The document discusses dengue infection in children. It describes the four types of dengue virus and how it is transmitted by mosquitoes. It outlines the severity of dengue globally, affecting billions of people annually. It also discusses dengue fever and dengue hemorrhagic fever, including classification, pathogenesis, clinical features, investigations, differential diagnosis, and management, with a focus on fluid management in the critical phase.

2. Dr. Zahid
Mehmood
FCPS Paediatrics
DENGUE INFECTION IN
CHILDREN

3. Dengue virus
 Four antigenic types.
 Members of the family Flaviviridae.
 Transmitted by mosquitoes , Aedes aegypti,
 is the principal vector,
 a daytime biting mosquito,
 all four virus types have been recovered from it.
 Dengue viruses have also been recovered from Aedes
albopictus,.
 Dengue 3 virus strains are associated with a particularly
severe clinical syndrome.

4. How it reached us
 In Chinese dynasty (AD 265- 420) known as
water poison
 Epidemics reported from 1779-80
 World’s largest epidemic 1981 Cuba
 In Pakistan, 1980s and so on

5. Gravity of situation
 2.5 Billion people at risk worldwide
 50 million new cases annually worldwide
 500,000 hospitalized annually
 2.5% of the affected DIE

6. Aedes aegypti
 Breed in fresh water
 stored for drinking
 bathing
 rainwater collected in any container.
 Dengue outbreaks in areas infested with A. aegypti may be
explosive;
 up to 70-80% of the population may be involved.
 Most disease occurs in older children and adults

7. DENGUE
FEVER
 A benign syndrome caused by several arthropod
borne viruses, is characterized by biphasic fever,
myalgia or arthralgia, rash, leukopenia and
lymphadenopathy.
 Probable dengue
 Dengue should be suspected when a high fever is
accompanied by 2 of the following symptoms during the
febrile phase.
○ Severe headache
○ Retro orbital pain
○ Muscle and joint pain
○ Nausea & vomiting
○ Lymphadenopathy
○ Rash

8. WHO Classification

9.  DENGUE HEMORRHAGIC FEVER
It is a severe, often fatal, febrile disease
characterized by
 fever 2 to 7 days duration
 hemorrhagic manifestation (minor or major)
 Thrombocytopenia(<1000,00/mm3)
 Objective evidence of increased capillary permeability
 Raised hematocrit > 20%
 Pleural effusion ascites
 Hypoalbuminemia
 Dengue shock syndrome
 Criteria include dengue hemorrhagic fever plus
○ Tachycardia
○ Hypotension
○ Narrow pulse pressure (≤ 20mmHg)
○ Signs of poor perfusion, cold extremities

10. Grading of DV infection
DF/DHF Grade Symptoms Lab
DF Fever with 2 or > of: headache/retro-orbital
pain, myalgia, arthralgia
Leukopenia,
occasionally
thrombocytopenia,
no evidence of
plasma leak
DHF I Above + +ve tourniquet test Platelets < 100,000,
Hct rise > 20%
DHF II Above + spontaneous bleeding ,,
DHF III/DSS Above + s/o circulatory failure ,,
DHF IV/DSS Profound shock with undetectable BP and
pulse
,,
Lab evidence of Dv
infection

11. Pathogenesis
 The pathogenesis of dengue fever is not clear.
 Early in the acute stage of secondary dengue infections, there is rapid
activation of the complement system.
 Shortly before or during shock,
 blood levels of soluble tumor necrosis factors,
 interferon-γ,
 interleukin 2 are elevated.
 C3 catabolic rates are elevated
 C1q, C3, C4, C5-C8, and C3 pro activators are depressed,
 These factors may interact at the endothelial cell to produce increased
vascular permeability through the nitric oxide final pathway.

 The blood clotting and fibrinolytic systems are activated, and levels of factor
XII (Hageman factor) are depressed.

