This webinar is organized by MyICID and Institute for Clinical Research (ICR), NIH, Ministry of Health in conjunction with Neglected Tropical Disease Day 2022. The purpose of this webinar is to refresh and update our knowledge on Dengue fever, which has been overshadowed by COVID-19 since the beginning of the pandemic. Presenter: Dr Nik Khairulddin Nik Yusoff, Consultant Paediatrician (Infectious Diseases) at Hospital Raja Perempuan Zainab II, Kota Bharu, Kelantan #dengue #WorldNTDDay #BeatNTDs #BestScienceforAll

1. Managing Dengue in
Children: an update
Dr Nik Khairulddin Nik Yusoff
Consultant Paediatrician (Infectious Diseases)
Hospital Raja Perempuan Zainab II
Kota Bharu, Kelantan

2. Disclaimer
• This slide was prepared for the Webinar Series on COVID-19 session on
3rd March 2021, by Dr Nik Khairulddin Nik Yusoff, Consultant
Paediatrician at Hospital Raja Perempuan Zainab II, Malaysia.
• This is intended to share within healthcare professionals, not for public.
• This webinar is organised by Malaysian Society of Infection Control and
Infectious Diseases (MyICID) & Institute for Clinical Research, NIH in
conjunction of World NTD Day 2022.

3. Managing Dengue in Children
• Epidemiology
• When to suspect dengue?
• Differential diagnosis
• Assessment
• History, examination, lab study
• Treatment
• Management decisions

4. Epidemiology of Dengue in Malaysia
Children
Cases: 12 – 16%
Mortality: 19% of total
deaths (2018)
Annual Dengue Cases Among Children and Adults in Malaysia
MOH. CPG Dengue in Children 2020

5. Burden of Childhood Dengue
• 5 Asian countries (n=3424) and 5 Latin America countries (n=6939)
• ~ 10% of the febrile episodes confirmed to be VCD:
• Asia (4.6 episodes per 100 person-years)
• Latin America (2.9 episodes per 100 person-years)
• Incidence of DHF < 0.3 episodes per 100 person-years in each cohort.
• Hospitalisation rate:
• Asia: 19.1%
• Latin America: 11.1%
• Burden of dengue was higher in Asia than in Latin America.
L’ Azou M. N Engl J Med 2016;374:1155-66.
Symptomatic Dengue in Children in 10 Asian and
Latin American Countries

6. Spectrum of Dengue Infection
• Asymptomatic infection
• Undifferentiated fever
• Dengue fever
• Severe dengue

7. Severe Dengue
1. Capillary Leak
• Fluid accumulation
• Shock
2. Bleeding
• GIT, mucosa
3. Organ involvement
• Liver – hepatitis, AST >1,000 IU/L
• Brain – encephalopathy, encephalitis
• Heart – myocarditis, myocardial
depression

8. Challenges in managing dengue in children
• Diagnosis
• Recognising dengue infection
• Atypical manifestation
• Young infants
• Recognising early signs of shock and/or occult bleeding
• Fluids

9. What’s new?
http://www.acadmed.org.my/

10. Managing Dengue in Children
• Epidemiology
• When to suspect dengue?
• Differential diagnosis
• Assessment
• History, examination, lab study
• Treatment
• Management decisions

11. When should dengue be suspected in a child?
• Live in / travel to dengue endemic area
• Fever plus TWO other symptoms/signs:
• Nausea/ vomiting
• Rash
• Aches and pains
• Leukopenia
• Any warning signs
• Need high index of suspicion
• Headache, retro-orbital pain less common than in adult
• Beware of uncommon presentations especially in young infants

12. *Other signs:
Refuse to eat or drink
Refuse to sit up – postural giddiness
Unexplained tachycardia MOH. CPG Dengue in Children 2020; WHO Handbook 2012

13. Thisyakorn U. Southeast Asian J Trop Med Public Health 2017;48 Suppl 1: 106-11

14. Thisyakorn U. Southeast Asian J Trop Med Public Health 2017;48 Suppl 1: 106-11
Common in all age groups – fever, nausea, anorexia and vomiting
Older children - abdominal pain and vomiting more common
Infants –
Seizures (25%)
URTI symptoms - rhinorrhoea, cough (56%)
Diarrhoea (40%)
rash
hepatomegaly and splenomegaly

