Pediatric Primary Care Case Studies, 1st Ed.

Chapter 5. An Adolescent with Fatigue

Dawn Lee Garzon

Fatigue is one of the most common adolescent complaints in primary care settings. A number of medical, behavioral, and psychosocial factors can produce this subjective complaint; therefore, pediatric healthcare providers must be able to differentiate among common causes of fatigue and determine the need for medical intervention for adolescents with this complaint.

Educational Objectives

1.  Consider adolescent development issues affecting both the diagnosis and treatment of fatigue.

2.  Describe the lifestyle factors that affect the incidence of adolescent fatigue.

3.  Describe the objective and subjective findings needed to establish a differential diagnosis in an adolescent with fatigue.

4.  Formulate a tailored plan of care to manage an adolescent with fatigue.

  Case Presentation and Discussion

Jennifer Styles is a 17-year-old who presents to your office with a complaint of “being tired all the time.” Jennifer admits that her fatigue has worsened significantly over the summer and is worried that she won’t make it through the day once school starts in a few weeks. She reports that she has two summer jobs, one at the community pool as a lifeguard and one where she helps babysit two school-age children. Jennifer is not accompanied by anyone else, but she says she can call her mother on the cell phone if “anyone needs her.” “But,” she tells you, “my mom thinks I have mono.”

What are the most common causes of fatigue in adolescents? image

Fatigue as a Symptom

Fatigue is a common somatic complaint that often presents with other symptoms like sleepiness, altered ability to focus, irritability, and weakness. By definition, fatigue is a sense of abnormal or excessive tiredness that results in a need for rest and results in an impaired ability to perform normal activities. It is one of the most common complaints in pediatrics and is especially prevalent during adolescence. Most teenagers complain of “being tired” at one time or another, and parents often complain that their adolescents seem exhausted or have very low energy. National studies show that 67% of adolescent females in 6th through 10th grade complain of morning fatigue at least once a week (Ghandour, Overpeck, Huang, Kogan, & Scheidt, 2004). The challenge of this condition is that fatigue can result from a self-limiting situation like staying up all night studying for final examinations, be a symptom of a mental illness like depression, or indicate the presence of a significant medical condition like anemia or cardiomyopathy.

Pathophysiology

There are multiple conditions that cause fatigue. It is the normal result of physical exertion or energy use that exceeds the body’s normal capacity (Ozuah & Sigler, 2001). Physiologic reasons for fatigue appear when the level of cellular metabolic need is greater than the cell’s adenosine triphosphate (ATP) stores, the body’s glucose or glycogen stores are depleted, metabolism is altered, or cerebral oxygenation is compromised. Busy school schedules, participation in extracurricular activities, inadequate sleep, inadequate caloric intake, substance use/abuse, and dysfunctional sleep patterns can all result in abnormally tired teens.

Many adolescents with fatigue experience symptoms as an abrupt complaint following an acute infection (Carter, Kronenberger, Edwards, Michalczyk, & Marshall, 1996). However, postinfectious fatigue can last for weeks to years. Illnesses that are known to cause fatigue include acute and chronic Epstein-Barr infection, cytomegalovirus, herpesvirus, human immunodeficiency virus (HIV), histoplasmosis, Mycoplasma pneumonia, toxoplasmosis, tuberculosis, rheumatoid arthritis, diabetes mellitus, cancer, Lyme disease, and hepatitis (Feins, 1999; Ozuah & Sigler, 2001; Tunnessen & Roberts, 1999).

Fatigue can also be a response to stress and is considered a symptom of depression.

Cultural Influences of Fatigue

Culture shapes and influences how individuals experience health symptoms and whether or not they seek medical attention. Fatigue is a universal human complaint and, therefore, occurs in all populations; however, there are some significant cultural variations that are worth noting. Some cultures value achievement and activity or “doing,” whereas others value just “being” (Giger & Davidhizer, 2004). Individuals from “doing” cultures may be less tolerant of fatigue symptoms and, therefore, are more likely to present to healthcare providers for treatment (Lubkin & Larsen, 2005; Ware & Kleinman, 1992). The belief that altered energy states should be treated to increase energy is also important. There are many homeopathic and complementary medical treatments used to combat fatigue that range from the use of herbal medications and dietary modification to guided imagery, meditation, and cognitive behavioral therapy.