12. Severity of disease depends on
 Age
 Previous infection
 Virus strain
 DHF risk is greatest for DEN-2, followed by DEN-3,
DEN-4 and DEN-1
 Host genetics
 Pre-existing anti-dengue antibody
 Maternal antibodies in infants

13. Dengue Viral Infection
Asymptomatic
(majority) (80-90%)
Symptomatic
(10%)
Undifferentiated
fever
DF DHF
Plasma leakage
DHF
(98%)
Grade-I & II
non shock
DSS
(1-2%)
Grade – III & IV
Shock
Unusual
dengue-
expanded
dengue
syndrom(<1%)
With
bleeding
No
bleeding

14. Clinical features
 Incubation period:
Approximately 6 days (3-14days)

16. Clinical features
In infants and young children
 The disease may be undifferentiated or
characterized by fever for 1-5 days.
 Children often experience symptoms similar
to those of the common cold and
gastroenteritis (vomiting and diarrhea).

17. Older children and adults:
 Sudden onset of fever, with temperature rapidly increasing to 39.4-41.1°C
(103-106°F), classically biphasic.
 Usually accompanied by frontal or retro-orbital pain,
 Particularly when pressure is applied to the eyes.
 Occasionally, severe back pain precedes the fever (back-break fever).
 a rash occurs in approximately 50–80%
 in the first or second day of symptoms as flushed skin,
 later in the course of illness (days 4–7), as a measles-like rash.[
 heamorrhagic manifestation (minor or major)

18. Investigation
 Full blood count (Hb%,TLC,DLC,PLATELETS,Hct%)
 CXR
 USG abdomen & chest
 S/cholestrol
 S/albumin
 PCR:
 < 3 days
 NS1 ANTIGEN
 <5days (sensitvity 60 to 90 percent)
 Dengue antibodies
IgM detectable on 5, 6 days after the onset of illness,
IgG: day 14 of illness in primary and
day2 in secondary infections.

19. Differential
Diagnosis
 Viral respiratory and influenza-like diseases
 Early stages of malaria
 Viral hepatitis
 Enteric fever
 Meningococcemia
 Yellow fever
 Other viral hemorrhagic fevers

20. Clinical features
In infants and young children
 The disease may be undifferentiated or
characterized by fever for 1-5 days.
 Children often experience symptoms similar
to those of the common cold and
gastroenteritis (vomiting and diarrhea).

21. Older children and adults:
 Sudden onset of fever, with temperature rapidly increasing to 39.4-41.1°C
(103-106°F), classically biphasic.
 Usually accompanied by frontal or retro-orbital pain,
 Particularly when pressure is applied to the eyes.
 Occasionally, severe back pain precedes the fever (back-break fever).
 a rash occurs in approximately 50–80%
 in the first or second day of symptoms as flushed skin,
 later in the course of illness (days 4–7), as a measles-like rash.[
 heamorrhagic manifestation (minor or major)

22. Investigation
 Full blood count (Hb%,TLC,DLC,PLATELETS,Hct%)
 CXR
 USG abdomen & chest
 S/cholestrol
 S/albumin
 PCR:
 < 3 days
 NS1 ANTIGEN
 <5days (sensitvity 60 to 90 percent)
 Dengue antibodies
IgM detectable on 5, 6 days after the onset of illness,
IgG: day 14 of illness in primary and
day2 in secondary infections.

23. DF or DHF?
DF vs DHF
 Important to differentiate
 Two different clinical conditions from the beginning of the illness;
Though they look very similar on the first 2 days
 However badly managed DF will never become DHF (DF does
not progress to DHF)

24. Natural Course of DF
9/5/2023
Zahid
mehmoodO
Febrile phase: High fever for 2 – 7 days
Convalescent phase:
2-5 days
Longer in adults
No critical phase in DF!!!

