What information should be communicated to parents and included in the referral when a child with suspected dengue and warning signs (e.g., platelet count ≤100 000/mm³, rapid platelet fall, rising hematocrit, persistent vomiting, severe abdominal pain, mucosal bleeding, lethargy, or shock) requires hospital admission?

What to Communicate to Parents and Include in Referral for Children with Suspected Dengue Requiring Hospital Admission

When referring a child with suspected dengue and warning signs for hospital admission, parents must be informed that their child requires immediate hospitalization for close monitoring and intravenous fluid management to prevent life-threatening complications, and the referral must include specific clinical parameters—platelet count, hematocrit trend, vital signs, bleeding manifestations, and warning signs present—to guide the receiving team's triage and initial management. 1

Critical Information to Communicate to Parents

Reason for Admission and Expected Course

• Explain that the child has entered the "critical phase" of dengue (typically days 3-7 of illness), when plasma leakage and shock can develop rapidly, requiring hospital monitoring every 2-4 hours to detect early deterioration 2
• Inform parents that the critical phase typically lasts 24-48 hours, followed by spontaneous recovery in most cases with appropriate supportive care 2
• Emphasize that hospitalization is necessary because warning signs indicate increased risk of progression to severe dengue, including dengue shock syndrome, which requires immediate intravenous fluid resuscitation 1, 2

Warning Signs That Prompted Referral

Parents should understand which specific warning signs their child exhibited:

• Platelet count ≤100,000/mm³ or rapid platelet fall indicates increased bleeding risk and plasma leakage 1, 3
• Rising hematocrit (>20% increase from baseline) signals plasma leakage requiring urgent fluid management 1, 4
• Persistent vomiting prevents adequate oral hydration and increases dehydration risk 1, 3
• Severe abdominal pain may indicate hepatic involvement, plasma leakage, or internal bleeding 1, 3
• Mucosal bleeding (gum bleeding, epistaxis, melena) indicates hemorrhagic complications 1, 5
• Lethargy or restlessness suggests impending shock or neurological involvement 1, 3
• Clinical fluid accumulation (pleural effusion, ascites) indicates severe plasma leakage 3

What to Expect During Hospitalization

• The child will receive intravenous fluid therapy as the cornerstone of management, with frequent adjustments based on vital signs, hematocrit, and urine output 2, 4
• Monitoring will include: vital signs every 2-4 hours, daily complete blood counts to track platelets and hematocrit, urine output measurement (target >0.5 mL/kg/hour), and assessment of peripheral perfusion 1, 2
• Acetaminophen will be used for fever and pain relief; aspirin and NSAIDs are strictly contraindicated due to bleeding risk 1, 2
• Platelet transfusion is reserved for active significant bleeding or platelet count <10,000/mm³ with high bleeding risk, not given routinely for low counts alone 2, 5

When to Expect Discharge

Parents should know the child can be discharged when:

• Afebrile for ≥48 hours without antipyretics 1
• Resolution or significant improvement of symptoms 1
• Stable hemodynamic parameters for ≥24 hours without support (normal heart rate, blood pressure, capillary refill <3 seconds) 1, 2
• Adequate oral intake and urine output (>0.5 mL/kg/hour) 1
• Platelet count >50,000/mm³ and stable hematocrit 2
• Laboratory parameters returning to normal ranges 1

Post-Discharge Instructions to Emphasize

• Monitor temperature twice daily and return immediately if fever recurs (≥38°C on two consecutive readings) 1
• Return immediately for: persistent or recurrent vomiting, severe abdominal pain, bleeding manifestations, lethargy, cold extremities, or decreased urine output 1
• Follow-up with complete blood count and liver function tests at 3-5 days post-discharge if transaminases were elevated 1

Essential Components of the Referral Document

Patient Demographics and Presentation

• Age, weight, and day of illness (critical for determining critical phase timing) 1
• Travel or residence history in dengue-endemic areas within past 14 days 1
• Complete symptom timeline: fever onset, headache, retro-orbital pain, myalgia, arthralgia, rash, vomiting, abdominal pain 1

Vital Signs and Clinical Assessment

• Current vital signs: temperature, heart rate, respiratory rate, blood pressure, oxygen saturation 6, 2
• Perfusion status: capillary refill time, peripheral temperature, mental status (alert, lethargic, restless) 6, 2
• Hydration status: skin turgor, mucous membranes, urine output over past 6-12 hours 6
• Bleeding manifestations: petechiae, purpura, gum bleeding, epistaxis, melena, hematemesis, menorrhagia 1, 5
• Abdominal examination: hepatomegaly (liver enlargement is a critical warning sign in infants), tenderness, ascites 3
• Respiratory examination: signs of pleural effusion or respiratory distress 3

Laboratory Results with Trends

Critical to include baseline and trend data:

