Treatment of Dengue in Pediatric Patients
The cornerstone of dengue treatment in pediatric patients is supportive care with careful fluid management, as there is no specific antiviral therapy currently approved for dengue. 1
Initial Assessment and Classification
- Assess for warning signs of severe dengue, including high hematocrit with rapidly falling platelet count, severe abdominal pain, persistent vomiting, lethargy or restlessness, and mucosal bleeding 1, 2
- Monitor for signs of shock, including tachycardia, hypotension, poor capillary refill, and altered mental status 2
- Daily complete blood count monitoring is essential, particularly to track platelet counts and hematocrit levels in patients at risk of progression to shock 1
Fluid Management
For Patients Without Shock
- Oral rehydration is appropriate for patients without signs of shock 1, 2
- Avoid routine use of bolus intravenous fluids in patients with "severe febrile illness" who are not in shock 1, 2
For Patients With Dengue Shock Syndrome
- Administer an initial fluid bolus of 20 mL/kg of isotonic crystalloid solution with careful patient reassessment afterward 1, 2, 3
- For severe dengue shock syndrome, colloid solutions may be beneficial when available 1
- For moderate dengue shock syndrome, crystalloid solutions are recommended as first-line 1
- Crystalloids are given as boluses as rapidly as possible, and 2-3 boluses may be needed in profound shock 4
- Colloids are indicated in patients with massive plasma leakage and in whom a large volume of crystalloids has been given 4
Monitoring Parameters
- Watch for clinical indicators of adequate tissue perfusion, including:
- Frequent recording of vital signs and determinations of hematocrit are important in evaluating treatment response 4
- A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock 4
Management of Complications
- For patients with persistent tissue hypoperfusion despite adequate fluid resuscitation, vasopressors such as dopamine or epinephrine may be required 1, 2
- Avoid overhydration, which can lead to pulmonary edema, particularly during the recovery phase 1
- Blood transfusion may be necessary in cases of significant bleeding 1, 2
- Oxygen therapy is mandatory in all patients with shock 4
- Some patients develop DIC and need supportive therapy with blood products (blood, FFP, and platelet transfusions) 4
- Polyserositis (pleural effusion and ascites) are common in dengue shock syndrome; if possible, drainage should be avoided as it can lead to severe hemorrhages and sudden circulatory collapse 4
Medication Considerations
- Avoid aspirin and other non-steroidal anti-inflammatory drugs due to increased bleeding risk 1
- Treatment with corticosteroids, carbazochorome sodium sulfonate, and recombinant activated factor VII have not been shown to reduce mortality in children with hemorrhagic dengue 5
Common Pitfalls to Avoid
- Administering excessive fluid boluses in patients without shock can lead to fluid overload and respiratory complications 1
- Failing to recognize the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 2
- Using aspirin or NSAIDs, which can worsen bleeding tendencies 1
- Delaying fluid resuscitation in patients with dengue shock syndrome 1
- Inadequate monitoring of patients during the critical phase of illness 1
Hospitalization Criteria
- Hospitalization is recommended for children with moderate to severe dengue, especially those with respiratory distress or hypoxemia 2
- ICU admission is indicated for children requiring ventilatory support, having impending respiratory failure, sustained tachycardia, inadequate blood pressure, or altered mental status 2
Early recognition and prompt treatment of shock are crucial for improving survival in pediatric patients with dengue 4, 6.