What is the recommended management for pediatric patients with dengue?

Dengue Management in Pediatrics

Initial Assessment and Risk Stratification

For pediatric dengue patients, begin with isotonic crystalloid solutions (normal saline or Ringer's lactate) as first-line therapy, reserving colloids specifically for severe shock with pulse pressure <10 mmHg or failure to respond to initial crystalloid resuscitation. 1

Fluid Management Based on Clinical Presentation

Non-Shock Dengue (Early Stage):

• Oral rehydration is appropriate for patients without signs of shock 2, 3
• Avoid routine bolus intravenous fluids in patients with severe febrile illness who are NOT in shock, as this increases risk of fluid overload and respiratory complications without improving outcomes 2
• Daily complete blood count monitoring is essential to track platelet counts and hematocrit levels 2

Dengue Shock Syndrome (DSS):

• Administer 20 mL/kg of isotonic crystalloid as the initial bolus over 5-10 minutes with immediate reassessment 1, 2
• If shock persists after initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour may be necessary 2
• For severe dengue shock syndrome with pulse pressure <10 mmHg, colloid solutions (dextran 70, hydroxyethyl starch, gelafundin, or albumin) provide better initial plasma volume support and faster resolution of shock (RR 1.09,95% CI 1.00-1.19) 1, 2
• Moderate-quality evidence shows colloids reduce the total volume of initial bolus needed (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) 2

The evidence here is nuanced: while a 2005 New England Journal of Medicine trial found similar efficacy between Ringer's lactate and colloids for moderate shock 4, and a 1999 trial showed colloids restored hemodynamics more rapidly 5, the most recent guidelines prioritize crystalloids first with colloids reserved for severe cases 1. This represents a shift toward more conservative colloid use given cost considerations (albumin costs ~140 Euro/L versus 1.5 Euro/L for saline) 1 and the finding that most DSS patients can be successfully treated with crystalloids alone 6.

Monitoring Parameters During Resuscitation

Watch for clinical indicators of adequate tissue perfusion: 1, 2

• Normal capillary refill time
• Absence of skin mottling
• Warm and dry extremities
• Well-felt peripheral pulses
• Return to baseline mental status
• Adequate urine output

Monitor for warning signs of progression to severe disease: 2

• High hematocrit with rapidly falling platelet count
• Severe abdominal pain
• Persistent vomiting
• Lethargy or restlessness
• Mucosal bleeding

Be vigilant during the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 2, 3

Management of Refractory Shock

For patients with persistent tissue hypoperfusion despite adequate fluid resuscitation: 2

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor 2
• Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor 2
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70% 2

Fluid Overload Management

Watch for signs of fluid overload: 2

• Hepatomegaly
• Rales on lung examination
• Respiratory distress

Do not continue aggressive fluid resuscitation once signs of fluid overload appear—switch to inotropic support instead 2. This is critical as overhydration can lead to pulmonary edema, particularly during the recovery phase 2.

Evidence from a 2005 Indian study demonstrated that aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 7, supporting the importance of balancing adequate resuscitation with prevention of fluid overload.

Supportive Care

• Avoid aspirin and NSAIDs due to increased bleeding risk 2, 3
• Blood transfusion may be necessary in cases of significant bleeding 2, 3
• Symptomatic management is the cornerstone as there is no specific antiviral therapy 2

Corticosteroids are NOT recommended: A Cochrane review found insufficient evidence to support corticosteroid use in either dengue shock or early-stage dengue, with no demonstrated benefit on mortality, shock development, or severe bleeding 8.

Critical Pitfalls to Avoid

• Delaying fluid resuscitation in patients with dengue shock syndrome leads to increased morbidity and mortality 1, 2
• Administering excessive fluid boluses in patients without shock causes fluid overload and respiratory complications 1, 2
• Failing to recognize the critical phase (days 3-7) when plasma leakage rapidly progresses to shock 1, 2, 3
• Using restrictive fluid strategies in established dengue shock syndrome—moderate-quality evidence shows no survival benefit, and restrictive fluids in severe malaria showed harm with increased need for rescue fluid (17.6% versus 0.0%; P<0.005) 9, 2