What should be included in a referral letter when referring a child with suspected dengue?

What to Include in a Referral Letter When Referring a Child with Suspected Dengue

When referring a child with suspected dengue to hospital, your referral letter must document vital signs with perfusion markers, warning signs of severe disease, laboratory values (especially platelet count and hematocrit), hydration status, and social factors that affect follow-up capability.

Essential Clinical Information to Document

Current Vital Signs and Hemodynamic Status

• Record temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation to allow the receiving team to assess hemodynamic stability 1
• Document perfusion status including capillary refill time, peripheral skin temperature, and mental status (alert versus lethargic/restless) as early indicators of shock 1
• Flag signs of impending or established shock: systolic blood pressure <80 mmHg (or <70 mmHg in infants <1 year), pulse pressure ≤20 mmHg, tachycardia, cool extremities, and capillary refill time ≥3 seconds 1

Warning Signs of Severe Dengue

• Persistent vomiting that prevents oral fluid intake 2, 1
• Abdominal pain or tenderness 3
• Mucosal bleeding (epistaxis, gum bleeding, hematemesis, melena) 3
• Lethargy, restlessness, or altered mental status (confusion, irritability) as indicators of possible severe dengue or encephalopathy 1
• Respiratory distress (tachypnea, increased work of breathing, SpO₂ <95%) as a sign of plasma leakage or secondary complications 1

Hydration Assessment

• Include hydration status with skin turgor, mucous membrane moisture, and urine output over the preceding 6-12 hours to guide fluid resuscitation decisions 1

Laboratory Values (If Available)

• Platelet count and trend (especially if ≤100,000/mm³ or rapidly declining) 3
• Hematocrit level and any rise from baseline (>20% increase suggests plasma leakage) 3
• Liver transaminases (SGOT/SGPT elevation, particularly if associated with hepatomegaly) 4
• Blood glucose level if checked, as hypoglycemia (<3 mmol/L or <54 mg/dL) is a critical risk factor requiring urgent correction 1
• Metabolic markers such as base deficit >8 mmol/L or hyperlactatemia indicating metabolic acidosis 1

Diagnostic Test Results

• Dengue PCR/NAAT or NS1 antigen results if performed (for symptoms ≤7 days) 3
• IgM antibody test results if performed (for symptoms >7 days) 3
• Note that malaria testing should be performed first in any febrile traveler from endemic regions before assuming dengue 1

High-Risk Features Requiring Urgent Attention

Comorbidities and Age-Related Risk

• Age >60 years or <1 year (higher risk of complications) 2, 3
• Diabetes with hypertension (2.16-fold higher risk of dengue hemorrhagic fever) 3
• Heart disease, immunocompromised status (increased risk of decompensation and disease progression) 3

Social and Logistical Factors

• Family resides a long distance from the hospital, as delayed access to care increases risk of deterioration 1
• Reliable daily follow-up cannot be guaranteed during the critical phase (days 3-7 of illness) 1
• Home supervision is inadequate, caregivers cannot reliably recognize warning signs, or language barriers exist to prevent missed escalation 1

Clinical Course and Treatment Given

Symptom Timeline

• Day of symptom onset and current day of illness (critical phase is typically days 3-7) 3
• Fever pattern and duration 4
• Associated symptoms: headache, retro-orbital pain, myalgia, arthralgia, rash, gastrointestinal symptoms 3, 4

Treatments Already Administered

• Fluids given (oral or intravenous, volume, type) 5
• Acetaminophen dosing (the only safe analgesic for dengue) 5
• Confirm NO aspirin or NSAIDs were given due to catastrophic bleeding risk 5
• Any other medications administered 5

Reason for Referral

State explicitly why hospital admission is needed, such as:

• Severe plasma leakage, severe bleeding, or organ failure 5
• Dengue shock syndrome (hypotension, narrow pulse pressure ≤20 mmHg) 3
• Persistent vomiting preventing oral hydration 5
• Rapidly declining platelets or rising hematocrit with falling platelets 3
• Inability to ensure reliable daily outpatient monitoring 1
• High-risk comorbidities requiring lower threshold for admission 3

Common Pitfalls to Avoid

• Do not delay referral while awaiting laboratory confirmation if clinical signs of shock are present 5
• Never prescribe oral quinine for children with suspected malaria co-infection; parenteral antimalarial therapy is recommended 1
• Avoid empiric antibiotics unless there is clear evidence of bacterial co-infection (occurs in <10% of viral illness cases) 5
• Do not assume dengue is ruled out by a negative IgM test obtained during the first few days of illness 3