What is the recommended management for pediatric patients with dengue?

Dengue Management in Pediatrics

General Management Approach

Symptomatic management with careful fluid titration based on shock status is the cornerstone of pediatric dengue treatment, as there is no specific antiviral therapy available. 1

Supportive Care and Monitoring

• Avoid aspirin and NSAIDs due to increased bleeding risk; use acetaminophen (paracetamol) only for fever and pain management 1, 2
• Perform daily complete blood count monitoring to track platelet counts and hematocrit levels, particularly in patients at risk of progression to shock 1
• Resume age-appropriate diet as soon as appetite returns 1

Warning Signs Requiring Escalation

Monitor closely for progression to severe disease, especially during the critical phase (days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 3, 2:

• High hematocrit with rapidly falling platelet count 1
• Severe abdominal pain and persistent vomiting 1, 2
• Lethargy, restlessness, or altered mental status 1, 2
• Mucosal bleeding 1, 2
• Clinical fluid accumulation (ascites, pleural effusion) 2
• Tachycardia, hypotension, poor capillary refill 2

Fluid Management Algorithm

For Patients WITHOUT Shock

Oral rehydration is the first-line treatment for dengue patients without shock. 1, 2

• Encourage 5 or more glasses of fluid throughout the day, targeting approximately 2,500-3,000 mL daily 1
• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water; avoid soft drinks due to high osmolality 1
• Critical pitfall to avoid: Do NOT administer 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 1, 3, 2

For Patients WITH Dengue Shock Syndrome

Administer 20 mL/kg of isotonic crystalloid (normal 0.9% saline or Ringer's lactate) as the initial bolus over 5-10 minutes, with immediate reassessment. 1, 3, 2

Initial Resuscitation Protocol:

• First-line fluid: Isotonic crystalloid solutions (normal saline or Ringer's lactate) for all pediatric dengue patients with shock 3, 4
• If shock persists after initial bolus, repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour 1
• Colloid indications: Reserve for severe dengue shock syndrome with pulse pressure <10 mmHg or persistent shock despite adequate crystalloid resuscitation 3, 5
• If colloid is necessary, 6% hydroxyethyl starch is preferable to dextran 70 due to fewer adverse reactions, despite similar efficacy 6

Monitoring During Resuscitation:

Watch for clinical indicators of adequate tissue perfusion 1, 3:

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

Signs of Fluid Overload (STOP aggressive fluids):

• Hepatomegaly 1
• Rales on lung examination 1
• Respiratory distress 1

When fluid overload appears, switch to inotropic support instead of continuing aggressive fluid resuscitation 1, 3—this approach decreased pediatric ICU mortality from 16.6% to 6.3% in one study 7

Management of Refractory Shock

If shock persists despite adequate fluid resuscitation 1:

• Cold shock with hypotension: Titrate epinephrine as first-line vasopressor
• Warm shock with hypotension: Titrate norepinephrine as first-line vasopressor
• Target mean arterial pressure appropriate for age and maintain ScvO2 >70%
• Consider invasive monitoring in resource-rich settings to guide therapy

Management of Complications

• Blood transfusion may be necessary in cases of significant bleeding 1, 2
• Avoid overhydration during the recovery phase, which can lead to pulmonary edema 1

Evidence Quality Notes

The fluid management recommendations are based on high-quality randomized controlled trials 5, 6 showing that crystalloids are effective for moderate shock, with colloids providing faster resolution in severe cases but no mortality benefit. The largest trial (N=512) demonstrated that Ringer's lactate performs similarly to colloids for moderately severe shock with <0.2% mortality when managed appropriately 6. Do not use corticosteroids, as systematic review evidence shows they are ineffective for both dengue shock and early-stage dengue 8.