Chronic fatigue syndrome
Chronic fatigue syndrome (CFS) is defined as generalized fatigue persist-ing after routine tests and investigations have failed to identify underlying cause. The fatigue in CFS may be associated with other symptoms:
• Difficulty in concentrating; cognitive dysfunction.
• Disturbed sleep.
• Fatigue (both mental and physical) exacerbated by effort.
• The diagnosis should be made as soon as it is clear that the symptoms are causing functional impairment and no alternative explanation has been found (3mths in children).
Routine investigations need to be undertaken to rule out plausible alterna-tive causes. Second-line investigations are only undertaken if symptoms/ signs or investigations suggest a particular diagnosis.
• FBC and film, ESR
• Glucose, biochemistry, CK (muscle), liver function test
• Thyroid tests
• Urine to exclude renal disease
• Screening tests for gluten sensitivity
• Assessment of ferritin levels
• EBV or viral tests only if history indicates recent infection
An assessment of psychological well-being is essential and psychiatric dis-orders need to be excluded. Psychological morbidities such as anxiety and depression are common and important to recognize.
There is no one single approach for all patients with CFS, but as a mini-mum the following should be addressed.
Establish baseline level and gradually increase as appropriate. Referral to physiotherapy and occupational therapy to supervise programme and treat symptoms. It is widely assumed that the correct approach is the use of graded activity and CBT, as supported by the literature in adults. However, some patients find it unacceptable to use psychological treat-ments and have found that any exercise is to be avoided. Parental men-tal illness, especially depression and anxiety, should be assessed. Treating these presentations may be important in a holistic treatment plan.
• Symptomatic treatment for pain, sleep.
• Dietary advice (e.g. poor appetite or weight gain due to immobility).
Treatment for depression and mood disorders—need referral to child psychiatry team.
CFS causes significant disruption to school. The length of absence from school depends on severity and will range from part time attendance to home tuition for many years. Liason with the school is essential in order to formulate a plan for return. Support in school may be needed for mobility or learning, and for some a statement of special educational needs will be required. If the child is too unwell to attend school, home tuition can be organized with support from the paediatrician but the maximum per week is usually a few hours and the child’s needs should be monitored closely.
Severe or very severe CFS (house bound or bedridden for 3mths) on rare occasions requires admission to hospital. Some cases the condition may persist for many years. Generally, though, outcome is favourable.1