Ghandour and associates (2004) conducted a population-based investigation of 8,250 U.S. teens and found racial/ethnic variation in the report of morning fatigue. In this study, the authors found that non-Hispanic white and Hispanic adolescents reported morning fatigue at least one to three times a week at higher rates than their Asian, non-Hispanic black, and Native American peers (38.3% and 34.2% versus 31.2%, 30.8%, and 26.5%, respectively).

Adolescent Development Factors

Adolescence has traditionally been described as a time to achieve four major milestones—separation from parents, establishment of peer relationships, achievement of sexual identity, and establishment of vocational goals for adulthood. Many authors have further broken down this 7 year or more phase of human development into three subunits—early, middle, and late adolescence—because teens do not achieve the four major goals along parallel trajectories. Rather, early teens are characterized as working on issues of physical development and comfort with one’s sexually maturing body and emerging sexual interests and behaviors, whereas middle teens are working to achieve parental separation and peer relationships with the opposite sex, and late teens are focused on development of intimate relationships with the opposite sex (or a single partner) and vocational choices and plans. The average 17-year-old is transitioning from middle to late adolescence.

Cognitively, following the traditional Piagetian characterizations, the adolescent can deal with abstract concepts, thoughts of the future, and goals rather than just dealing with concrete or current issues.

Gathering Key Data

History

When obtaining a patient history for a fatigue complaint, the primary care provider should carefully try to determine the presence of underlying illness and also to establish the degree of impairment caused by fatigue. Ideally, the health history should be obtained from the teen and parent separately. Especially important is the need to distinguish among senses of tiredness, activity intolerance, weakness, and lethargy (Tunnessen & Roberts, 1999). The health history should include the following: Diseases:

•  History of present illness/symptom analysis

image  Ranked scoring of energy level (scale of 1–10 sufficient)

image  Onset of and duration of symptoms (acute symptoms defined as less than 2 months whereas chronic is 2 months or more)

image  Associated symptoms including fever, rash, vomiting, abdominal pain, sore throat, myalgias, headache, back pain, polydipsia, polyuria, heart palpitations, and painful or swollen lymph nodes

image  Feelings of sadness, loss of interest in normal activities, impaired concentration, quality of affect, interaction with others, and stress levels

image  Alleviating/aggravating factors

image  Pharmacologic and nonpharmacologic treatments used and effectiveness of these therapies (special care should be paid to note medications that are known to cause tiredness, e.g., first-generation antihistamines)

image  Degree of impairment of normal activities (extracurricular, school, social) and presence of activity intolerance

•  Past medical history

image  Anemia, allergies, CNS disorders

image  Recent travel, insect/tick bites, or exposure to infectious disease

•  Review of systems

image  Menstrual history and sexual history (to determine likelihood of pregnancy)

image  Significant head injury, presence of dizziness, clumsiness

image  Alcohol, tobacco, and illicit drug use

•  Family history of diseases

Functional health patterns:

•  Nutrition: Appetite and 24-hour diet recall (note type and frequency of carbohydrate intake, caloric restrictions, caffeine use)

•  Sleep and rest: Thorough sleep history including normal sleep habits and the presence of insomnia or parasomnias

•  Psychosocial history

image  Job history and occupational exposures (note numbers of hours worked, time of day worked, and chemical/infectious exposures)

image  Family life issues

image  School issues

Developmental history:

•  Independence from parents

•  Peer relationships

•  Sexual patterns

•  Vocational issues

•  Cognitive level

Jennifer reveals that she has had no recent travel except for a weekend trip to the beach with her family. She denies fever and is able to keep up her daily routines despite her fatigue. There is no history of recent tick, mosquito, or other insect bites. No one at home is ill, and she has no known sick contacts. She denies feelings of sadness, impaired concentration, and alcohol, tobacco, or other substance use. Jennifer’s mom has hypothyroidism and takes “some pill once a day” to treat it.

Routine medications include daily use of a multivitamin with iron and ibuprofen 600 mg every 6 hours as needed for menstrual discomfort. She has seasonal allergies but is not currently taking medication for them. Jennifer reports that she is not currently sexually active and that she is currently menstruating so her last dose of ibuprofen was this morning. Her 24-hour diet recall is listed in Table 5-1. Jennifer states that she keeps a water bottle with her at work and she drinks at least 36 ounces of water a day. She denies constipation and diarrhea. She has no polyuria or dysuria.

