What is the recommended evaluation and management for a child with suspected dengue presenting to a clinic?

Evaluation and Management of Dengue in Children Presenting to Clinic

Immediate Diagnostic Testing

For children presenting within 7 days of fever onset, order dengue PCR/NAAT or NS1 antigen detection on serum as the preferred initial diagnostic test, because viral RNA and NS1 antigen are detectable during the acute phase and provide the highest sensitivity for early diagnosis. 1, 2

• NS1 antigen detection is detectable from day 1 to day 10 after symptom onset, with peak sensitivity of 75-90% during days 1-5, making it an excellent alternative when NAAT is unavailable 1, 2, 3
• For children with symptoms >7 days, IgM capture ELISA becomes the primary diagnostic test, as IgM antibodies appear 3-5 days after onset and remain detectable for 2-3 months 1, 2
• Document complete flavivirus vaccination history (yellow fever, Japanese encephalitis, Zika) to avoid false-positive IgM results from cross-reactivity 1, 2
• Before dengue testing, perform a rapid malaria test to exclude malaria in any febrile child from endemic regions 1

Clinical Assessment and Risk Stratification

Suspect dengue in any child with fever plus at least one of the following: nausea, vomiting, rash, headache, retro-orbital pain, myalgia, arthralgia, positive tourniquet test, or leukopenia—particularly with travel to or residence in endemic areas within the past 14 days. 1, 2

Warning Signs Requiring Immediate Hospitalization:

• Persistent vomiting preventing adequate oral hydration 1, 2, 4
• Severe abdominal pain or tenderness 1, 2
• Lethargy, restlessness, or altered mental status 1, 2
• Mucosal bleeding (epistaxis, gingival bleeding, hematemesis) 1, 2
• Rising hematocrit (>20% increase from baseline) with falling platelet count 1, 2, 4
• Thrombocytopenia ≤100,000/mm³ with rapid decline 1, 2
• Signs of shock: hypotension, pulse pressure ≤20 mmHg, cool extremities, capillary refill ≥3 seconds 1, 2

Additional High-Risk Criteria for Admission:

• Age >60 years or <1 year 1, 2
• Comorbidities: diabetes, hypertension (confers 2.16-fold higher risk of dengue hemorrhagic fever), heart disease, immunocompromised status 1, 2
• Pregnancy (increased risk of maternal death, hemorrhage, pre-eclampsia, vertical transmission) 1, 2, 4
• Family lives far from hospital or unreliable follow-up 1
• Inadequate home supervision or language barriers 1

Outpatient Management Criteria

Children may be managed as outpatients ONLY if ALL of the following are met:

• No warning signs present 1, 2
• No significant comorbidities 1, 2
• Platelet count >100,000/mm³ without rapid decline 1, 2
• Stable hematocrit without hemoconcentration 1, 2
• Reliable daily follow-up available 1, 2
• Family can maintain adequate oral hydration 1, 2

Laboratory Monitoring

Order daily complete blood count (CBC) to track platelet trends and hematocrit changes during the critical phase (days 3-7 of illness). 1, 2, 4

• Absence of thrombocytopenia significantly reduces the probability of dengue, making it a useful rule-out finding 1
• Monitor for hemoconcentration (rising hematocrit) as an early indicator of plasma leakage 1, 2

Supportive Care and Fluid Management

For Non-Shock Patients:

Encourage oral rehydration solutions targeting >2,500 mL daily intake to maintain adequate hydration. 1, 2

For Dengue Shock Syndrome:

Administer an initial isotonic crystalloid bolus of 20 mL/kg over 5-10 minutes, then reassess immediately for response. 1, 2

• Consider colloid solutions for severe shock when pulse pressure falls below 10 mmHg 1, 2
• Continuous cardiac telemetry and pulse oximetry monitoring are recommended for children in shock 1, 2

Pain and Fever Management

Use acetaminophen at weight-based dosing for analgesia and antipyresis; NEVER use aspirin or NSAIDs due to heightened bleeding risk with thrombocytopenia. 1, 2, 4

• Acetaminophen is the safest option for all pediatric patients, including pregnant adolescents 1, 2, 4
• Consider alternative cooling measures (tepid water sponging) if fever recurs rather than increasing acetaminophen dose 1

Discharge Criteria

Children may be safely discharged when ALL of the following are met:

• Afebrile for ≥48 hours without antipyretics 1, 2
• Resolution or significant improvement of symptoms 1, 2
• Stable hemodynamic parameters for ≥24 hours without support 1, 2
• Adequate oral intake and urine output (>0.5 mL/kg/hour) 1, 2
• Laboratory parameters returning to normal ranges 1, 2

Post-Discharge Instructions

Instruct caregivers to measure temperature twice daily and return immediately if:

• Two consecutive readings reach ≥38°C 1, 2
• Any warning signs develop (persistent vomiting, abdominal pain, lethargy, bleeding, decreased urine output) 1, 2
• Persistent vomiting preventing oral fluid intake 1, 2

Arrange repeat CBC and liver function tests 3-5 days after discharge. 1, 2

• If transaminases are 2-5× upper normal limit at discharge, monitor weekly 1
• If transaminases are >5× upper normal limit, monitor every 3 days initially 1

Special Considerations for Pregnant Adolescents

Test by NAAT for both dengue AND Zika viruses regardless of current outbreak patterns, because dengue infection during pregnancy raises the risk of maternal death, hemorrhage, pre-eclampsia/eclampsia, and vertical transmission. 5, 1, 2, 4

Common Pitfalls to Avoid

• Never prescribe aspirin or NSAIDs when dengue cannot be excluded 1, 2, 4
• Do not delay fluid resuscitation in children showing signs of shock 1, 2
• Do not assume acute infection based solely on positive IgG antibodies, as IgG persists for months to years 1, 2
• Do not rule out dengue based on a negative IgM test obtained during the first few days of illness, as IgM may not yet be detectable 1, 2
• Hospital admission criteria should be based on clinical warning signs rather than positive NS1 antigen test alone, as NS1 positivity does not predict severe dengue 6
• Avoid empiric antibiotics unless there is clear evidence of bacterial co-infection (which occurs in <10% of viral illness cases) 1

Differential Diagnosis

Consider other infectious etiologies including:

• Chikungunya, Zika virus (especially in arbovirus-endemic areas) 1, 2
• Malaria (must be excluded first in endemic regions) 1
• Rickettsial infections, leptospirosis 4
• Measles, rubella, parvovirus, adenovirus, enterovirus 1, 2