25. Natural Course of DHF
9/5/2023
Zahid
mehmood
Febrile phase: High fever for 2 – 7 days
Critical phase:
Plasma leakage
Lasts 24- 48 h
Usually on D5/ D6, but earliest on D3
Convalescent phase:
2-5 days
Longer in adults

26. Patient is in critical phase and confirmed to be DHF if …
 Fever D 3 or beyond
 Platelet < 100,000 (WBC < 5,000)
 Evidence of plasma leak
○ Effusions : pleura/ peritoneum (CXR/ USS)
○ Hct rise of 20% from baseline
○ Low albumin/ low cholesterol
 Hemorrhagic manifestations
 (not essential if objective evidence of plasma leak+)
Laboratory confirmation of dengue infection NOT
essential

27. Diagnosis and management
at OPD level and by primary
care physician

28. When to suspect DF/DHF in a child with
acute onset of fever plus
any 2 or more of the following features:
 Headache and retro orbital pain
 Nausea or vomiting
 Rash diffuse, erythematous, macular
 Arthralgia and myalgia
 Leucopenia (WBC <5000/mm3)
 Positive tourniquet test (negative test does not exlude the possibility
of dengue)
 Platelet count ≤ 150,000/mm3
 Rising HCT 5-10%

29. Management of those who do not need admission at first contact
level
1. Ensure adequate oral fluid intake.
2. Adequate physical rest
3. Paracetamol 10-15 mg/kg/dose for fever.
4. Avoid all NSAIDS and steroids
5. Review daily.
 A full blood count must be done on the third day of illness or earlier if the
clinical situation warrants (if the first count is normal may have to repeat the
count depending on the clinical situation)

30. Advise immediate return for review if any of the following
occur:
 Clinical deterioration with settling of fever
 Inability to tolerate oral fluid
 Refuse to eat or drink
 Feeling extremely thirsty
 Severe abdominal pain / vomiting
 Cold and clammy extremities
 Bleeding manifestations
 Not passing urine for more than 6 hours
 Behavior changes e.g. confusion / restlessness / lethargy /
irritability

31. Criteria for admission
 All patients with a platelet count of ≤ 100,000/mm3
(Platelet count above 100,000/mm3 but below 150,000/mm3 and dropping rapidly
may be admitted depending on the circumstances)
 All patients with the following warning signs:
o Abdominal pain or tenderness
o Persistent vomiting
o Cold extremities and features of shock
o Clinical fluid accumulation – pleural effusion, ascites
o Mucosal bleeding

32. Warning signs in suspected DF/DHF warrant admission for
intense and close monitoring
o Lethargy, restlessness and drowsiness
o Liver enlargement > 2cm
o Laboratory:
 Increase in HCT > 10%
 Decrease in platelet count ≤ 100,000/mm3
 Elevated SGOT well above SGPT

33. Following categories of patients with probable dengue also
should be admitted
 Infants
 Obese patients
 Patients with major co-morbidities / medical problems
 diabetes, nephrotic syndrome, CRF, haemolytic diseases, poorly controlled
asthma.
 Adverse social circumstances –
 living alone,
 living far from health care facility without reliable means of transport,
 unreliable parents.

34. Fluid Management in Dengue
• Initially (During the 1st 2 days)
dengue shock is extremely rare within 1st 2 days
There is NO LEAKAGE Can give fluids freely
• How Much to Give?
– GIVE THE NORMAL MAINTENANCE(M) or More as replacement if
there is vomiting diarrhea
• Give electrolyte solutions not plain water

35. FLUID MANAGEMENT IN
CRITICAL PHASE

36. Fluid Management in Dengue…
 After 3rd Day
 May start leaking any time
 DONT ASK TO DRINK PLENTY OF FLUIDS
 SOME FLUID RESTRICTION IS USEFUL
 LOOK FOR SIGNS OF LEAKING & platelets dropping <100,000
 The critical phase is only 48 hrs (24- 50+)
 The final outcome/morbidity/mortality will largely depend on the
fluid management of the critical phase

37. How to confirm pt is in the critical phase..?
 Look for evidence of LEAKING  effusions pleural and/or
peritoneal cavities
 Oedema, facial puffiness, leg/arm swelling are not suggestive of
leaking but only suggest fluid overload

