Overview/Definition
Definition:
• Dengue fever in children is acute viral infection caused by dengue virus (DENV 1-4) transmitted by Aedes aegypti mosquitoes
Spectrum ranges from asymptomatic infection to life-threatening dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS)
Leading cause of hospitalization during monsoon season in India with case fatality rate 1-2%.
Epidemiology:
• India reports 100,000-200,000 dengue cases annually with children comprising 40-50% of cases
Peak incidence during monsoon and post-monsoon period (July-November)
States with highest burden: Tamil Nadu, Karnataka, Kerala, West Bengal, Delhi
Children 5-15 years most commonly affected age group with secondary infections showing more severe disease.
Age Distribution:
• Infants (<1 year): Maternal antibody protection initially, severe disease with primary infection
Children (1-5 years): Classical dengue fever presentation, lower DHF/DSS rates
School age (6-12 years): Highest incidence, increased DHF risk with secondary infections
Adolescents (13-18 years): Adult-like presentations with more atypical manifestations.
Clinical Significance:
• High-yield topic for DNB Pediatrics and NEET SS examinations focusing on warning signs recognition, fluid management protocols, and WHO classification criteria
Understanding pathophysiology of plasma leakage crucial for appropriate management
Knowledge of fluid calculation formulas essential for board preparation.
Age-Specific Considerations
Newborn:
• Neonates (0-28 days): Rare due to maternal antibody protection
Vertical transmission possible during maternal dengue in pregnancy
Severe neonatal dengue with hemorrhagic manifestations reported
Close monitoring for bleeding, plasma leakage
Breastfeeding safe during maternal dengue infection.
Infant:
• Infants (1-24 months): Primary dengue infection typically milder
Fever, irritability, poor feeding common presentations
Febrile convulsions more frequent due to high fever
Plasma leakage may be subtle requiring careful monitoring
Dehydration tolerance poor requiring early intervention.
Child:
• Children (2-12 years): Classic triad of fever, headache, myalgia
Secondary infections carry higher DHF/DSS risk due to antibody-dependent enhancement
Warning signs more apparent: abdominal pain, vomiting, bleeding
Tourniquet test positive in 80-90% cases
Better cooperation for clinical assessment.
Adolescent:
• Adolescents (12-18 years): Adult-like presentations with severe myalgia, arthralgia
Higher rates of depression and anxiety during illness
Menstrual irregularities in females
Risk-taking behavior may delay medical care
Better understanding of warning signs for self-monitoring.
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Clinical Presentation
Symptoms:
• Acute onset high fever (39-40°C) lasting 2-7 days with biphasic pattern
Severe headache, retro-orbital pain pathognomonic for dengue
Myalgia and arthralgia ("breakbone fever")
Nausea, vomiting especially during critical phase
Skin manifestations: Flushing, petechial rash, maculopapular rash after fever subsides.
Physical Signs:
• Positive tourniquet test (>20 petechiae in 1-inch square) in 80-90% cases
Hepatomegaly in 60-70% cases, splenomegaly less common
Bleeding manifestations: Epistaxis, gum bleeding, menorrhagia in adolescent females
Signs of plasma leakage: Ascites, pleural effusion, pericardial effusion
Capillary refill time >2 seconds indicating shock.
Severity Assessment:
• WHO 2009 classification: Dengue without warning signs
Dengue with warning signs (abdominal pain, persistent vomiting, clinical fluid accumulation, mucosal bleeding, lethargy, liver enlargement >2 cm, increasing hematocrit with decreasing platelets)
Severe dengue: Shock, severe bleeding, severe organ involvement.
Differential Diagnosis:
• Malaria: Thick and thin smears, rapid antigen test
Typhoid fever: Blood culture, Widal test
Viral fever: Other viral markers
Acute gastroenteritis: Stool examination
Kawasaki disease: Diagnostic criteria assessment
Thrombocytopenic purpura: Peripheral smear examination.
Diagnostic Approach
History Taking:
• Detailed travel history to endemic areas within past 2 weeks
Contact with confirmed dengue cases
Previous dengue infection history (secondary infection risk)
Mosquito exposure assessment
Day care or school attendance
Vaccination status for other febrile illnesses.
Investigations:
• Complete blood count with platelet count: Daily monitoring during critical phase (day 3-7)
Hematocrit rise >20% from baseline indicates plasma leakage
Liver function tests: ALT/AST elevation in 80% cases
Dengue NS1 antigen (day 1-7), IgM/IgG antibodies (day 5 onwards)
Rapid diagnostic tests for field diagnosis.
Normal Values:
• Normal platelet count: 150,000-450,000/μL
Thrombocytopenia <100,000/μL significant
Normal hematocrit: Males 40-50%, Females 36-46%
Hematocrit rise >20% baseline suggests plasma leakage
Normal ALT/AST <40 IU/L, elevation common in dengue.
Interpretation:
• NS1 antigen positive in early phase (sensitivity 85-90% days 1-3)
IgM appears day 3-5 indicating recent infection
IgG elevation with low/absent IgM suggests secondary infection
Thrombocytopenia with normal/elevated hematocrit classical for dengue
Leucopenia (<4000/μL) supportive of viral etiology.
Management/Treatment
Acute Management:
• Supportive care with careful fluid management based on WHO guidelines
Phase-based approach: Febrile phase (symptomatic care), Critical phase (day 3-7, intensive monitoring), Recovery phase (fluid mobilization)
Paracetamol for fever, avoid aspirin and NSAIDs due to bleeding risk
Close monitoring for warning signs.
