What is the recommended management for dengue fever in children?

Management of Dengue Fever in Children

Children with dengue fever require risk-stratified management based on the presence of shock, with oral rehydration for stable patients and aggressive crystalloid resuscitation (20 mL/kg boluses) for dengue shock syndrome, while avoiding routine IV fluids in non-shock patients and NSAIDs in all cases. 1, 2

Initial Assessment and Risk Stratification

Classify patients into three categories to guide management:

• Dengue without warning signs: Stable vital signs, adequate oral intake, no concerning symptoms 1
• Dengue with warning signs: Severe abdominal pain, persistent vomiting, lethargy/restlessness, mucosal bleeding, high hematocrit with rapidly falling platelets 1, 2, 3
• Severe dengue/dengue shock syndrome: Hypotension, tachycardia, poor capillary refill, altered mental status, cold extremities, narrow pulse pressure 1, 4

Key warning signs that predict progression to severe disease include: 3, 5

• Lethargy (most accurate predictor with positive likelihood ratio >19) 5
• Hepatomegaly 3
• Abdominal distension and pleural effusion (sensitivity 82.6%) 5
• Hypoalbuminemia 5

Critical pitfall: The absence of hemoconcentration does not exclude plasma leakage, particularly in children who have already received fluid replacement at referral hospitals. 5

Fluid Management for Non-Shock Dengue

For children without shock, oral rehydration is first-line therapy: 1, 2, 4

• Encourage 5 or more glasses of fluid throughout the day, targeting approximately 2,500-3,000 mL daily, which reduces hospitalization rates 1, 4
• Use any locally available fluids including water, oral rehydration solutions, cereal-based gruels, soup, and rice water 1, 4
• Avoid soft drinks due to high osmolality 1, 4

Critical pitfall to avoid: 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

Management of Dengue Shock Syndrome

For children presenting with shock, immediate aggressive fluid resuscitation is life-saving and achieves near 100% survival when properly administered: 1

Initial Resuscitation Protocol

Administer 20 mL/kg of isotonic crystalloid (Ringer's lactate or 0.9% normal saline) as a rapid bolus over 5-10 minutes: 1, 2, 4

• Reassess immediately after each bolus for signs of improvement (decreased tachycardia and tachypnea) 1
• Repeat crystalloid boluses up to a total of 40-60 mL/kg in the first hour if shock persists 1, 4
• Crystalloids are first-line; colloids may provide faster shock resolution and require less total volume (mean 31.7 mL/kg versus 40.63 mL/kg for crystalloids) but clinical outcomes are similar 1

Critical monitoring during resuscitation: 1

• STOP fluid resuscitation immediately if hepatomegaly or pulmonary rales develop—this signals fluid overload requiring switch to inotropic support 1
• Rising hematocrit indicates ongoing plasma leakage and need for continued resuscitation 1, 4
• Falling hematocrit suggests successful plasma expansion 1

Management of Refractory Shock

If shock persists despite 40-60 mL/kg of crystalloid in the first hour, switch strategy from aggressive fluid administration to inotropic support rather than continuing fluid boluses: 1, 4

• For cold shock with hypotension: titrate epinephrine as first-line vasopressor 1, 4
• For warm shock with hypotension: titrate norepinephrine as first-line vasopressor 1, 4
• Target mean arterial pressure appropriate for age and ScvO2 >70% 1
• Begin peripheral inotropic support immediately if central venous access is not readily available, as delays in vasopressor therapy are associated with major increases in mortality 1

Critical pitfall: Delaying fluid resuscitation in established dengue shock syndrome significantly increases mortality—once hypotension occurs, cardiovascular collapse may rapidly follow. 1

Monitoring Parameters

Track these clinical indicators of adequate tissue perfusion: 1, 2, 4

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

Laboratory monitoring: 1

• Daily complete blood count to track platelet counts and hematocrit levels
• Be particularly vigilant during the critical phase (typically days 3-7 of illness) when plasma leakage can rapidly progress to shock 1, 2

Post-Resuscitation Fluid Management

After initial shock reversal, fluid removal may be necessary: 1

• Evidence shows that aggressive shock management followed by judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 1
• Consider continuous renal replacement therapy (CRRT) if fluid overload >10% develops, as outcomes are better when CRRT is initiated early 1

Critical pitfall: Avoid overhydration during the recovery phase, which can lead to pulmonary edema. 1

Supportive Care and Medications

Pain and fever management: 1, 4

• Use acetaminophen (paracetamol) ONLY for pain and fever management 1, 4
• Absolutely avoid aspirin and NSAIDs due to increased bleeding risk 1

Blood product support: 1, 2, 4

• Blood transfusion may be necessary in cases of significant bleeding 1, 2
• Target hemoglobin >10 g/dL if ScvO2 <70% 1, 4

Nutritional support: 1

• Resume age-appropriate diet as soon as appetite returns 1

Hospitalization and ICU Criteria

Hospitalize children with: 2

• Moderate to severe dengue, especially those with respiratory distress or hypoxemia 2

ICU admission is indicated for children with: 2

• Requirement for ventilatory support or impending respiratory failure
• Sustained tachycardia
• Inadequate blood pressure
• Altered mental status

Management of Complications

Pleural effusion and ascites: 6

• Common in dengue shock syndrome
• Avoid drainage if possible, as it can lead to severe hemorrhages and sudden circulatory collapse 6

Disseminated intravascular coagulation (DIC): 6

• May require supportive therapy with blood products (blood, fresh frozen plasma, and platelet transfusions) 6