38. Fluid Management in
Dengue…
 Once patient is in the critical phase (24-48hrs)
TOTAL FLUIDS= MAINTENANCE+5% DEFICIT
OVER THE ENTIRE CRITICAL PHASE (USUALLY 48 HRS)

39. CALCULATION OF TOTAL FLUIDS FOR CRITICAL PERIOD
• M (Maintenance)
• 100ml/kg for 1st 10kg
+ 50 ml/kg for next 10 kg
+ 20 ml/kg for balance wt
• plus
• 5% of body weight = +50ml x body wt (kg)

40. Choice of fluids:
Crystalloids:
• 0.9% N/S
• 5% DW + 0.9% N/S
• < 6months of age: 5% DW + 0.45% N/S
Colloids:
• 6% starch
• Dextran 40 (when available)
• Rate of infusion of colloids 10ml/kg/hr
• ½ bulus in 30 minutes or full bolus in 60 minutes

41. Algorithm for fluid management in critical phase
Profound shock
(BP un-recordable/Pulse not
palpable)
Shock
(Pulse pressure ≤ 20, pulse
palpable
Without shock
Pulse palpable, pulse pressure >20
0.9% N/S 10ml/kg IV rapid (until
pulse pressure > 20)
Pulse pressure still ≤ 20
0.9% N/S 10ml/kg IV rapid (uptill
pulse pressure > 20)
Pulse pressure still ≤ 20
Colloid 10ml/kg over 1hr
IV furosemide 0.5ml/kg midway, monitor for 1hour)
20ml/kg of 0.9% N/S Bolus
Wide open until pulse is palpable
Pulse still not palpable
Repeat bolus 10ml/kg of 0.9% N/S
bolus
Pulse not palpable
(a) Consider colloid (6%
starch/dextran 40) 10ml/kg over
1hr (IV Furosemide 0.5mg/kg
midway, monitor for 1hr)
6% starch: maximum 5 boluses in
24hrs
Dextran 40: Maximum 3 in 24hrs
≥10 points + haemodynamic
instability
Bleed
Pulse pressure still <20mmHg
HCT fall with 1 bolus of colloid
Fluids calculated in 48hrs oral + IV
TOTAL FLUIDS = MAINTENANCE +
5% DEFICIT
Calculation based on ideal body
weight or current weight
whichever is lower, Max 50kg
Patient wt < 50kg
1st 10kg – 100ml/kg
+ 2nd 10kg – 50ml/kg
+ Balance wt – 20ml/kg
+5% body wt = 50ml/kg
Patient wt >
50kg
Maximum fluid
4600ml/in
48hrs
Pulse palpable and pulse
pressure ≥ 20mmHg
< 10 points
Repeat colloid (6% starch: Maximum 5 boluses in 24hrs
Dextran 40: maximum 3 boluses in 24hrs (IV Furosemide
0.5mg/kg midway, monitor for 1 hour)

42. Algorithm for fluid management in critical phase
• Consider whole blood transfusion (10ml/kg) or packed cell
volume (5ml/kg) (IV furosemide 0.5mg/kg midway, monitor for 1
hr)
• Important:
– Boluses / blood / oral all included in total fluid calculation.
– Shock defined as pulse pressure ≤20mmHg
Note:
 Infusion rate for total fluids should vary from 1.5-7ml/kg/hr (IV + oral)
keeping an eye on degree of plasma leakage.
 Keep urine output 0.5-1.0 ml/kg/hr and give fluid accordingly.
 If heading towards fluid overload:
 Switching to colloids can be needed as higher rate of crystalloids cannot be continued for longer
hours.
 If patient is not improving consider complications (c):

43. Guidance for rate of fluid intake in Critical phase without shock
10
9
8
7
6
5
4
3
2
1
0
6 12 18 24 30 36 42 48
Time (hours)
Amount
of
fluids
(ml/kg/h)
7ml/kg/h (120-150ml/h)
5ml/kg/h (100-120ml/h) 5 ml/kg/h
3 ml/kg/h (80-100ml/h) 3 ml/kg/h
1.5 ml/kg/h (40-50ml/h) 1.5 ml/kg/h
End of critical phase is indicated by:
1. stable vital signs, (2) Returning of PCV /Hct to normal
along with