Jennifer has an active social life and tries to get together with her friends “at least two to three times a week” but she has been “hanging out” with her closest circle of friends “most nights since summer is almost over.” Hanging out usually consists of meeting at a friend’s house, watching TV or playing video games, and listening to music. She is a senior in high school and achieves A and B grades without difficulty and anticipates going to college next year, though without a vocation in mind.

Jennifer has two jobs over the summer. She works 4 days a week at the local swimming pool. Her workday typically begins at 10 a.m. and ends around 6:30 p.m. Three days during the work week and one day on the weekend she babysits her neighbor’s two children in the evening. During the week, she goes from the pool directly to her neighbor’s and works until 10 p.m. On Saturday, she babysits from 7:30 a.m. until 4 p.m. She is allowed to sleep after the children go to sleep, but she is usually awake when the mother comes home because “their sofa is too uncomfortable to sleep on and I am usually chatting with my friends online.” Most evenings, Jennifer falls asleep around midnight, “but there are nights I watch movies until 2 a.m.” She sets her alarm to wake her at 7:30 a.m. but admits she often uses the snooze button three to four times before getting up. Jennifer falls asleep listening to her MP3 player, and she reports often awakening 2 to 3 hours after falling asleep to find her lights are on and her music is still playing.

Given these history findings, what is the most likely cause of Jennifer’s fatigue? image

Table 5–1 Jennifer’s 24-Hour Diet Recall

image

What additional questions regarding Jennifer’s sleep habits would help establish the diagnosis? image

Physical Examination Findings

Jennifer is a well-groomed adolescent with a normal affect. Her mental status is normal. Her height is 5′6″, and her weight is 145 pounds (BMI 23.4). There are no rashes or lymphadenopathy and her vital signs are normal. Skin tone is nonjaundiced and capillary refill is less than 2 seconds in all extremities. There is no nasal turbinate edema, her conjunctiva are noninjected, and her tympanic membranes and oropharynx are normal. Jennifer’s thyroid is nontender, normal sized, and without palpable lesions. There are no heart murmurs, and her heart rate is regular. Lung sounds are clear, and there are no signs of allergy, cyanosis, or clubbing. Both liver and spleen are nonpalpable, and the other abdominal exam findings are negative. Neurologic exam reveals 2+ deep tendon reflexes (DTRs) in all extremities with normal movement, strength, and sensation. All other exam findings are normal. Pelvic examination is deferred.

Is it possible Jennifer’s fatigue is caused by a significant medical condition? image

What diagnostic testing can be used to determine the cause of Jennifer’s fatigue? image

While performing the physical examination, Jennifer’s cell phone rings, and her mother asks to speak with you. The mother requests that you test Jennifer for mononucleosis and hypothyroidism because she first showed symptoms of hypothyroidism during her junior year of high school. You talk to Jennifer about her mother’s request, and Jennifer agrees to the testing. Laboratory findings are as follows:

image  Complete blood count (CBC): WBC 6.2 × 103/mm3 (normal), RBC 4.7 million/mL (normal), hematocrit 40% (normal), and hemoglobin 13.2 g/dL (normal).

image  Thyroid function tests: T4 7.2 µg/dL (normal), TSH 1.9 µIU/mL (normal).

image  Urinalysis: pH 5.0, specific gravity 1.020 and negative for nitrites, blood, sugar, bilirubin, and protein (normal UA).

image  Epstein-Barr titers and heterophile antibody: negative for acute and chronic infection.

Making the Diagnosis

In order to determine if the root of Jennifer’s symptoms is behavioral or physical, it is important to understand the clinical presentations of the most common causes of adolescent fatigue. In many instances, a detailed history and physical examination are all that are needed. Laboratory testing should be used to rule out serious illness and help narrow the differential diagnosis in cases where history and physical examination data prove inconclusive. Table 5-2contains a list of commonly used laboratory tests with clinical indications.

