diabetic Ketoacidosis: 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 Electrolytes Correction Adrenal crisis : 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

• Most of the cases of fatigue do not require emergency management.
• In case of congenital cardiac causes, fatigue may develop as a result of heart failure and hemodynamically unstable patients require urgent direct-current cardioversion.
• Endocrine disorders: Diabetic ketoacidosis or nonketotic hyperglycemic states and Addison's crisis require urgent correction of blood sugar levels, acidosis, electrolyte & fluid imbalances.
• Infectious disease requires urgent antibiotics and evaluation.
• Order all the relevant labs and investigations in case of unresolved fatigue.
• Orthostatic hypotension may require urgent intravascular fluids.

Don'ts

• Sedating drugs should be avoided in infectious causes of fatigue.
• Dehydration should be avoided in the patient with the history of orthostatic hypotension.