Approach to the child with fatigue: A focus for the general pediatrician 2022, De Nardi et al

Sly Saint

Sly Saint

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Background: Fatigue is a common, nonspecific complaint commonly used to describe various conditions, ranging from a vague, subjective sense of weariness to muscular weakness, fatigability, exercise intolerance or excessive daytime somnolence. Despite its high frequency in the general population, literature addressing the approach to the child with fatigue from a general pediatrician perspective is poor. We herein propose a review of the available evidence on the topic, providing a practical framework to assist physicians in dealing with the issue.

Methods: Data were identified by searches of MEDLINE, UpToDate, Google Scholar and references from relevant articles. Articles published between 1990 and 2021 were considered, prioritizing systematic reviews and meta-analyses. Then, an empirically-based model of approaching the tired child was proposed according to our center experience.

Results: To correctly characterize the meaning of fatigue reporting, specific clues from history and physical examination should be emphasized. Duration, severity, and the age at onset are to be considered. Then, specific queries about everyday activities, sleep hygiene and social domain could be useful in reaching a specific diagnosis and offering an appropriate treatment.

Conclusions: We suggest a pragmatic approach to fatigue in children based on age assessment, targeted questions, physical examination clues, and some laboratory first-level tests. This could provide pediatricians with a useful tool to discriminate the broad etiology of such a complaint, disentangling between psychological and organic causes. Further studies are needed to investigate the predictive value, specificity and sensitivity of this diagnostic workflow in managing the child with fatigue.
https://www.frontiersin.org/articles/10.3389/fped.2022.1044170/full

Dealing with chronic fatigue syndrome
Once all the possible organic causes at the base of fatigue have been excluded, the literature suggests considering the diagnosis of Chronic Fatigue Syndrome (CFS), a condition also known as myalgic encephalomyelitis, with uncertain etiology and a reported prevalence of 1%–2% in children and adolescents (11). The pediatric diagnostic criteria are less well-defined than adults' ones. Guidelines vary slightly among different groups (24, 25, 66, 67). However, they mostly agree on some key differences compared to the adult guidelines. In particular, the diagnosis of pediatric CFS should be considered when symptoms persist for more than three months (compared to six in the adult population), symptom onset must be gradual, and a debilitating and chronic sense of fatigue should be associated with post-exertional malaise, pain, dizziness, alterations in sleep and decreased neurocognitive performance. Furthermore, all authors include elements to distinguish CFS from “school phobia” (27). Indeed, one of the main issues plaguing children diagnosed with CFS is school absenteeism (68), associated with a severe decrease in general functioning, with some patients even becoming bed-ridden or wheelchair-bound (69). These features suggest an overlap between CFS, SSD, and psychiatric populations. One-third of adolescents diagnosed with CFS are actually affected by mental health problems (70), presenting higher rates of emotional distress, “internalizing” symptoms (mainly anxiety and depression) and personality disorders (71). This overlap is further supported by the fact that SSDs and CFS are more common in female adolescents than males (24). A somatic or psychological rather than organic origin of CFS appears to be likely, considering that the most effective therapeutic intervention was found to be cognitive behavioral therapy (72).

From a pragmatic perspective, we suggest that CFS should be an exclusion diagnosis well before the three months needed to formalize it. Notably, strong consideration should be given to the presence of an underlying SSD, a condition much more prevalent than CFS in the pediatric population (10%–15%) (73–75). A recognized fact is that doctors are often uncomfortable diagnosing SSDs; hence patients with functional disorders are frequently misdiagnosed as having some medically unexplained syndrome (76) or some blurred clinical entity that can be identified on a case-by-case basis within CFS, fibromyalgia, or chronic Lyme disease (77–79). This issue becomes relevant in pediatrics for the associated risks of perpetuating over-medicalization (80) and over-diagnosing the above-cited conditions (81).
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The paper said:
Fatigue is a common, nonspecific complaint commonly used to describe various conditions, ranging from a vague, subjective sense of weariness to muscular weakness, fatigability, exercise intolerance or excessive daytime somnolence
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Uh, no, it is not. Fatigue means its own thing. Muscle weakness is its own thing. Sleepiness is also its own thing. PEM is definitely its own thing. This is FUBAR, a "scientific" paper where basic words are essentially meaningless. We can't have a serious discussion when basic facts are in dispute.

Enough with the pragmatic stuff. Complex problems cannot be solved without understanding their cause. Generic solutions are never good, by definition. It's universally garbage when the people doing those things don't even understand the words they are using. Evidence-based medicine is a complete disaster.
 
Once all the possible organic causes​

Not off to a good start.

A somatic or psychological rather than organic origin of CFS appears to be likely, considering that the most effective therapeutic intervention was found to be cognitive behavioral therapy.​

And proceeds to shred what remained of its credibility.
 
Sean said:
Once all the possible organic causes​

Not off to a good start.

A somatic or psychological rather than organic origin of CFS appears to be likely, considering that the most effective therapeutic intervention was found to be cognitive behavioral therapy.​

And proceeds to shred what remained of its credibility.
Click to expand...
Pragmatic trials aren't even supposed to be used to infer cause or etiology. They are not capable of it, especially not with the evidence they have, all a bunch of "may be" and "could be" lacking a single bit of objective evidence. This is reckless endangerment, blatant disregard for the role medicine is supposed to play, and scientifically inept.

Shows how most of the so-called principles are just a bunch of words whenever convenient.
 
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