Table 5–2 Commonly Used Laboratory Tests Used to Establish the Diagnosis of Adolescent Fatigue

Laboratory Test

Indication

 

Complete blood count (CBC) with differential

Ill-appearing teens; unexplained fever; pallor, pica, or poor iron intake; suspected cancer; abnormal bleeding

Thyroid function testing (T4 and TSH)

Enlarged or tender thyroid, unexplained weight loss/gain, constipation/diarrhea, heat/cold intolerance

Throat culture

Cervical adenopathy, fever, exudative pharyngitis

Epstein-Barr titers or heterophile antibody test

Cervical adenopathy, exudative pharyngitis, splenomegaly, known contact with EBV-infected individual

Erythrocyte sedimentation rate

Chronic inflammation and suspected autoimmune disease, chronic infection, inflammatory bowel disease

Routine urinalysis

Dependent edema, oligouria, polyuria, polydipsia, polyphagia

Liver function tests

Jaundice, chronic abdominal pain, hepatitis exposure

Pregnancy test

Missed menstrual period, unprotected sexual activity

Drug screen


Suspected substance abuse, confusion, erratic behavior


Several common differential diagnoses and clinical presentations should be considered when adolescents present with fatigue. Mononucleosis, or Epstein-Barr virus (EBV) infection, is one of the most common causes of adolescent fatigue. Acute mononucleosis is characterized by marked sore throat, anorexia, anterior and posterior cervical adenopathy, fever, malaise, and myalgias. Approximately half of all cases may be accompanied by splenomegaly. Chronic mononucleosis follows acute symptoms and most often presents with marked fatigue, painful glands, and loss of appetite, although mild presentation of acute symptoms is possible (White, Sullivan, & Buchwald, 2004). Chronic EBV symptoms can last for up to 6 months following an acute episode. Positive EBV titers and heterophile antibody test (Mono Spot) indicate acute EBV infection, although up to 10% of adolescents with this disease will have a negative Mono Spot (Ozuah & Sigler, 2001). Complete blood counts indicate elevated white blood counts and may demonstrate the presence of atypical lymphocytes. In this case, Jennifer’s history, physical examination, and laboratory results are not consistent with this diagnosis. Because she has had symptoms all summer and the white blood cell counts are normal, it will not be necessary to repeat the EBV titer.

Depression impacts the lives of up to 5% of teens and is one of the most common causes of chronic fatigue (American Academy of Child and Adolescent Psychiatry, 2004; Green, 1998). The classic symptoms of depression include marked loss of interest in activities and feelings of sadness. However, also common are irritation, agitation, impaired concentration, decreased school performance, substance use, and risk taking. Jennifer does not report any of these symptoms, thus making this diagnosis unlikely.

Allergies can disrupt sleep, and many of the medications commonly used to treat allergies (especially first-generation antihistamines) cause drowsiness. Pale, boggy nasal turbinates; clear rhinorrhea; pharyngeal cobblestoning; nonexudative conjunctivitis; sneezing; and increased tearing are signs of allergic disease. Even though Jennifer does have seasonal allergies, she is not currently taking antihistamines and her physical examination does not support this diagnosis.

Anemia may occur secondary to dietary restriction (especially iron intake), infection, chronic illness, and idiopathic causes. Most older children and teens with anemia are asymptomatic, although complaints of fatigue, activity intolerance, and pallor are common. Adolescents are especially susceptible to iron-deficiency anemia because of increased metabolic needs and dietary habits. Jennifer’s CBC indicates that she is not anemic.

Behavioral causes of fatigue include excessive exercise, overscheduling, and caloric restriction. Adolescents often have busy academic lives, social obligations, sports activities, and jobs that, in combination, result in physical and mental fatigue. Adolescents are very body conscious and will commonly use caloric restriction as a means of losing weight quickly. Skipped meals, high caffeine intake that impacts sleep, and diets that are often too high in carbohydrates, both simple and complex, also cause fatigue. Jennifer’s 24-hour diet recall does not support caloric restriction as a cause of her fatigue, but her work schedule is rigorous and may be contributing to her symptoms.

Despite the need for 9 to 9½ hours of sleep each night, most teens sleep for only an average of 7 to 7½ hours (Mindell & Owens, 2003). The epidemic of fatigue caused by inadequate sleep is so great that as many as 68% of high school students report excessive daytime sleepiness (Kothare & Kaleyias, 2008). Work schedules, busy social calendars, and the need to finish school assignments often result in late bedtimes and fragmented sleep. Most high schools begin before 8:00 a.m., resulting in very early wake-up times, often as early as 5:00 a.m. (Mindell & Owens). Puberty causes increased sleep needs secondary to rapid growth and metabolic needs, and a resetting of the circadian sleep rhythms that result in teens actually becoming sleepy 2 hours later than their prepubertal peers (Mindell & Owens; Kothare & Kaleyias).

Based upon the history and physical findings in this case, the most likely cause of Jennifer’s fatigue is sleep deprivation.

