How should a 10‑year‑old boy on day 3 of confirmed dengue presenting with left retro‑orbital pain, early satiety, loss of appetite, and post‑prandial intestinal cramping be evaluated and managed?

Management of Day‑3 Dengue with Retro‑Orbital Pain and Gastrointestinal Symptoms in a 10‑Year‑Old

This child is entering the critical phase (days 3–7) and presenting classic warning signs—retro‑orbital pain, anorexia, and post‑prandial cramping—that mandate daily monitoring for progression to severe dengue, aggressive oral hydration exceeding 2500 mL/day, acetaminophen‑only analgesia, and immediate hospital referral if persistent vomiting, abdominal tenderness, lethargy, or bleeding develop. 1, 2, 3

Immediate Risk Stratification

Current Warning Signs Present

• Left retro‑orbital (eye) pain is a hallmark dengue symptom that appears during the febrile phase and does not by itself indicate severe disease, but signals active infection requiring close observation. 1, 4
• Loss of appetite (anorexia) occurs in 91.7% of hospitalized dengue children and is the most common gastrointestinal manifestation; it does not independently predict severity but contributes to dehydration risk. 5
• Post‑prandial intestinal cramping and early satiety ("stomach become small") reflect gastrointestinal involvement common in dengue; abdominal pain is present in 38.3% of pediatric cases and becomes a warning sign when it is persistent or severe with tenderness on examination. 5, 3

Critical Phase Timing (Day 3–7)

• Day 3 marks the beginning of the critical phase, when plasma leakage, shock, and severe complications typically emerge; warning signs appear around defervescence (fever resolution) during days 3–7. 1, 3
• Children younger than 5 years and those with secondary dengue infections carry the highest risk for severe disease, but this 10‑year‑old remains at significant risk and requires daily assessment. 6, 2

Mandatory Daily Monitoring During Critical Phase

Clinical Parameters to Track Every 24 Hours

• Vital signs: Record temperature, heart rate, blood pressure, and calculate pulse pressure (systolic minus diastolic); a pulse pressure ≤20 mmHg is an early indicator of impending shock and requires immediate hospital referral. 3, 1
• Perfusion status: Check capillary refill time (normal <2 seconds), skin temperature of extremities, and mental status (alert vs. lethargic/restless). 1
• Hydration assessment: Monitor urine output (should exceed 0.5 mL/kg/hour), skin turgor, and mucous membrane moisture. 1
• Abdominal examination: Palpate daily for hepatomegaly (liver enlargement >2 cm below costal margin) and tenderness; both are independent predictors of severe dengue in children. 7, 5

Laboratory Monitoring

• Complete blood count (CBC) daily to track:
  • Platelet count: Thrombocytopenia is universal in dengue; rapidly falling platelets (<100,000/mm³) combined with rising hematocrit signal plasma leakage. 1, 2
  • Hematocrit: A >20% rise from baseline indicates plasma leakage and warns of impending shock; this is the single most important laboratory parameter. 1, 3
• Liver enzymes (AST/ALT): Obtain baseline and repeat if abdominal symptoms worsen; AST >450 U/L is independently associated with severe dengue in children. 5
• Serum albumin: <3.5 g/dL predicts severe dengue and reflects plasma leakage. 5

Outpatient Management Protocol (If No Danger Signs Present)

Aggressive Oral Hydration

• Goal: >2500–3000 mL daily using oral rehydration solution (ORS), water, soup, or rice water to prevent progression to shock in most cases. 2, 1
• Instruct caregivers to offer fluids every 1–2 hours even if appetite is poor; small frequent sips are better tolerated than large volumes. 1

Pain and Fever Control

• Acetaminophen (paracetamol) ONLY at standard pediatric doses (10–15 mg/kg every 4–6 hours, maximum 60 mg/kg/day). 2, 1
• Never use aspirin or NSAIDs (ibuprofen, diclofenac) because they increase bleeding risk and worsen platelet dysfunction. 2, 1

Dietary Management

• Do not force feeding; anorexia is expected and will resolve as the child recovers. 5
• Offer small, frequent, bland meals (rice porridge, bananas, toast) when the child is willing to eat; post‑prandial cramping often improves with smaller portions. 5
• Resume age‑appropriate balanced diet with adequate protein as appetite returns during the recovery phase (typically after day 7). 2

Immediate Hospital Referral Criteria (Danger Signs)

Gastrointestinal Red Flags

• Persistent vomiting that prevents oral fluid intake—this is the most critical warning sign requiring immediate IV fluid therapy. 3, 1, 5
• Severe or persistent abdominal pain/tenderness on examination, especially right upper quadrant pain suggesting liver involvement. 3, 7
• Any mucosal bleeding: gum bleeding, nosebleeds, blood in vomit or stool, or heavy menstrual bleeding. 3, 1

Systemic Danger Signs

• Lethargy, restlessness, or altered mental status (confusion, irritability beyond normal for illness). 3, 1
• Clinical fluid accumulation: ascites (fluid in abdomen) or pleural effusion (difficulty breathing). 3
• Signs of shock: cold/clammy extremities, capillary refill ≥3 seconds, pulse pressure ≤20 mmHg, systolic BP <80 mmHg. 3, 1

Laboratory Triggers for Admission

• Hematocrit rise >20% from baseline with concurrent platelet drop <100,000/mm³. 3, 1
• AST >450 U/L or albumin <3.5 g/dL. 5

Common Pitfalls to Avoid

Do Not Delay Referral Based on Fever Pattern

• Danger signs typically appear as fever resolves (defervescence), not during peak fever; a child who "feels better" after 3–4 days of fever may actually be entering the critical phase. 3, 1

Do Not Assume Mild Symptoms Mean Mild Disease

• More than 90% of dengue cases are mild, but the critical phase (days 3–7) is when severe complications emerge; this child is exactly in that window. 4, 1

Do Not Restrict Fluids Due to Vomiting Risk

• Adequate hydration is the cornerstone of preventing shock; if the child cannot tolerate oral fluids due to nausea, hospital admission for IV fluids is required rather than restricting intake. 2, 1

Do Not Use Antibiotics Empirically

• Bacterial co‑infection occurs in <10% of dengue cases; prescribing antibiotics without evidence of bacterial infection contributes to resistance without benefit. 1

Post‑Discharge Recovery (After Critical Phase)

Gradual Return to Activity

• Implement gentle movement therapies (walking, stretching) rather than aggressive physical activity initially; post‑viral fatigue is common. 2
• Avoid strenuous sports or exercise until full recovery (typically 2–3 weeks after fever resolution). 2

Nutritional Rehabilitation

• Encourage balanced nutrition with adequate protein to support tissue recovery and immune function as appetite normalizes. 2

Summary Algorithm for This Child

1. Confirm dengue diagnosis if not already done: NS1 antigen or PCR on day 3 is still within the detection window. 1
2. Obtain baseline CBC, AST, and albumin today (day 3). 5, 1
3. Prescribe acetaminophen 10–15 mg/kg every 4–6 hours for eye pain and fever. 2
4. Instruct aggressive oral hydration >2500 mL/day with ORS or clear fluids. 2
5. Schedule daily follow‑up visits (or telemedicine checks) through day 7 to monitor vital signs, perfusion, abdominal exam, and repeat CBC. 1
6. Educate caregivers on danger signs (persistent vomiting, severe abdominal pain, bleeding, lethargy, cold extremities) and provide 24‑hour contact for urgent questions. 3, 1
7. Admit immediately if any danger sign develops or if daily monitoring cannot be reliably ensured. 3, 1