What is the appropriate workup and treatment for a 9-year-old patient presenting with fatigue?

Workup of Fatigue in a 9-Year-Old Child

Begin by quantifying fatigue severity using a simplified 1-5 numeric scale (or simply "tired" vs "not tired" for younger children), then conduct a focused evaluation targeting treatable conditions with limited laboratory testing rather than extensive workups. 1, 2

Initial Severity Assessment

• Use a numeric rating scale to quantify fatigue: scores 1-3 indicate mild fatigue, 4-6 moderate fatigue, and 7-10 severe fatigue requiring urgent attention 1, 2
• For a 9-year-old, a simplified 1-5 scale works well, or even asking if they are "tired" or "not tired" 1
• Scores ≥7 indicate marked functional impairment and decreased physical functioning 1

Focused History (Key Elements to Document)

• Onset, pattern, duration, and temporal changes in fatigue—when did it start, is it constant or intermittent, getting better or worse 1, 2
• Changes in exercise or activity patterns since fatigue began—can they do normal daily activities, participate in sports, play with friends 3, 1
• Sleep assessment: quantity (hours per night), quality (frequent awakenings, snoring), bedtime routine, screen time before bed 1, 4, 2
• Medication review: all current medications including over-the-counter drugs, herbal supplements, and vitamins that may cause drowsiness 1, 4
• Screen for depression and anxiety: mood changes, loss of interest in activities, school performance decline, social withdrawal 1, 2
• Constitutional symptoms: fever, night sweats, unintentional weight loss 1

Physical Examination (Specific Findings to Assess)

• Assess for lymphadenopathy and hepatosplenomegaly 1
• Perform neurologic assessment for focal findings, muscle weakness, or abnormal reflexes 2
• Evaluate weight changes and nutritional status 1

Laboratory Testing (Keep It Limited and Targeted)

Initial screening tests only: 1, 4

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

Avoid extensive testing—laboratory results affect management in only 5% of patients, and imaging studies should only be pursued if red flags are present 1, 5, 6

Management Approach (Regardless of Underlying Cause)

Physical Activity (Most Important Intervention)

Prescribe structured physical activity: stretching and aerobic exercise (walking, swimming, cycling) 2-3 times weekly for 30-60 minutes—this lowers fatigue levels regardless of cause 1, 4, 2, 6

Sleep Hygiene Optimization

• Establish consistent bedtime routine with sleep-conducive environment (dark, quiet, comfortable) 3, 2
• Limit daytime naps so they don't interfere with nighttime sleep 3
• Reduce late-night screen time, gaming, and social media use 3, 4
• Consider formal polysomnography if sleep disturbance is suspected 1, 2

Treat Identified Contributing Factors

• Anemia: treat based on etiology 2
• Hypothyroidism: thyroid hormone replacement 2
• Depression/anxiety: consider selective serotonin reuptake inhibitors or psychosocial interventions 4, 2
• Nutritional deficiencies: appropriate supplementation 1, 4

Energy Conservation Strategies

• Help the child set realistic expectations, prioritize activities, and pace themselves 3
• Counsel that it's okay to postpone nonessential activities when experiencing moderate-to-severe fatigue 3

Psychoeducational Support

• Provide education about fatigue patterns and coping strategies to child and family 3, 2
• Consider cognitive behavioral therapy if fatigue persists 3, 4

What NOT to Do (Common Pitfalls)

• Do not use psychostimulants (methylphenidate, modafinil)—they lack proven efficacy for fatigue 3
• Avoid dietary supplements like L-carnitine or coenzyme Q10—ineffective in trials 3
• Do not perform extensive imaging unless red flags present 1, 4
• Do not overlook medication side effects as potential contributors 1

Follow-Up Strategy

• Schedule regular follow-up visits and reassess fatigue severity at each visit 1, 2
• Use watchful waiting with regularly scheduled appointments if diagnosis remains unclear after initial workup 4, 7
• Recognize that children with chronic fatigue have more optimistic outcomes than adults 1

Red Flags Requiring Urgent Specialist Referral

• Hematologic concerns: WBC >20,000/mm³ 2
• Neurologic abnormalities: focal findings, severe muscle weakness, abnormal reflexes 2
• Severe fatigue (7-10/10) with concerning features 2