Management

What additional information needs to be considered prior to making a management plan for Jennifer? image

Jennifer is actively working on her adolescent developmental milestones. In her case, she has achieved some degree of independence from her parents in that they trust her to visit your office unaccompanied and allow her to schedule her own activities fairly independently of the family. She is obviously very involved with peer relationships given her many phone, texting, and “hanging out” hours per week. Although not directly working on a future vocation, her two jobs indicate that she is working on issues related to employment—employee roles and responsibilities and financial gain. Her involvement with school indicates that she is a goal-directed young woman who is cognitively developing as predicted.

Given these characterizations, your plan will need to:

•  Acknowledge that she is the primary decision maker related to her problem, not her parents. (independence from parents developmental task)

•  Peer time needs to be assumed, though with adjustments. (peer relations task)

•  Her involvement with employment as well as school is important to maintain to some degree. (cognitive and vocational goals)

Therapeutic Management Plan

Sleep Hygiene Measures

Management of fatigue caused by poor sleep hygiene and insufficient sleep primarily focuses on behavioral modification and promotion of healthy sleep habits. Medications should be used for only brief periods of time and are not indicated for the majority of children.

The first step in forming an appropriate management plan is the determination of each adolescent’s practices that increase arousal and/or disrupt sleep cues (Mindell & Owens, 2003). Behaviors that arouse include caffeine intake, engaging in exercise in the late evening, watching television or playing video games while in bed, or trying to sleep in a nondarkened room. Behaviors that disrupt normal sleep cues include falling asleep while watching television or listening to music, spending long periods of time in bed while not sleeping, taking late naps, and sleeping in too late. Altered sleep cues are quite common during adolescence because most teens sleep too little during the work week, thus causing their “sleep clock” to be readjusted. This causes them to not feel sleepy until late evening to early morning (11:00 p.m. to 1:00 a.m.). Then, because they are so tired, they attempt to “make up” sleep on the weekends, thus resetting their sleep cycle even later. Sleep diaries are an excellent way to determine sleep patterns and behaviors and provide for greater depth of information than sleep recalls.

When you call Jennifer to give her the laboratory results, you ask her to keep a sleep diary and request a follow-up visit in 10 days. Jennifer’s sleep diary reveals that she routinely gets 5 to 6 hours of sleep on weekday nights, she naps for 4 to 5 hours on weekends, and rarely falls asleep until after midnight. Her diary also reveals that her sleep is disrupted at least twice a week by friends who call her cell phone or send text messages after 1:00 a.m.

Medications

There is little scientific evidence for best approaches to pharmacologic treatment of sleep problems in children and adolescents. Most medications used to treat sleep problems are prescribed without Food and Drug Administration (FDA) approval, also known as off label use (Pelayo & Dubik, 2008). Most teens do not require medications, but pharmacologic therapies should be considered in cases where there is significant trouble initiating or maintaining sleep. Because prescription hypnotics are not indicated for use in children younger than 18 years, primary care therapies for insomnia should be used for only brief periods and should focus on use of two types of medications: antihistamines and melatonin.

The first generation antihistamines are known for causing drowsiness. Diphenhydramine is the most common ingredient in over-the-counter sleep aids and has been shown to decrease time to sleep and number of night-time awakenings when taken shortly before sleep (Pelayo & Dubik, 2008). Peak blood levels typically occur within 2 hours of dosing, and average duration of activity is 4 to 6 hours (Pelayo & Dubik). Normal adult doses are 25 to 50 milligrams. Common side effects include dizziness and daytime drowsiness, although significant side effects are rare and diphenhydramine is considered to have a good safety profile. A small but significant number of children will actually have paradoxical arousal from this medication, so caution should be used with the first dose.

Melatonin is available over the counter and is given to mimic the normal secretion of melatonin by the pineal gland. Melatonin levels cycle in a circadian rhythm and are generally highest at night and lowest during the day (Pelayo & Dubik, 2008). Blood levels typically increase 1 to 2 hours prior to bedtime and are considered to be the final trigger for sleep (Wagner, Wagner, & Hening, 1998). Melatonin is indicated for use in jet lag, in blindness-induced circadian rhythm disturbances, and in delayed sleep patterns (Mindell & Owens, 2003). Adult doses of melatonin are 1 to 3 mg and demonstrate best response when taken 2 hours prior to sleep (Pelayo & Dubik). There are two important issues to consider with melatonin. First, it is considered a diet supplement and therefore is not regulated by the FDA for safety, purity, or efficacy (Wagner et al.). Second, the National Sleep Foundation warns against melatonin use in individuals with immunodeficiencies, lymphoproliferative disease, and those taking corticosteroids or immunosuppressants because of its effect of enhancing immune function (Toitu, 2001). Side effects include nausea, headache, and lightheadedness (Mindell & Owens).

