Paeds · mental-behavioural-and-psychosomatic
Chronic fatigue and post-viral fatigue syndromes
Also known as Myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) · Post-viral fatigue · Post-COVID condition with fatigue · The tired teenager · Post-exertional malaise syndrome · Chronic fatigue syndrome in young people
A fellowship approach to chronic fatigue and post-viral fatigue in children and adolescents: separating post-viral fatigue from CFS/ME, recognising post-exertional malaise as the hallmark, the differential of the tired young person, a validating biopsychosocial assessment, function-first management (energy management, CBT, individualised activity), school reintegration, and the regional divide on graded exercise — across ANZ, UK, US and Canada.
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Target exams
Red flags
- New weight loss, fever, night sweats or anaemia in a 'tired' child — exclude organic disease before accepting a functional label
- Post-exertional malaise (a crash 24-72 hours after effort, out of all proportion to the trigger) — the hallmark of CFS/ME
- Syncope, presyncope or a marked postural tachycardia on standing — orthostatic intolerance may need cardiology
- Anhedonia, hopelessness or any self-harm in a tired adolescent — depression may be driving or complicating the presentation
- Severe or complete school absence lasting weeks — a marker of severity and a primary treatment target, not a coping choice
- A new or progressive neurological deficit, or headache that wakes the child — reassess; never let a functional label stop thinking
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Behavioural and mental-health presentations including chronic fatigue and post-viral syndromes
- Learning Goal 19 — Adolescent and young adult medicine: assess and manage chronic fatigue and refer appropriately
- Learning Goal 11 — Behaviour, development and mental health: recognise CFS/ME and post-viral fatigue and coordinate multidisciplinary care
- Renewed curriculum for first-year trainees from 2027 — Learning goal 7: Behavioural and mental health presentations including fatigue
- Behavioural Paediatrics and Mental Health
- Growth, Development and Behaviour
- Written Exam: the differential of the tired young person, diagnostic criteria for CFS/ME, and function-first management
- Long Cases — chronic fatigue in an adolescent with school absence and family conflict
- Short Cases — distinguishing post-viral fatigue from CFS/ME and from depression
- Communication stations — validating the illness, explaining post-exertional malaise, and negotiating a return-to-school plan
- Level 2 — Behavioural, emotional and mental health: recognises chronic fatigue and post-viral syndromes
- Level 3 — Adolescent health: manages CFS/ME with energy management and CBT and refers appropriately
- General Paediatrics: distinguishes fatigue from sleepiness, screens for organic disease and mood disorder
- Foundation of Practice (FOP) — chronic fatigue and post-viral fatigue syndromes
- Applied Knowledge in Practice (AKP) — diagnosis and management of CFS/ME and the differential of the tired adolescent
- TAS — biopsychosocial model, central sensitivity and adolescent mental health
- History and Communication — taking a fatigue and activity history and validating the illness
- Communication — counselling on energy management, pacing and a graded return-to-school
- Clinical — long case on the tired adolescent with school absence
- General Pediatrics Content Outline — Domain 7: Behaviour and Mental Health — chronic fatigue
- General Pediatrics Content Outline — Domain 3: Adolescent Care — the tired teenager
- General Pediatrics EPA 3: Providing adolescent care including assessment of persistent fatigue
- Medical Knowledge — recognise post-exertional malaise and CFS/ME diagnostic criteria
- Patient Care 1: History and Physical Examination — fatigue and activity assessment
- Medical Knowledge 2: Diagnostic Decision Making — differential of the tired young person
- Medical Knowledge: Adolescent medicine — CFS/ME, post-viral fatigue and post-COVID condition
- Systems-Based Practice 4: coordinating school liaison and multidisciplinary care
- Medical Expert — chronic fatigue and post-viral syndromes; CFS/ME diagnostic criteria
- Development, Behaviour and Mental Health (10-15%) — chronic fatigue
