Fatigue

 DO

• Perform a complete history including sleep anamnesis and physical examination for quality of life and treatable causes of fatigue. Use the bio psychosocial model as a starting point.

• Consider performing diagnostics for treatable causes of fatigue.
• Consider using an instrument to gain insight into what is important to the child and contributes to the child's quality of life.
• For further diagnostics related to sleep, consider referral to a specialised sleep centre if there are clinical reasons for this.

 DO

• Use the PedsQL Multidimensional Fatigue Scale to assess the dimensions and degree of fatigue in children between 2 and 18 years of age.
• Use a Visual Analogue scale to readily monitor fatigue in children during the period of stable disease.

 Consider

• Consider using a Visual Analogue scale with faces to map fatigue for children with intellectual disabilities.

• Use of the PEDS FACIT-F is not recommended.

 DO

• Provide education about the consequences of reported/measured fatigue, the factors that may affect its severity, and the possibilities and impossibilities for alleviating or reducing fatigue.
• Repeat this conversation as needed.
• If possible, support the education with written advice and instruction.
• When choosing treatment, connect to modifiable triggering and/or maintaining factors that play a role in fatigue and fit the parents' and child's request for help and expectations.
• Establish treatment according to the principle of "the right care in the right place”. That is, provide treatment and support close to home where possible, supplemented by remote expertise where needed.

• Consider using a discussion tool (e.g. child and adolescent tool My Positive Health) as a tool for choice of treatment to gain insight into what child and parents find important.

 DO

• Treat electrolyte disorders, metabolic disturbances, dehydration, malnutrition.  
• Treat comorbidities, such as asthma and/or bacterial infections, pain and itching.
• With underlying depression, discuss therapeutic support. With underlying depression, discuss therapeutic support.
• For sleep disorders, promote strategies for regular sleep/wake rhythms.
• Avoid stimulants, such as caffeinated beverages.
• Recommend relaxation and distraction activities.

• With weight loss, consider treating the underlying cause.
• If Hb < 5, consider blood transfusion.  
• In sleep disorders, consider short-term treatment with short-acting benzodiazepines.
• Consider remediating potentially fatigue-inducing medications such as psychopharmaceuticals, antihistamines and beta-blockers.

 DO

• Provide psycho education focused on fatigue and strategies for coping with fatigue to the child and parents.

• Consider referral to a health care provider or psychologist with expertise in treating fatigue.

 DO

• Offer lifestyle advice aimed at fatigue in the areas of diet, exercise, and sleep.
• Emphasise the importance of balancing physical, mental activities, relaxation, and rest in a day.

• In case of physical fatigue, cognitive fatigue, or functional limitations, consider referral to an occupational therapist for an intervention aimed at optimising the balance between load and load capacity.

 DO

• Advise the child to move daily (out of bed) according to individual (physical) capabilities (including bedridden children).
• If desired and physically possible, offer the child an exercise/training program supervised by the (paediatric) physical therapist.

• Consider consultation or referral to a rehabilitation physician for an integrated (multidisciplinary) approach to fatigue and functional (physical) limitations.

 DO

• Recommend nutrition with adequate calories, protein and other nutrients to support energy needs during (exercise) intervention.

• Consider diagnosis and treatment of nutritional deficiencies because they may contribute to fatigue.
• Consider referral to a dietitian.

 DO

• Offer advice on sleep hygiene to create optimal conditions for good sleep.

• Consider offering the child and parents, e-health interventions focused on fatigue.

 
DO

• Keep in mind that there is no scientific evidence for pharmacological treatment of fatigue. If there is any effect at all, the effect often wears off quickly.

• In children with a limited life expectancy with fatigue, if treatment options are ineffective or if the aforementioned measures are not feasible, consider treatment with methylphenidate. Keep in mind possible side effects.

 DO

• Evaluate the effect and side effects of the treatment instituted at the appropriate time, and adjust treatment as needed. Involve child and family in this process.