How would you manage Jennifer at this time? image

Patient Education

The cornerstone of treatment for inadequate sleep is patient and family education about sleep needs and good sleep hygiene. Parents and adolescents must be taught that teens need 9 to 9½ hours sleep at night and that naps, when taken, should be brief (no longer than 30 to 45 minutes). Naps should only take place in the early afternoon. Sleep hygiene instruction should focus on developing good sleep schedules, making the bedroom “sleep friendly,” encouraging health habits, promoting bedtime routines, and avoiding sleep disturbances (Table 5-3).

You help Jennifer recognize that her sleep patterns are the most likely cause of her fatigue. Your education begins by talking to Jennifer about ways she might make her bedroom more sleep friendly. You teach her to turn off her cell phone and computer before going to bed. You suggest that she only go to bed when sleepy and that she listen to music before getting into bed. Jennifer agrees to go to bed once she feels sleepy and to not try to “fight” her sleep. She agrees to set routine sleep and awake times and to not deviate more than one hour from these times. You review healthy nutrition and suggest a routine exercise program in the mid to late afternoon. Jennifer’s mother commits to making sure she does not schedule evening activities and promises to help Jennifer wake up in the morning.

Once school starts, she will no longer work her lifeguard job. When babysitting, Jennifer decides to make phone calls and work on homework after her neighbor’s children go to sleep so that she can go to bed within 30 minutes of arriving home.

Lastly, you decide to have her try melatonin 3 mg PO at bedtime for the next week until her sleep routines are better regulated.

Is there anything else you would add to the plan at this time? image

Jennifer may need to make some adjustments in the time she spends with friends and the hours in which she talks with them. You and Jennifer need to agree upon a plan to inform her mother of the diagnosis and the plan that has been established.

When do you want Jennifer to follow up with you? image

Follow-Up Parameters and Expected Outcomes

Adolescents with fatigue should be followed closely until a cause of their fatigue is found. Parents and adolescents should be asked to keep in close contact with the healthcare provider and should return for re-evaluation if symptoms change or worsen. Most critical for prompt evaluation is the development of fever, activity intolerance, abnormal bleeding or bruising, or fatigue that suddenly worsens or persists beyond a few weeks. Psychiatric referral for evaluation is indicated for fatigue that lasts more than 3 months in afebrile adolescents with normal physical findings and laboratory results (Feins, 1999). Referral to sleep specialists is indicated for failure to respond within 1 month of establishing sleep routines, if primary care pharmacologic intervention fails or if prolonged pharmacologic treatment is required (Howard, 2001; Mindell & Owens, 2003).

Table 5–3 Good Sleep Hygiene for Adolescents

Hygiene Goals

Steps to Improve Sleep Area

 

Make the bedroom “sleep friendly”

Bed should be comfortable with clean sheets and adequate covers and blankets.

 

Temperature should be cool (less than 75 degrees).

 

The room should be quiet and dark.

Establish good sleep schedules

Teens should go to bed and awaken at approximately the same time each day.

 

Don’t move bedtimes more than one hour a day.

 

Limit naps to 30 to 45 minutes in the early afternoon.

 

Never let teens sleep past 10:00 a.m.

 

Don’t use “all nighters” when studying—learning is processed during sleep and memory is best after “sleeping on it.”

Encourage health habits

Routine exercise can help promote deep sleep, but vigorous exercise after 7:00 p.m. should be discouraged.

 

Don’t use caffeine, tobacco, and alcohol.

 

Eat a well-balanced diet and avoid eating less than 2 hours before sleep.

Promote bedtime routines

Only engage in “quiet” activities like reading, listening to calm music, and watching television for 30 to 60 minutes before sleep.

 

Eat a light snack or drink a glass of milk before bed, if hungry.

Avoid sleep disturbances

Turn off cell phones, computers, video games, televisions, and music prior to going to sleep.

 

Use shades, blinds, or sheets to darken east-facing bedroom windows.

 

Close doors and windows when noise might interrupt sleep.

Source: Table adapted from Mindell & Owens (2003) and Howard (2001).