Chronic Management:
• Hospital admission criteria: Warning signs present, social factors, inability to maintain oral intake
Daily monitoring during critical phase: Vital signs every 4-6 hours, hematocrit and platelet count, urine output
Discharge criteria: 48 hours after fever resolution, platelet count >50,000/μL, stable vital signs.
Lifestyle Modifications:
• Adequate rest during acute illness with gradual activity increase
High fluid intake: 2-3 L/day in older children
Oral rehydration solution preferred over plain water
Mosquito control measures: Bed nets, repellents, environmental management
Nutritious diet with adequate protein for recovery.
Follow Up:
• Daily follow-up during critical phase (day 3-7) either outpatient or inpatient
Post-recovery follow-up at 1 week and 4 weeks
Complete blood count monitoring until normalization
Patient education on warning signs for future episodes
Vector control counseling for family.
Age-Specific Dosing
Medications:
• Paracetamol: 10-15 mg/kg every 6 hours, maximum 60 mg/kg/day
Avoid aspirin due to Reye syndrome risk
NSAIDs contraindicated due to bleeding risk
Antibiotics not indicated unless secondary bacterial infection suspected
Antiemetics: Ondansetron 0.1-0.15 mg/kg if severe vomiting.
Formulations:
• Paracetamol: Syrup 120 mg/5 ml for children, tablets for adolescents
Dispersible tablets for easy administration
Rectal suppositories if oral route not possible
ORS packets: Pediatric formulation with lower sodium content
IV fluids: Normal saline, Ringer's lactate for resuscitation.
Safety Considerations:
• Monitor for paracetamol toxicity with prolonged use
Avoid IM injections due to bleeding risk
Careful IV fluid administration to prevent fluid overload
Monitor for signs of hepatotoxicity with high-dose paracetamol
Aspirin absolutely contraindicated in children with viral fever.
Monitoring:
• Vital signs monitoring: Temperature, pulse, blood pressure, respiratory rate every 4-6 hours during critical phase
Hematocrit and platelet count: Daily during critical phase
Liver enzymes weekly if elevated
Signs of fluid overload: Pulmonary edema, congestive heart failure.
Prevention & Follow-up
Prevention Strategies:
• Vector control: Elimination of breeding sites (stagnant water containers)
Personal protection: Full-sleeve clothing, mosquito repellents
Community measures: Fogging, larvicide application
School-based education programs
Early detection and case management to prevent outbreaks.
Vaccination Considerations:
• Dengvaxia vaccine available but WHO recommends only for seropositive individuals in high-endemic areas
Pre-vaccination screening required to determine serostatus
Not recommended for children <9 years
Risk of severe disease in seronegative recipients
Currently not part of routine immunization in India.
Follow Up Schedule:
• Critical phase monitoring: Daily during day 3-7 of illness
Post-critical phase: Every 2-3 days until platelet recovery
Recovery phase: Weekly follow-up for 2 weeks
Annual follow-up for recurrent fever evaluation
Seasonal counseling before monsoon season.
Monitoring Parameters:
• Complete blood count: Weekly during recovery until normalization
Liver function tests: If initially elevated, monitor until normalization
Growth parameters in children with prolonged illness
Psychological assessment for anxiety related to illness
Family education on vector control measures.
Complications
Acute Complications:
• Dengue shock syndrome (DSS): Rapid pulse, narrow pulse pressure, cold extremities requiring immediate fluid resuscitation
Dengue hemorrhagic fever (DHF): Bleeding manifestations with thrombocytopenia and hemoconcentration
Plasma leakage: Pleural effusion, ascites, pericardial effusion
Acute liver failure in severe cases.
Chronic Complications:
• Post-dengue fatigue syndrome lasting weeks to months
Depression and anxiety following severe illness
Cardiac complications: Myocarditis, pericarditis rare but reported
Long-term liver dysfunction in severe hepatitis cases
Secondary bacterial infections during recovery phase.
Warning Signs:
• Abdominal pain, persistent vomiting >3 episodes/hour
Lethargy, restlessness, mucosal bleeding
Clinical fluid accumulation: Ascites, pleural effusion
Liver enlargement >2 cm below costal margin
Rapid rise in hematocrit >20% with falling platelet count <100,000/μL.
Emergency Referral:
• Immediate referral for warning signs, signs of shock, severe bleeding
ICU consultation for DSS requiring inotropic support
Hematology consultation for severe bleeding or refractory thrombocytopenia
Gastroenterology referral for acute liver failure
Cardiology consultation for cardiac complications.
Parent Education Points
Counseling Points:
• Dengue is viral infection with no specific antiviral treatment, supportive care essential
Recognition of warning signs crucial for timely intervention
Importance of maintaining adequate fluid intake
Vector control measures to prevent reinfection
Dengue can recur with different serotypes causing more severe illness.
Home Care:
• Maintain adequate fluid intake: ORS, coconut water, fruit juices
Paracetamol for fever, avoid aspirin and ibuprofen
Rest and avoid strenuous activities
Light, nutritious diet as tolerated
Mosquito protection measures: Nets, repellents
Temperature and symptom monitoring charts.
Medication Administration:
• Paracetamol dosing based on child weight, not age
Administer every 6 hours, maximum 4 doses per day
Avoid crushing tablets unless dispersible formulation
Store medications in cool, dry place
Complete medication course as prescribed
Report any adverse reactions immediately.
When To Seek Help:
• Immediate medical attention for warning signs: Severe abdominal pain, persistent vomiting, bleeding from any site
Signs of shock: Cold hands and feet, rapid weak pulse, drowsiness
Difficulty breathing, chest pain
Convulsions or altered consciousness
Inability to maintain oral fluid intake.