Fatigue resident survival guide (pediatrics)

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
  

Manage Accordingly

Unexplained fatigue

Psychological component likely?

❑Lifestyle advice as appropriate ❑Behavioral Changes

❑Rule out and manage according to the psychological cause

Treatment should be according to the cause of fatigue and should meet individual patient’s requirements.

• 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.^[5]

Advice the adolescent and teenager to 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

• 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.^[6]
• Orthostatic hypotension should be treated with intravascular fluids (at least 2L/day).^[7]
• Cancer-related fatigue is usually treated with the following interventions:^[8]
  

❑Exercise plus leisure activities
❑Exercise plus psychosocial intervention
❑Healing touch
❑Massage 
❑Acupressure

• Chronic Fatigue Syndrome: Behavorial and Lifestyle Changes.^[9]
• Diabetic Ketoacidosis:^[10]

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 :^[11]

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