What is the recommended management for dengue fever in children?

Management of Dengue Fever in Children

The management of dengue fever in children should focus on appropriate fluid therapy, close monitoring for warning signs, and supportive care, with crystalloids as the primary fluid of choice and careful avoidance of NSAIDs due to bleeding risk. 1

Diagnosis and Assessment

• Consider dengue testing in children with fever plus one or more symptoms:

  • Nausea/vomiting
  • Rash
  • Headache
  • Retro-orbital pain
  • Myalgia/arthralgia
  • Positive tourniquet test
  • Leukopenia
  • Warning signs of severe disease 1

• Key laboratory findings:

  • Thrombocytopenia (low platelet count)
  • Leukopenia
  • Elevated hematocrit (indicating hemoconcentration)
  • Elevated liver enzymes 1

• Diagnostic tests:

  • Acute phase (first 5 days): RT-PCR for dengue virus RNA or NS1 antigen detection
  • Convalescent phase: IgM antibody detection or demonstration of fourfold rise/fall in antibody titers 1

Treatment Algorithm

1. Mild Dengue (No Warning Signs)

• Fluid management:
  • Encourage oral fluids
  • Monitor for warning signs
  • Avoid aspirin and NSAIDs (use acetaminophen for fever and pain) 1

2. Dengue with Warning Signs

• Warning signs include:

  • Abdominal pain or tenderness
  • Persistent vomiting
  • Clinical fluid accumulation
  • Mucosal bleeding
  • Lethargy or restlessness
  • Liver enlargement
  • Increasing hematocrit with rapid decrease in platelet count 1

• Management:

  • Initiate crystalloid fluid therapy at 5-10 ml/kg/hour
  • Adjust rate according to clinical response
  • Monitor vital signs every 15-30 minutes during rapid fluid administration
  • Document weight, vital signs, baseline hematocrit, urine output, and respiratory status 1

3. Severe Dengue/Dengue Shock Syndrome

• Initial resuscitation:

  • Administer crystalloid fluid bolus of 20 ml/kg as rapidly as possible
  • May need 2-3 boluses in profound shock 2, 3
  • Consider colloids (including albumin) in patients with massive plasma leakage or when large volumes of crystalloids have been given 3

• Monitoring:

  • Frequent vital signs assessment
  • Serial hematocrit determinations
  • Urine output monitoring
  • Oxygen administration in all shock patients 3

• Blood product support:

  • For patients who develop DIC: blood, fresh frozen plasma, and platelet transfusions as needed 3

Special Considerations

Fluid Management Pitfalls

• Signs of fluid overload:

  • Increasing respiratory rate with normal/falling hematocrit
  • New crackles on lung examination
  • Rising JVP
  • New onset hepatomegaly
  • Peripheral edema 1

• Action: Reduce or stop intravenous fluids if hemodynamically stable 1

High-Risk Groups

• Children require closer monitoring and are more susceptible to fluid overload 1
• Pregnant women are at higher risk of complications and require more intensive surveillance 1
• Older children with comorbidities may require more aggressive management 1

Polyserositis Management

• Pleural effusion and ascites are common in dengue shock syndrome
• Drainage should be avoided if possible as it can lead to severe hemorrhages and sudden circulatory collapse 3

Discharge Criteria

• No fever for 48 hours without antipyretics
• Improving clinical status
• Increasing platelet count
• Stable hematocrit
• No respiratory distress
• Good urine output 1

Prevention

• Protect patients from further mosquito exposure to prevent transmission 1
• After initial infection, patients are only immune to the specific dengue serotype they contracted, not to other serotypes 1

The key to successful management is frequent monitoring and adjusting treatment strategies based on the patient's clinical response. Early recognition and treatment of shock significantly improves prognosis 3. Myocardial dysfunction may occur in some cases (16.7% in one study), so cardiac function assessment should be considered in patients with persistent hypotension despite adequate hydration 4.