15. Differential Diagnosis
CONDITIONS THAT MIMIC THE FEBRILE PHASE OF DENGUE INFECTION
Flu-like syndromes influenza, measles, chikungunya, infectious mononucleosis, HIV, COVID-19
Illnesses with a rash rubella, measles, scarlet fever, meningococcal infection, chikungunya, drug reactions, MIS-C
Diarrhoeal diseases rotavirus, other enteric infections
Illnesses with CNS manifestations febrile seizures, meningitis, encephalitis, meningoencephalitis, MIS-C
CONDITIONS THAT MIMIC THE CRITICAL PHASE OF DENGUE INFECTION
Infectious acute gastroenteritis, malaria, leptospirosis, typhoid, typhus, viral hepatitis, bacterial sepsis,
septic shock, HIV, MIS-C
Malignancies acute leukaemia and other malignancies
Other clinical pictures acute abdomen
diabetic ketoacidosis
lactic acidosis
leukopenia and thrombocytopaenia ± bleeding
platelet disorders
renal failure
respiratory distress (Kussmaul’s breathing)
Systemic Lupus Erythematosus
MOH: CPG Dengue in Children 2020 (adapted)

16. Multisystem Inflammatory
Syndrome in Children (MIS-C)
• Severe hyperinflammatory syndrome
occurring 2–6 weeks after acute SARS-CoV-2
infection among persons <21 years old
• Clinical features: toxic shock syndrome,
Kawasaki disease
• 1 in 3000 cases 1
• 60-70% admitted to ICU
• 1-2% mortality 2
1. Payne AB et al. JAMA Network Open. 2021;4(6):e2116420; 2. Kaushik A. Pediatr Infect Dis J 2020;39(11):e340

17. Dengue vs MIS-C
Features Dengue MIS-C
Fever Yes Yes (maybe prolonged)
Rash Yes Yes
Abdominal pain Yes Yes
Altered sensorium Yes Yes
Conjunctival injection No Yes
Swelling of hand and feet No Yes
Hypotension Yes (severe dengue) Yes
Thrombocytopenia Yes Yes (mild)
Haemoconcentration Yes (critical phase) Unusual
CRP Low High
Other inflammatory markers elevated Very elevated
LV dysfunction (echo) No Yes
Dhooria GS, et al. Indian Pediatr. 2021; 58(10): 951–954 (adapted)

18. Managing Dengue in Children
• Epidemiology
• When to suspect dengue?
• Differential diagnosis
• Assessment
• History, examination, lab study
• Treatment
• Management decisions

19. History
• Date of onset of fever or illness
• Symptoms and severity
• 3 golden questions:
• How much oral fluid intake?
• How much urine output: frequency, volume and time of most recent voiding?
• What activities could the patient do during the febrile illness?
• Other fluid losses: diarrhoea, vomiting
• Presence of warning signs
• Family/neighbour history of dengue
• Other exposure e.g environmental exposure, travelling
• Risk factors - comorbids
WHO Handbook 2012

20. Physical examination
• General assessment:
• Mental state
• Hydration state
• Haemodynamic state
• Clinical evidence of warning signs:
• Bleeding manifestations: mucosal bleeding
• Abdominal tenderness
• Liver enlargement
• Fluid accumulation: pleural effusion, ascites
• Other important signs:
• Rash
• Tachypnoea/acidotic breathing

21. Haemodynamic Assessment
Parameters Normal
circulation
Compensated shock Hypotensive shock
Conscious level Clear and alert Clear and alert Restless, drowsy
Capillary refill time Brisk (< 2 sec) Prolonged (> 2 sec) Very prolonged
Extremities Warm and pink Cool extremities Cold, clammy
Peripheral pulse
volume
Good volume Weak & thready Feeble or absent
Heart rate Normal HR for age Tachycardia Severe tachycardia or
bradycardia (late shock)
Blood pressure Normal BP for age Normal systolic BP, rising
diastolic pressure
Postural hypotension
Hypotension
Unrecordable BP
Pulse pressure Normal PP for age Narrowed PP Narrowed PP (< 20mmHg)
Respiratory rate Normal RR for age “Quiet’ tachypnoea Metabolic acidosis/
hyperpnoea
Urine output Normal Reducing trend Oliguria / anuria
MOH: CPG Dengue in Children 2020; WHO Handbook 2012
C
C
T
V
R
Unless the child is touched, parameters of shock may be missed

22. Heart Rates & Blood Pressure in Children
Paediatric Protocols for Malaysian Hospitals 4th Ed., 2018.
*HR may be affected by child’s activity, anxiety or fever

24. Laboratory Investigations
• FBC
• Dengue rapid combo test (NS1
Antigen/IgM/IgG) or ELISA
• RFT, LFT, RBS, ABG
• in patients with risk factors and severe disease
• Dengue PCR - suspected severe dengue or mortality
cases.
• Laboratory results should be correlated with
clinical presentation of children suspected of
dengue.
MOH: CPG Dengue in Children 2020

