Current Problems in Pediatric and Adolescent Health Care
Adolescent Fatigue, POTS, and Recovery: A Guide for Clinicians
Introduction
Fatigue is common during adolescence, with 31% of American adolescents experiencing significant morning tiredness more than one day each week.1 A significant number of affected individuals are unable to participate in some routine daily activities2 or are debilitated with fatigue.3 Wolbeek et al.2 found that approximately 20% of adolescent Dutch girls and 6% of adolescent Dutch boys reported experiencing severe fatigue, with almost 50% of those girls and 35% of those boys reporting fatigue lasting greater than 3 months. Consequently, adolescent fatigue is a common presenting complaint in clinics around the world. In these tired patients, the diagnosis of chronic fatigue is evident based on the clinical course and examination findings that do not reveal any other worrisome fatigue-causing condition.
In our practices, we frequently encounter chronically fatigued patients who also report symptoms of dizziness, lightheadedness, nausea, vomiting, sleep disturbances, pain, altered mental quality (sometimes described as “brain fog”), or altered temperature sensations as well as changes in sweating and purplish skin discoloration in dependent extremities. Many of these symptoms are autonomic in nature and suggest some sort of autonomic dysfunction in this group of patients. There is increasing evidence that chronic fatigue is often accompanied by significant dysfunction in the autonomic nervous system. It seems likely that chronic fatigue and autonomic dysfunction are often overlapping conditions.
Autonomic dysfunction is a broad umbrella term for conditions involving abnormally altered regulation of the involuntary nervous system. Postural orthostatic tachycardia syndrome, POTS, is a type of autonomic dysfunction characterized by chronic fatigue, orthostatic intolerance, and excessive postural tachycardia. Some other different and distinct types of autonomic dysfunction are neurocardiogenic syncope, pure autonomic failure, and orthostatic hypotension. In clinical practice, the terms “autonomic dysfunction” and “POTS” are sometimes used interchangeably. Nonetheless, some physicians do not yet recognize POTS as a legitimate physical diagnosis.
Each patient with debilitating fatigue or POTS is unique, but their stories often sound similar.26 Parents and adolescent patients with POTS often describe the long and difficult process they experience from the moment they became ill to decreased school attendance with dropped extracurricular activities and poor academic performance to visiting a variety of doctors and, frequently, numerous medical centers in order to find answers about their child׳s illness. In this process, they often receive different diagnoses, try numerous medications, and sometimes even undergo surgical procedures. As a result, there are significant social and economic consequences related to undiagnosed POTS. Without accurate and timely diagnosis, education, and motivation to incorporate new healthy living practices into their lives to remediate their symptoms, affected adolescents are at heightened risk for academic decline, truancy, and delayed graduation from high school and college. This condition takes a financial toll on families due to personal costs related to multiple health care visits, out-of-pocket expenses for non-insurance-covered integrative alternative therapies, missed work, and travel expenses to multiple medical centers for care.
This article pulls together input from the world׳s medical and psychologic literature combined with the experiences of the 14 authors who represent general pediatrics and nine pediatric sub-specialties at five institutions on two continents. In so doing, we explore links between fatigue and autonomic dysfunction as well as relationships between fatigue and multisystem symptoms. We seek to provide a broad understanding of the underlying pathophysiology of chronic fatigue and autonomic dysfunction that will help readers understand multidisciplinary treatment modalities that offer affected adolescents good hope for full recovery.
Section snippets
Definitions, Incidence/Prevalence, and Factors Associated With Fatigue
Chronic fatigue (CF) is common in adolescents. The classification of chronic fatigue ranges from prolonged fatigue (>1-month duration) to chronic fatigue syndrome (CFS). CFS is characterized by 6 or more months of debilitating physical and mental fatigue for which an alternate medical and psychiatric explanation is lacking. The current case definition of CFS and the conceptual framework for its study was proposed by the International Chronic Fatigue Syndrome Study Group at the Centers for
Autonomic Abnormalities in “Chronic Fatigue” Patients
Our chronically tired patients often have findings suggestive of autonomic dysfunction, and others have reported similar observations. Dizziness, palpitations, diarrhea, and even nocturia have been reported as common symptoms experienced by patients with CFS.25 In addition, patients with postural orthostatic tachycardia syndrome, a clinical manifestation of autonomic dysfunction, often report chronic fatigue.26
The association between chronic fatigue and autonomic abnormality was first
Organization of Care for Patients With POTS
Patient and family education is vital in the care of adolescents with POTS and must be incorporated into the multidisciplinary programs where POTS patients are evaluated and treated. This is especially important as the treatment plan for POTS needs to be multidisciplinary and no single medication or treatment is adequately effective. Patient education must be designed to improve the family׳s knowledge of POTS along with promoting teen health behavior change. Patients and their parents often
Conclusion
Thus, many adolescents are tired, even chronically fatigued. Sometimes, the fatigue is the consequence of a concurrent medical condition, inadequate sleep habits, or coexisting psychological challenges. Often, however, the fatigue persists in the absence of other identifiable medical conditions. Increasingly, however, autonomic dysfunction is identified in chronically tired teenagers with its constellation of orthostatic intolerance and excessive postural tachycardia. Even while research
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