Chronic fatigue syndrome in children
Introduction
Despite the Chief Medical Officer's (CMO) report1 chronic fatigue syndrome/myalgic encephalopathy (CFS/ME) remains a controversial condition. The Australian Medical Association rightly describes it as an illness that causes significant disability both in adults and children,2 but is not a disease such as meningoccocal meningitis where aetiology, pathophysiology and treatment are clearly understood. Moreover it is a condition with significant morbidity causing more time to be lost from school than any other childhood condition including malignancies.3
In this article current views on aetiology and management of the syndrome will be reviewed and areas for future research discussed.
Section snippets
Demography
United Kingdom prevalence studies suggest that approximately 0.05–0.2% of children and adolescents are affected by CFS/ME.4 This equates to approximately one or two children in each secondary school in the United Kingdom being affected by the condition at any one time. Similar prevalence figures are given for the United States and Australasia.5, 6 The condition seems to be more common in girls. In the paper by Haines et al.7 the incidence was similar in boys and girls between the ages of 5 and
Diagnosis
There are two frequently used diagnostic criteria for CFS (Box 1, Box 2).11, 12 Both state that the fatigue must be debilitating, present for at least 6 months and cause some degree of functional impairment and that there must not be any other clinical condition that could account for the fatigue. The, soon to be published, Royal College of Paediatrics and Child Health (RCPCH) guidelines on the management of CFS/ME suggest that the investigations outlined in Box 3 should be performed as
Symptomology
There have been two studies in the United Kingdom that have specifically looked at the symptoms that occur in young people with CFS/ME. G. Saidi & L. Haines (unpublished results), in a cross-sectional survey in primary care, found that in addition to fatigue, 69% of their study group had sore throats, 65% headaches, 58% mood disturbance, 57% sleeping difficulties, 44% myalgia, 39% abdominal pain, 37% nausea and vomiting and 32% concentration difficulties. Other symptoms such as joint pain,
Aetiology
Despite extensive research there is no consensus on the cause of CFS/ME: it is likely that in such a heterogeneous condition no one single cause will be found. However, many theories as to its aetiology have been proposed, some of which have a scientific basis (see below):
- (1)
Infection. Self-reporting of symptoms prior to the onset of CFS/ME has suggested that infections may be an important predisposing factor in the development of CFS/ME. A variety of agents have been implicated including
Management
Unfortunately, all the therapies reported in adults have been based on small studies, which have been poorly designed and have given contradictory results. There have been very few studies undertaken in children and adolescents, which makes the extrapolation from the adult data very difficult. What is very clear is that whatever treatment plan is embarked upon there must be a collaborative approach involving closely the parent and the child in the decisions about treatment options. This is
Outcome
In a tertiary setting, Rangel et al. described the mean duration of symptoms to be just over 3 years44 and others have suggested a longer duration of symptoms of up years.45 In the more severely affected children, up to 30% have symptoms resistant to treatment that lasted for years.46 However, most children have a better prognosis. One sample of paediatric outpatients had a good overall outcome in nearly 95% of cases.47 Carter et al.'s48 case series reported that in children with fatigue of
Future research
It is quite apparent that the quality of current research in CFS/ME is poor; with most papers either being observational, case series, or very small randomised controlled trials. The RCPCH clinical guidelines will confirm the paucity of research work in that only seven out of the 45 recommendations to be published are based on good or at least reasonable quality evidence. Larger trials are necessary to have the necessary power to answer many of the outstanding questions in relation to aetiology
Conclusions
Chronic fatigue syndrome is an illness that causes significant morbidity at a crucial time in a young person's growth and development. Its treatment remains a challenge to paediatricians. With good management, many teenagers will improve or make a complete recovery. There is an urgency for further research work to determine aetiology and optimum treatment of this condition in young people.
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