• Platelet count with trend over past 24-48 hours (e.g., "Day 3: 150,000/mm³ → Day 4: 80,000/mm³ → Day 5: 45,000/mm³") 1, 3
• Hematocrit with percentage change from baseline (e.g., "Baseline 38% → Current 46%, representing 21% increase") 1, 4
• Hemoglobin (elevated hemoglobin indicates hemoconcentration from plasma leakage) 2
• White blood cell count (typically normal or low; leukocytosis may indicate secondary bacterial infection) 7
• Liver transaminases (AST, ALT—commonly elevated in dengue) 2
• Serum creatinine (to assess renal function) 2
• Electrolytes (hyponatremia is common) 2

Diagnostic Confirmation Status

• Dengue testing performed: NS1 antigen (positive days 1-10), PCR/NAAT (positive days 1-7), or IgM antibody (positive after day 7) 1
• Results pending or confirmed: specify which test and when results expected 1
• Other diagnostic tests: malaria rapid test (to exclude malaria in endemic areas), blood cultures if secondary infection suspected 1, 7

Specific Warning Signs Present

Document which WHO 2009 warning signs are present:

• Abdominal pain or tenderness 1, 3
• Persistent vomiting (≥3 episodes in 24 hours) 1, 3
• Clinical fluid accumulation (pleural effusion, ascites) 1, 3
• Mucosal bleeding 1, 5
• Lethargy or restlessness 1, 3
• Liver enlargement >2 cm below costal margin 3
• Increase in hematocrit concurrent with rapid decrease in platelet count 3

Treatment Provided Prior to Transfer

• Fluids administered: type (oral rehydration solution, IV crystalloid), volume, and response 1, 4
• Medications given: acetaminophen dose and timing (document that aspirin/NSAIDs were avoided) 1, 2
• Any blood products: platelet transfusion, fresh frozen plasma, packed red blood cells 2, 5
• Oxygen therapy: if hypoxia present 6

High-Risk Features Requiring Immediate Attention

Flag these for urgent triage:

• Age <1 year (infants have higher risk; liver enlargement and clinical fluid accumulation are most discriminative warning signs) 3
• Comorbidities: diabetes, hypertension, heart disease, immunocompromised states (2.16 times higher risk of dengue hemorrhagic fever) 1
• Pregnancy (increased risk of maternal mortality, hemorrhage, preeclampsia, vertical transmission) 1
• Signs of impending or established shock: systolic BP <80 mmHg (or <70 mmHg if <1 year), narrow pulse pressure ≤20 mmHg, tachycardia, cool peripheries, prolonged capillary refill ≥3 seconds 6, 2
• Severe thrombocytopenia <20,000/mm³ with active bleeding 2, 5
• Hematocrit increase >20% from baseline 1, 4
• Metabolic acidosis (base deficit >8 mmol/L) or hyperlactatemia 6
• Hypoglycemia (<3 mmol/L or <54 mg/dL) 6
• Altered mental status (confusion, lethargy, irritability) 6, 1
• Respiratory distress: tachypnea, increased work of breathing, hypoxia (SpO₂ <95%) 6

Social and Logistical Considerations

• Distance from hospital: if family lives far from hospital, lower threshold for admission 6
• Ability to ensure follow-up: if reliable daily follow-up cannot be guaranteed, admission is preferable 6
• Social concerns: inadequate home supervision, inability to recognize warning signs, language barriers 6
• Contact information: reliable phone number for updates and discharge instructions 1

Age-Specific Considerations for Referral Communication

Infants (<1 Year)

• Highest risk group requiring lowest threshold for admission 1
• Most discriminative warning signs: liver enlargement (NPV 80.8%) and clinical fluid accumulation (NPV 75%) 3
• Emphasize to parents that infants can deteriorate rapidly and require intensive monitoring 3
• Document feeding tolerance and urine output (wet diapers per day) 1

Children (1-14 Years)

• Key warning signs: increase in hematocrit with rapid platelet decrease (NPV 76.6%), abdominal pain (NPV 72%), vomiting (NPV 70%), clinical fluid accumulation (NPV 69.3%) 3
• Explain that multiple warning signs significantly increase risk of severe dengue 3
• Document school absence duration and activity level changes 1

Adolescents (15-18 Years)

• Most discriminative warning sign: increase in hematocrit with rapid platelet decrease (NPV 91.9%) 3
• Other important signs: abdominal pain (NPV 80.7%), vomiting (NPV 75.7%), clinical fluid accumulation (NPV 82.7%) 3
• For females, document menstrual history (menorrhagia is a bleeding manifestation) 5

Common Pitfalls to Avoid in Referral Communication

• Do not reassure parents that "low platelets alone" require transfusion—platelet transfusion is indicated only for active significant bleeding or platelet count <10,000/mm³, not for asymptomatic thrombocytopenia 2, 5
• Do not delay referral while awaiting dengue test results if warning signs are present—treatment should not be delayed for diagnostic confirmation 1
• Do not minimize warning signs even if child appears well at moment of referral—dengue can deteriorate rapidly during critical phase 1, 4
• Do not prescribe aspirin or NSAIDs for fever or pain—document explicitly that these were avoided and only acetaminophen used 1, 2
• Do not recommend oral quinine for children if malaria co-infection suspected—it is unpalatable and poorly tolerated; refer for parenteral therapy 6