What are the guidelines for managing dengue in children?

Guidelines for Managing Dengue in Children

Initial fluid resuscitation with 20 mL/kg bolus of crystalloids is recommended for children with dengue shock syndrome, with subsequent patient reassessment to guide further management. 1, 2

Diagnosis

• Essential laboratory tests:
  • Complete blood count with hematocrit and platelets
  • Liver function tests
  • Coagulation tests
  • Specific diagnostic tests 2:
    • Acute phase (≤7 days): RT-PCR for dengue virus RNA and NS1 antigen detection
    • Convalescent phase (>5-7 days): IgM antibody detection or demonstration of fourfold rise/fall in IgG/IgM antibody titers in paired samples

Classification and Warning Signs

• Monitor for warning signs 2:
  • Intense abdominal pain
  • Persistent vomiting
  • Fluid accumulation (pleural effusion, ascites)
  • Mucosal bleeding
  • Lethargy or irritability
  • Hepatomegaly
  • Increased hematocrit with rapid decrease in platelet count

Fluid Management Algorithm

1. Non-Shock Dengue

• Oral rehydration is first-line for patients without shock
• IV fluids indicated if:
  • Unable to tolerate oral fluids
  • Persistent vomiting
  • Rising hematocrit despite oral hydration
• Initial IV rate: 5-10 mL/kg/hour of crystalloids 2
• Adjust based on:
  • Clinical status
  • Hematocrit trends
  • Urine output (target >1 mL/kg/hour) 2
  • Vital signs

2. Dengue Shock Syndrome

• Initial resuscitation: 20 mL/kg bolus of crystalloids 1, 2
• Reassess after initial bolus:
  • If improving: Reduce to 10 mL/kg/hour for 1-2 hours, then gradually decrease
  • If not improving: Repeat 20 mL/kg bolus or consider colloids
• For severe shock (based on moderate-quality evidence):
  • Consider 6% hydroxyethyl starch over dextran due to fewer adverse reactions 3
  • Monitor closely for signs of fluid overload

3. Monitoring During Fluid Therapy

• Vital signs: Every 15-30 minutes until stable, then hourly
• Hematocrit: Every 4-6 hours during critical phase
• Fluid balance: Strict input/output monitoring
• Clinical signs: Capillary refill, pulse volume, mental status
• Position patient: Semi-recumbent position (head elevated 30-45°) 2

Supportive Care

• Fever management: Acetaminophen/paracetamol only 2
• Avoid NSAIDs and aspirin due to increased bleeding risk 2
• Blood products:
  • Platelets: Consider if significant bleeding with thrombocytopenia
  • Fresh frozen plasma: For coagulopathy with bleeding
  • Packed red cells: For significant hemorrhage

Common Pitfalls to Avoid

• Overhydration: Can lead to pulmonary edema, pleural effusions, and respiratory distress
• Underhydration: May result in prolonged shock and organ damage
• Using NSAIDs: Increases bleeding risk
• Delayed recognition of shock: Monitor for early signs of compensated shock
• Failure to adjust fluid rates: Fluid requirements change rapidly during different phases of illness

Special Considerations

• Infants: More susceptible to fluid overload; require more careful fluid management
• Secondary infections: Higher risk for severe disease; monitor more intensively 2, 4
• Comorbidities: Adjust fluid management for patients with cardiac or renal disease

The evidence strongly supports that most children with dengue shock syndrome can be successfully treated with isotonic crystalloid solutions 5, with colloids reserved for severe cases or those not responding to initial crystalloid therapy. Mortality can be reduced to less than 0.5% with appropriate fluid management 2.