25. What is normal Haematocrit?
*Baseline HCT on D1-3 of illness is a useful reference point
*HCT should not be used on its own to decide fluid therapy
MOH: CPG Dengue in Children 2020

26. Managing Dengue in Children
• Epidemiology
• When to suspect dengue?
• Differential diagnosis
• Assessment
• History, examination, lab study
• Treatment
• Management decisions

27. The key is early recognition and understanding
of the clinical problems during the different
phases of the disease, leading to a rational
approach to case management and a good
clinical outcome
WHO 2009

28. MOH: CPG Dengue in Children 2020

29. When to refer for admission?
• Presence of warning signs
• Features of severe dengue
• Presence of co-morbidities
• Infants age <12 months
• Social factors e.g. difficulty for outpatient monitoring
MOH: CPG Dengue in Children 2020

30. Management Decisions
• Dengue Fever
• Dengue Fever with warning signs
• Severe Dengue

31. Dengue Fever
• Home management
• Adequate fluids intake
• Manage fever – tepid sponge, antipyretics*
• Identify warning signs early
• Follow up - daily
*PCM -Child - 10 mg/kg/dose, not more than 4 times a day
MOH: CPG Dengue in Children 2020

32. Dengue Fever with Warning Signs
• Admit for inpatient care
• Monitor hemodynamic status frequently
• Use HCT to guide interventions
• Use isotonic IV fluids judiciously
• Correct metabolic acidosis, electrolytes as needed

33. Dengue Fever with Warning Signs – IV Fluids
• Give isotonic crystalloids (NS)
• Start with: 5-7 mls/kg for 1 hr
• If improved, reduce to 3-5 mls/kg/hr for 2-4 hrs
• Then, reduce 2-3 mls/kg/hr for 24-48 hrs
• Titrate IV fluids based on haemodynamic status, urine
output and HCT
• Stop IV fluids within 24-48 hrs
DO NOT use hypotonic solutions
e.g. D5%, ½NS D5%, 1/5NS D5%
MOH: CPG Dengue in Children 2020

34. Severe Dengue
1. Capillary Leak
• Fluid accumulation
• Shock
2. Bleeding
• GIT, mucosa
3. Organ involvement
• Liver – hepatitis, AST >1,000 IU/L
• Brain – encephalopathy, encephalitis
• Heart – myocarditis, myocardial
depression
Requires emergency treatment
and urgent referral

35. Severe Dengue with Compensated Shock
IV fluid bolus NS 10-20mls/kg over 1hr
If unstable:
HCT high - Give 2nd IVF bolus
HCT low - ? Bleed – Fresh PRC or FWB
FPRC or FWB – 10-20mls/kg
If stable:
Gradually reduce
the rate of infusion
*Continuous ECG and pulse oximetry monitoring
*IV fluid given using infusion/syringe pumps

36. Severe Dengue with Hypotension
If stable:
Gradually reduce
the rate of infusion
IVF N/S 20mls/kg over 15-30min
If unstable:
HCT high - Give 2nd IVF bolus (colloid)
HCT low - ? Bleed – Fresh PRC or FWB
FPC or FWB – 10-20mls/kg
MOH: CPG Dengue in Children 2020
If refractory:
Assisted ventilation
Continuous bleed/ leak?
Co-infection?
Myocardial dysfunction?
Electrolytes / acidosis?

37. Type of IV Fluids in Dengue?
• Crystalloid solutions (isotonic)
• Indication: use in resuscitation and maintenance therapy in children
• 0.9% NS, Ringer’s lactate, Hartmann’s solution
• Sterofundin
• Colloid solutions
• Indication: use in persistent shock despite resuscitation with the crystalloid
solutions
• Succinylated gelatin (gelafundin, Infusol)
• Hydroxyethyl starch (Voluven)
• Albumin 5%
MOH: CPG Dengue in Children 2020

38. Overweight / obese children?
• Use ideal body weight
• Multiple methods to calculate ideal BW
• If normal height (5th and 95th centile of age),
use Moore method
• the IBW is the weight for age on the same
percentile as height
• If tall (>95th centile), use McLaren method
• Weight at 50th centile for height age chart
MOH: CPG Dengue in Children 2020

39. Take Home Message
• Consider dengue in any child presenting with fever
• may present atypically (URTI, febrile fits etc) especially in young children
• Assess the child thoroughly & systematically
• Focus history taking, physical examination
• Relevant investigations
• Monitor the child adequately
• Frequency of monitoring based on phase of illness and severity
• Emphasis on haemodynamic status, HCT and urine output
• Use IV fluids judiciously in a child
• At risk of either undervolume or overloading of circulatory system
• Isotonic crystalloids

40. Thank you