What is the recommended fluid management strategy for children with dengue?

Fluid Management for Dengue in Children

For children with dengue shock syndrome, administer an initial bolus of 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) over 5-10 minutes, with immediate reassessment after each bolus and readiness to repeat up to 40-60 mL/kg in the first hour if shock persists. 1, 2

Risk Stratification and Initial Assessment

Before initiating fluid therapy, rapidly assess shock indicators:

• Signs of shock requiring immediate IV resuscitation: tachycardia, hypotension, poor capillary refill (>2 seconds), altered mental status, cold extremities, narrow pulse pressure 2, 3
• Warning signs of impending shock: persistent vomiting, severe abdominal pain, lethargy/restlessness, mucosal bleeding, rising hematocrit with rapidly falling platelet count 2, 3
• No shock present: oral rehydration is appropriate 2, 3

Fluid Management Protocol by Clinical Presentation

For Children WITHOUT Shock

Oral rehydration is the cornerstone of management for non-shocked dengue patients. 2, 3

• Target approximately 2,500-3,000 mL daily oral intake, which evidence demonstrates reduces hospitalization rates 2, 3
• Use any locally available fluids: water, oral rehydration solutions, cereal-based gruels, soup, rice water 2, 3
• Avoid soft drinks due to high osmolality 2, 3
• Critical pitfall: Do NOT give routine bolus IV fluids to children with "severe febrile illness" who are not in shock—this increases fluid overload and respiratory complications without improving outcomes 1, 2, 4

For Children WITH Dengue Shock Syndrome

Aggressive crystalloid resuscitation is life-saving and achieves near 100% survival when properly administered. 1, 2

Initial Resuscitation (First Hour)

• First bolus: 20 mL/kg of Ringer's lactate or 0.9% normal saline pushed rapidly over 5-10 minutes 1, 2
• Reassess immediately after each bolus for signs of improvement: decreased tachycardia, improved capillary refill, warming of extremities, improved mental status, rising blood pressure 1, 2, 3
• Repeat crystalloid boluses of 20 mL/kg if shock persists, up to a total of 40-60 mL/kg in the first hour 1, 2
• Stop fluid boluses immediately if signs of fluid overload develop: hepatomegaly, pulmonary rales, respiratory distress 1, 2

Choice of Fluid: Crystalloid vs. Colloid

The evidence shows nuanced differences between fluid types:

• For moderate dengue shock: Crystalloids (Ringer's lactate or normal saline) are first-line and highly effective 2, 5, 6
• For severe dengue shock: Colloids may provide faster shock resolution and require less total volume (mean 31.7 mL/kg vs. 40.63 mL/kg for crystalloids), though clinical outcomes are similar 1, 2, 7, 5
• If colloid is needed: Dextran 70 or 6% hydroxyethyl starch are options, though starch may be preferable due to fewer adverse reactions with dextran 7, 5, 6
• Practical approach: Most children with DSS can be successfully treated with crystalloids alone; reserve colloids for severe shock not responding to initial crystalloid resuscitation 2, 6

Monitoring Parameters During Resuscitation

Track these endpoints to guide ongoing therapy:

• Adequate perfusion indicators: normal capillary refill time (<2 seconds), absence of skin mottling, warm and dry extremities, well-felt peripheral pulses, return to baseline mental status, adequate urine output (>1 mL/kg/h) 2, 3
• Hematocrit monitoring: Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation; falling hematocrit suggests successful plasma expansion 1, 2, 3
• Daily complete blood counts to track platelet counts and hematocrit trends 2
• Critical phase awareness: Days 3-7 of illness represent the highest risk period for rapid progression to shock 2, 4

Management of Refractory Shock

If shock persists despite 40-60 mL/kg of crystalloid in the first hour:

• Switch strategy: Transition from aggressive fluid administration to inotropic support rather than continuing fluid boluses 2, 3
• Vasopressor selection based on hemodynamic state:
  • Cold shock with hypotension: titrate epinephrine as first-line 2, 3
  • Warm shock with hypotension: titrate norepinephrine as first-line 2, 3
• Target: Mean arterial pressure appropriate for age and ScvO2 >70% 1, 2
• Do not delay vasopressor therapy if central access is not immediately available—begin peripheral inotropic support, as delays significantly increase mortality 2

Post-Resuscitation Fluid Management

After initial shock reversal, a critical shift in strategy is required:

• Fluid removal may be necessary: Evidence shows that aggressive shock management followed by judicious fluid removal (using diuretics or peritoneal dialysis if oliguria develops) decreased pediatric ICU mortality from 16.6% to 6.3% 1, 2
• Avoid overhydration during recovery phase, which can lead to pulmonary edema 2
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early 1

Supportive Care

• Pain and fever management: Acetaminophen (paracetamol) only 2, 3
• Absolute contraindications: Aspirin and NSAIDs due to increased bleeding risk 2, 3, 4
• Blood transfusion: May be necessary for significant bleeding; target hemoglobin >10 g/dL if ScvO2 <70% 1, 2, 3
• Resume age-appropriate diet as soon as appetite returns 2

Critical Pitfalls to Avoid

1. Delaying fluid resuscitation in established dengue shock syndrome—once hypotension occurs, cardiovascular collapse may rapidly follow; blood pressure alone is not a reliable endpoint in children 2

2. Using restrictive fluid strategies in dengue shock syndrome—three RCTs demonstrate near 100% survival with aggressive fluid management; restrictive approaches have no survival benefit and may worsen outcomes 1, 2, 5

3. Continuing aggressive fluid boluses after signs of fluid overload appear—switch to inotropic support instead 1, 2

4. Giving bolus IV fluids to febrile children without shock—the FEAST trial context is important here; avoid routine boluses in "severe febrile illness" without established shock 1, 2

5. Failing to recognize the critical phase (days 3-7) when plasma leakage can rapidly progress to shock 2, 4

6. Draining pleural effusions or ascites—polyserositis is common in DSS; drainage should be avoided as it can lead to severe hemorrhage and sudden circulatory collapse 8