4.1 Fatigue in children with IBD
The results of this study showed that the total fatigue score of children with IBD was 27.20±14.79, which was different from the results of Lucia [24], which might be related to racial differences. According to the study of Grossman [25], children with Crohn's disease of different races reported different levels of anxiety and fatigue.
In this study, the scores of various dimensions were compared, sleep/rest fatigue and general fatigue were at a higher level, while cognitive fatigue was at a lower level, which was the same as Marcus [21], possibly related to the fact that patients were more sensitive to physical symptoms than psychological symptoms. Found in the study of adult patients with IBD, fatigue is closely related to anxiety, depression and other emotional [26]. However, relevant studies in children are insufficient [27], so they are easily ignored. It suggests that we should not only pay attention to physical fatigue, but also psychological fatigue when managing fatigue symptoms in children with IBD.
4.2 Analysis of influencing factors of fatigue in children with IBD
4.2.1 Fatigue and region
The study suggests that the fatigue degree of children living in cities is lower than that in rural areas. The reason is that the income of urban population is higher than that of rural population [28], and the per capita income will affect the investment in health [29]. Moreover, the health literacy level of urban residents is generally higher than that of rural residents. In addition, high-quality medical resources are mostly concentrated in big cities, while rural medical and health resources are insufficient to form reasonable medical guidance, leading to lagging development of medical. In addition, in the construction of equal access to basic medical and health services in urban and rural areas, there are problems such as insufficient total supply and unbalanced supply structure, so rural residents have relatively limited access to public health resources compared with urban residents [30]. Therefore, children living in cities are more timely in disease diagnosis and treatment. In addition, parents of children in cities have more support from communities and schools than parents living in rural areas. There are more ways to acquire disease-related health knowledge and it is easier to understand these knowledge. Moreover, they can better master the methods of drug application and management for children, and also guide children to symptom management according to the relevant content of health education. They pay more attention to insist on regular follow-up and long-term control treatment, so fatigue symptom management of children is more scientific.
It is suggested that in addition to improving access to medical treatment in rural areas, targeted health education should be carried out for children in different areas, with special emphasis on disease management and fatigue symptom relief in rural children. Furthermore, More attention should be paid to the regular follow-up of children in rural areas to promote scientific symptom management and relieve fatigue symptoms of children.
4.2.2 Fatigue and age:
Our study shows that age is positively correlated with the degree of fatigue in children, which is the same as the Tomlinson’s study of cancer-related fatigue in children with hematopoietic stem transplantation [31]. From the perspective of social psychology, children gradually enter puberty from school age, which is a critical period of growth and development. They are facing great changes in body and mind, and are more sensitive to changes in all aspects of body and mind [32]. As the child grows, the understanding of the disease and the perception of symptoms increases. Furthermore, IBD negatively impacts on school attendance due to hospital attendance, disease burden and then causes school difficulties [33], as a consequence, cause greater psychological stress to children. In addition, disease symptoms such as abdominal pain and diarrhea cause great inconvenience in life, making children feel confused about their future, leading to irritability, low self-esteem, anxiety, depression and other emotions in children, affecting the disease management of children and aggravating children's fatigue. Needs of children with IBD must be addressed by ensuring effective partnership between education and health and targeting those with risk factors for poor attendance with preventative measures. This reminds us focus on the emotional and mental state of adolescent children, using strategies to minimize healthcare burden and provide more integrated care can directly impact service provision.
4.2.3 Fatigue and drug use:
This study showed that children treated with biologics had less fatigue than those not treated with biologics. This is similar to the results of Borren [34]. Borren studied the longitudinal trajectory of fatigue in patients who started biotherapy for more than one year, and the results showed that fatigue improved with the start of biotherapy and relief of clinical symptoms. At present, the only biological agent approved for clinical use in China is infliximab [35], which mainly targets soluble and transmembrane tumor necrosis factor (TNF)-α, which is a powerful pro-inflammatory cytokine and plays a role in the dysregulation of mucosal immune response in IBD [36]. Thus, infliximab may alleviate fatigue through cytokine action and may also alleviate fatigue by improving clinical symptoms in children.
The study found that the fatigue degree of children who used glucocorticoids was higher than that of those who did not, which was the same as the results of vanLangenberg et al. [37]. It was considered that the reason might be related to the serious side effects of corticosteroids. Studies have shown that corticosteroid treatment can lead to adrenal insufficiency in IBD patients, affect the healing of peptic ulcer, and increase the risk of respiratory tract infection and sepsis [38,39]. Therefore, in the future management of fatigue symptoms in children and adolescents, attention should be paid to drug use in children and timely treatment of drug side effects.
4.2.4 fatigue and BMI:
BMI are reliable indicators of protein energy malnutrition, and are simple and feasible methods for screening malnutrition. According to the diagnosis of BMI grade, this study showed that 46.67% of the children with IBD were malnourished. It is reported in foreign literature that the incidence of malnutrition in IBD is 16%, 85%, 85%, 100% in children with CD, who have a history of malnutrition [40,41]. This study shows that the fatigue symptoms of malnourished children are more serious than other children, which is the same as that of Whelan et al [42]. Inflammatory bowel disease is associated with anorexia. Typical symptoms include abdominal pain, diarrhea and vomiting. These symptoms further lead to discomfort and loss of appetite [43]. IBD children often lead to changes in dietary behavior due to hospitalization and dietary restrictions in order to control gastrointestinal symptoms. Further hinder dietary intake [44], which in turn aggravates the symptoms of fatigue. In addition, there are many micronutrient deficiencies in children with IBD, such as iron [45] and vitamin B12 [46]. These trace elements are closely related to fatigue symptoms. Therefore, a number of guidelines emphasize attention to the nutritional status of children with inflammatory bowel disease, and recommend enteral nutrition therapy as a first-line dietary source of CD-induced remission in mild to moderate children, emphasizing regular detection and timely correction of micronutrient levels [35,40,42]. However, in this study, there is no significant correlation between the use of enteral nutrition and the symptoms of fatigue in children. The reason may be related to the time and preparation of enteral nutrition, or to the size of the sample. A large sample study is needed to determine the relationship between the use or time of enteral nutrition and the symptoms of fatigue in children.
4.2.5 Fatigue and disease severity
Our study shows that children with moderate to severe disease severity are more fatigued than children with mild disease, which is the same as that of Pellino [47], but different from that of Chavarría [48]. Research tool to assess fatigue and disease activity. In addition, the sample size of the study and the type of study have an impact on the results of the study. Children with severe disease are often accompanied by severe clinical symptoms, such as abdominal pain and diarrhea, and the severity of the disease is closely related to children's anxiety, depression, and loneliness [49], while mental factors can directly affect the symptoms of fatigue [50]. Therefore, the severity of illness affects children's fatigue symptoms both physically and psychologically.
There are some limitations in this study. First of all, a cross-sectional survey was adopted in the study. Due to the limitations of the survey method, the causal relationship cannot be determined. In addition, due to the small sample size, the study results may be affected by confounding factors. Future studies with larger sample sizes are needed to confirm relevant conclusions. However, this study directly evaluated fatigue and related variables from the perspective of children, and identified multiple related factors of fatigue in children with IBD, providing a reference for further research and eventual clinical application. This study suggests that in addition to actively treating diseases and managing concurrent mental disorders, attention should also be paid to children's nutritional status and cognition of diseases, and personalized management methods should be provided.