What is the appropriate workup and treatment for an 8-year-old child presenting with fatigue?

Workup for Fatigue in an 8-Year-Old Child

Begin by quantifying fatigue severity using a 0-10 numeric rating scale (simplified to 1-5 for children this age), and if the score is ≥4, proceed immediately with a focused evaluation targeting treatable conditions rather than extensive laboratory testing. 1, 2

Initial Severity Assessment

• Use a numeric rating scale where 0 = no fatigue and 10 = worst fatigue imaginable, with scores 0-3 indicating mild fatigue (requiring only routine rescreening), and scores 4-10 indicating moderate to severe fatigue warranting immediate focused evaluation 1, 2
• For an 8-year-old, the scale can be simplified to 1-5, or even asking if they are "tired" or "not tired" 3
• Scores ≥7 typically indicate marked functional impairment and decreased physical functioning 1, 2

Focused History and Physical Examination

Document specific fatigue characteristics:

• Onset, pattern, duration, and temporal changes in fatigue 1, 2
• Associated or alleviating factors 1, 2
• Interference with school attendance, daily activities, and social functioning (children with severe fatigue commonly show worsening school performance and decreased social activities) 4
• Changes in exercise or activity patterns since fatigue onset 1

Conduct thorough review of systems:

• Assess for lymphadenopathy and hepatosplenomegaly 1
• Evaluate for fever, night sweats, unintentional weight loss 5
• Screen for headache, sore throat, abdominal pain (commonly reported in pediatric fatigue) 4
• Assess for difficulties with concentration and/or memory 4
• Evaluate for hot and cold spells, blurred vision, pain in arms and legs, back pain, and constipation (these somatic complaints predict worse outcomes) 6

Assessment of Treatable Contributing Factors

Medication review:

• Review all current medications, including over-the-counter drugs, herbal supplements, and vitamins for potential side effects causing excessive drowsiness 1, 2

Sleep evaluation:

• Assess sleep quality, quantity, and sleep hygiene practices 1, 2
• Screen for sleep disorders including insomnia and sleep apnea (sleep problems predict persistent fatigue with odds ratio 1.4) 6
• Consider formal polysomnography if sleep disturbance is suspected 3

Mental health screening:

• Screen for depression and anxiety, which frequently co-occur with fatigue 1, 2
• Note that fatigue and depression are independent conditions with different patterns 1

Activity level:

• Assess current physical activity patterns (physically inactive lifestyle predicts worse outcomes, while active lifestyle is associated with resolved fatigue with odds ratio 1.3) 6

Laboratory Studies

Keep initial testing limited and targeted:

• Complete blood count with differential 1
• Comprehensive metabolic panel 1
• Thyroid-stimulating hormone (TSH) 1
• Erythrocyte sedimentation rate (ESR) 1
• C-reactive protein (CRP) for inflammation 1

Nutritional assessment:

• Evaluate weight changes, caloric intake, and appetite 1
• Assess for impediments to nutritional intake and fluid/electrolyte imbalances 1
• Consider nutrition expert consultation if substantial abnormalities exist 1

Management Approach

Implement structured physical activity:

• Prescribe stretching and aerobic exercise 2-3 times weekly for 30-60 minutes, regardless of underlying cause, as this lowers fatigue levels 1, 7
• Note: Male gender and physically active lifestyle are associated with better outcomes (odds ratio 5.0 and 1.3 respectively) 6

Address identified causes:

• Treat any underlying medical conditions identified 1
• Implement good sleep hygiene practices 1
• Address nutritional deficiencies with appropriate supplementation 1
• Consider psychosocial interventions for emotional distress 1

Avoid unnecessary interventions:

• Do not use psychostimulants or dietary supplements 1
• Avoid extensive imaging studies unless red flags are present 1

Follow-Up Strategy

• Schedule regular follow-up visits and reassess fatigue severity at each visit 1, 2
• Be aware that fatigue rarely occurs in isolation and often clusters with other symptoms 1, 2
• Recognize that children and adolescents with chronic fatigue have a more optimistic outcome than adults, with 43% considered "cured" and 52% "improved" at follow-up 4
• Many patients show significant improvement during summer months after initial visit, with continued improvement over 2-3 years 4

Common Pitfalls to Avoid

• Do not perform extensive laboratory testing without clinical indication, as results affect management in only 5% of patients 7
• Do not overlook medication side effects as potential contributors 2
• Do not miss sleep disorders, as they are strong predictors of persistent fatigue 6
• Female gender predicts worse outcomes (odds ratio 5.0 for males having resolved fatigue), so monitor girls more closely 6