Case control study of chronic fatigue in pediatric patients

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OBJECTIVE. To determine the demographic characteristics, medical

features, psychological profile, and natural history of

children with chronic fatigue.

DESIGN. Case control study.

SETTING. Pediatric Infectious Diseases Clinic of Kosair

Children’s Hospital, 1990 to 1992.

PARTICIPANTS. Forty-four

patients referred for persistent fatigue were evaluated.

Twenty patients participated in a psychological study; 20

healthy controls of similar age and gender were recruited from

community pediatric practices and 20 matched depressed

controls were recruited from university psychiatry services

(subjects were treated as groups in the analyses).

MEASURES.

Demographic data were obtained for all referred patients.

Those with fatigue for at least 2 months and no alternative

diagnosis received a detailed history, physical, and battery

of laboratory tests (complete blood count, sedimentation rate,

chemistry panel, chest X-ray thyroid stimulating hormone,

thyroxine, anti-nuclear antibodies, urinalysis,

immunoglobulins, and Epstein-Barr virus (EBV), toxoplasma, and

cytomegalovirus serologies). Psychological study participants

completed the following: background structured interview;

Kaufman Brief Intelligence Test; Children’s Depression

Inventory; Child Behavior Checklist; Youth Self Report;

Diagnostic Interview for Children and Adolescents-Revised;

mail-in follow-up survey.

RESULTS. The median age of fatigue

patients was 14.3 years; 60% were female, 96% white, and 87%

from the mid/upper socioeconomic status (SES). Fatigue

patients were demographically similar to 21 patients referred

for infectious mononucleosis (IM) but were older than other

clinic patients (P < .0001). White race (P = .0568) and

mid/upper SES (P = .0403) were over-represented among fatigue

patients compared to patients referred for other diagnoses. Of

36 patients meeting criteria for further study, 5 had an

IM-like illness including evidence of recent EBV infection.

For the remaining 31 patients, clinical and laboratory

evaluations were unrevealing. Psychological study subjects

reported marked declines in quality-of-life and scored high on

measures of internalizing, withdrawal, and social isolation.

Nine met diagnostic criteria for depression, although

depressive symptoms were not as prominent as those reported by

depressed controls. Fatigue subjects scored higher on

somatization than both control groups. The follow-up survey

indicated symptomatic improvement in most patients.

CONCLUSIONS. Chronic fatigue was a common reason for

referral, with over-representation of white children from

mid/upper SES. After exclusion of EBV-associated IM, screening

laboratory tests were not helpful in establishing specific

organic diagnoses. Whereas the natural history was favorable,

chronic fatigue resulted in major quality-of-life changes and

was associated with significant levels of psychosocial

distress.

IMPLICATIONS. Psychological evaluation is warranted

in these patients, as some may have treatable psychological

conditions. Given the absence of proved medical therapies,

psychosocial interventions to improve quality-of-life should

be studied.

Carter BD, Edwards JF, Kronenberger WG, Michalczyk L, Marshall GS