You call Jennifer 2 weeks after her recheck appointment. She informs you that her fatigue is significantly decreased and she is no longer using the melatonin. She eliminated caffeine after 6:00 p.m. and implemented the sleep hygiene plan you created with her. You schedule a well examination in 3 months and tell her to call you if her symptoms recur or if she has questions or concerns.

Key Points from the Case

1. Fatigue is a complex symptom that is influenced by a number of factors.

2. Fatigue is a universal complaint that is especially common during adolescence.

3. It is essential that the evaluation of fatigue focuses on the diagnosis of underlying medical conditions that result in fatigue.

4. The most common cause of adolescent fatigue is insufficient sleep and poor sleep hygiene.

5. Adolescent sleep problems are best managed with behavioral modification and the development of good sleep habits. Medications should not be used in most cases and should be limited to use of antihistamines and melatonin in primary care settings.

6. The management plan needs to consider the adolescent’s developmental level and milestones currently being achieved in order to support those important activities of their age.

REFERENCES

American Academy of Child and Adolescent Psychiatry. (2004). Depression in children and adolescents. Washington, DC: American Academy of Child and Adolescent Psychiatry.

Carter, B. D., Kronenberger, W. G., Edwards, J. F., Michalczyk, L., & Marshall, G. S. (1996). Differential diagnosis of chronic fatigue in children: Behavioral and emotional dimensions. Developmental and Behavioral Pediatrics, 17(1), 16–21.

Feins, A. (1999). Fatigue. In R. A. Dershewitz (Ed.), Ambulatory pediatric care (3rd ed., pp. 913–915). Philadelphia: Lippincott-Raven.

Ghandour, R. M., Overpeck, M. D., Huang, Z. J., Kogan, M. D., & Scheidt, P. C. (2004). Headache, stomachache, backache, and morning fatigue among adolescent girls in the United States. Archives of Pediatric and Adolescent Medicine, 158, 797–803.

Giger, J. N., & Davidhizer, R. E. (2004). Transcultural nursing: Assessment and intervention (4th ed.). St. Louis, MO: Mosby.

Green, M. (1998). Pediatric diagnosis: Interpretation of symptoms and signs in children and adolescents. Philadelphia: WB Saunders.

Howard, B. J. (2001). Sleep disturbances. In R. A. Hoekelman, H. M. Adam, N. M. Nelson, M. L. Weitzman, & M. H. Wilson (Eds.), Primary pediatric care (4th ed., pp. 858–868). St. Louis: Mosby.

Kothare, S. V., & Kaleyias, J. K. (2008). The clinical and laboratory assessment of the sleepy child. Seminars in Pediatric Neurology, 15(2), 61–69.

Lubkin, I. M, & Larsen, P. D. (2005). Chronic illness: Impact and interventions. Boston: Jones and Bartlett.

Mindell, J. A., & Owens, J. A. (2003). A clinical guide to pediatric sleep: Diagnosis and management of sleep problems. Philadelphia: Lippincott, Williams & Wilkins.

Ozuah, P. O., & Sigler, A. T. (2001). Fatigue and weakness. In R. A. Hoekelman, H. M. Adam, N. M. Nelson, M. L. Weitzman, & M. H. Wilson (Eds.), Primary pediatric care (4th ed., pp. 1079–1084). St. Louis: Mosby.

Pelayo, R., & Dubik, M. (2008). Pediatric sleep pharmacology. Seminars in Pediatric Neurology, 15, 79–90.

Toitu, Y. (2001). Human aging and melatonin: Clinical relevance. Experts in Gerontology, 36, 1083–1100.

Tunnessen, W. W., & Roberts, K. B. (1999). Fatigue. In Tunnessen & Roberts (Eds.), Signs and symptoms in pediatrics (3rd ed., pp. 46–52). Philadelphia: Lippincott, Williams, & Wilkins.

Wagner, J., Wagner, M. L., & Hening, W. A. (1998). Beyond benzodiazepines: Alternative pharmacologic agents for the treatment of insomnia. Annals of Pharmacotherapy, 32, 680–691.

Ware, N. C., & Kleinman, A. (1992). Culture and somatic experience: The social course of illness in neurasthenia and chronic fatigue syndrome. Psychosomatic Medicine, 54, 546–560.

White, P. D., Sullivan, T. P. F., & Buchwald, D. (2004). The nosology of sub-acute and chronic fatigue syndromes that follow infectious mononucleosis. Psychological Medicine, 34, 499–507.