- Pediatrics: Foundations EPA — Adolescent care including fatigue assessment
- Communicator — validating the illness and negotiating energy management and school return
Overview & Definition
A 14-year-old girl returns to the general paediatric clinic eight weeks after a confirmed Epstein-Barr virus (EBV) infection. Her glandular fever settled, but she is still exhausted: she manages only half-days at school, sleeps twelve hours and wakes unrefreshed, and describes a "crash" for two days after PE. Her mother thinks she is depressed; her father thinks she needs to "push through." Ask the question that reframes the whole encounter — does exertion reliably make her symptoms worse the next day? — and you are doing paediatric chronic-fatigue medicine. [9]
Fatigue is a subjective sense of exhaustion that is not relieved by rest and that limits what a person can do. It is not the same as sleepiness (the tendency to doze, which points to a sleep disorder) or depressive anergia (low energy driven by anhedonia and low mood). Persistent fatigue is common after viral illness and usually resolves; in a minority it becomes a chronic, disabling, multi-system illness. The clinical task is to find out which tired child is which, and to resist both dismissal and premature labelling. [1]
The label itself has been contested for decades, and that matters clinically because the name carries stigma. Myalgic encephalomyelitis / chronic fatigue syndrome (ME/CFS) is a real, biologically grounded illness classified under neurological disorders in the WHO International Classification of Diseases (ICD G93.3). The Institute of Medicine's 2015 review concluded that ME/CFS is a "serious, chronic, complex, multisystem disease" and reframed the diagnosis around its cardinal feature — post-exertional malaise. The UK NICE guideline (NG206, 2021) applies the same logic to children. The examiner will reward a candidate who can hold three ideas at once: fatigue is real, it has a recognisable syndrome, and it is over-diagnosed as readily as it is under-diagnosed. [1]
[5]References10ShowHide
- [1]Carruthers BM, van de Sande MI, De Meirleir KL, Klimas NG, Broderick G, Mitchell T, Staines D, Powles AC, Speight N, Vallings R, Bateman L Myalgic encephalomyelitis: International Consensus Criteria. Journal of internal medicine, 2011.PMID 21777306
- [2]Nijhof SL, Bleijenberg G, Uiterwaal CS, Kimpen JL, van de Putte EM Effectiveness of internet-based cognitive behavioural treatment for adolescents with chronic fatigue syndrome (FITNET): a randomised controlled trial. Lancet (London, England), 2012.PMID 22385683
- [3]White PD, Goldsmith KA, Johnson AL, Potts L, Walwyn R, DeCesare JC, Baber HL, Burgess M, Clark LV, Cox DL, Bavinton J, Angus BJ, Murphy G, Murphy M, O'Dowd H, Wilks D, McCrone P, Chalder T, Sharpe M Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet (London, England), 2011.PMID 21334061
- [4]Larun L, Brurberg KG, Odgaard-Jensen J, Price JR Exercise therapy for chronic fatigue syndrome. The Cochrane database of systematic reviews, 2019.PMID 31577366
- [5]Collin SM, Norris T, Nuevo R, Tilling K, Joinson C, Sterne JA, Crawley E Chronic Fatigue Syndrome at Age 16 Years. Pediatrics, 2016.PMID 26810786
- [6]Moore Y, Serafimova T, Anderson N, King H, Richards A, Brigden A, Sinai P, Higgins J, Ascough C, Clery P, Crawley EM Recovery from chronic fatigue syndrome: a systematic review-heterogeneity of definition limits study comparison. Archives of disease in childhood, 2021.PMID 33846138
- [7]Zimmermann P, Pittet LF, Curtis N How Common is Long COVID in Children and Adolescents? The Pediatric infectious disease journal, 2021.PMID 34870392
- [8]Jason LA, Evans M, Brown A, Sunnquist M, Newton JL Chronic fatigue syndrome versus sudden onset myalgic encephalomyelitis. Journal of prevention & intervention in the community, 2015.PMID 25584529
- [9]Katz BZ, Reuter C, Lupovitch Y, Gleason K, McClellan D, Cotler J, Jason LA A Validated Scale for Assessing the Severity of Acute Infectious Mononucleosis. The Journal of pediatrics, 2019.PMID 30853204
- [10]Crawley EM Internet-based cognitive behavioural therapy (FITNET) is an effective treatment for adolescents with chronic fatigue syndrome. Archives of disease in childhood. Education and practice edition, 2012.PMID 22952037