44. Fluid therapy...
 Each patient can be managed in many different ways and with
different rate and choice of IV fluids but try to master the ways of
giving the ‘smoothest’ and the most ‘uneventful’ recovery for the pt
 AIM: AVOID BOTH SHOCK & FLUID OVERLOAD

45. Complication (consider
when no improvement)
A: Acidosis Correct acidosis if pH is < 7.35 and if HCO3
level <15mmol/L, NaHCO3 1ml/kg slow
bolus Max. 10ml (can be repeated up to
50ml)
B: Bleeding Consider whole blood (10ml/kg) or packed cell
(5ml/kg)
C:
Hypocalcemia
Check serum calcium and QT intervals Give
10% calcium gluconate. Dose 1ml/kg/min, max
10ml at one time, repeat 6 hourly if needed.
D. Sugar Levels Monitor blood sugar levels and manage
accordingly

46. Indications of furosemide
• Midway in the infusion of colloids in patients who are already in fluid overload or
who are likely to be overloaded depending on the fluids already given
• Midway between blood transfusion
• In patients passing less than 0.5ml/kg/hr of urine despite receiving adequate fluids
and having stable BP, Pulse, Hct to improve the UOP.
• During recovery phase when there is pulmonary oedema or fluid overload.

47. Platelet transfusion
 At the initial phase the platelet drop 100000 to 150000 is due to BM
suppression but later
○ when it drops <100,000 the cause is increase platelet consumption and the BM
become hypercellular with increase production
 No prophylaxis of plt. Transfusion
 When platelets are low may need but only in very exceptional
circumstances
9/5/2023

48. Tachycardia...
 When heart rate is high (more than the fever)
 Things to consider....
 Shock/impending shock
 Bleeding
 Impending respiratory failure
 Hypocalcaemia
 Myocarditis  not usually needing intervention

49. Place of dopamine and dobutamine...
 Very limited in DHF
 May do harm than good by giving a false impression about BP
 When using 1st make sure that there is enough intravascular
volume shown by increased CVP
9/5/2023

50. Prolonged shock
 10 hours untreated - Death!!!
 > 4 hours untreated
 Liver failure- prognosis 50%
 Liver + Renal failure – prognosis 10%
 3 organs failure (+respiratory failure) – Prognosis is a miracle!!!
9/5/2023

51. What not to do
 Do not give Aspirin or Ibuprofen for treatment of fever
 Avoid intravenous therapy before evidence of haemorrhage and bleeding
 Avoid blood transfusion unless indicated
 Avoid giving steroids
 Do not use antibiotics
 Do not change the speed of fluid rapidly,( i.e. avoid rapidly increasing or
rapidly slowing the speed of fluids)
 Avoid. Insertion of nasogastric tube to determine concealed bleeding or to
stop bleeding (by cold lavage) is not recommended since it is hazardous

52. Transmission of dengue viral infection
in perinatal period

53. Threats to the Pregnant Mother
 Worsening of proteinuria and hypertension
 Liver Dysfunction
 Coagulopathies
 Peripartum hemorrhage

54. Affects on fetus
Usual time of presentation
Birth to 2 weeks

55. Clinical Scenario at birth
tachypnea
Bleeding
Leak syndromes
Mimics Sepsis
Petechea
Frank
Hemorrhagic

56. Prevention
 Antimosquito measures
 Avoid open stagnant water in and around
home
 Bed nets
 Long sleeved clothing
 In house spraying
 repellants
 Pediatric dengue vaccine

57. Prevention

58. Prevention

59. Prevention

60. Prevention

61. Prevention

62. Prevention

63. Prevention

64. Prevention

65. Prevention

66. Prevention

67. Prevention

68. Prevention

69. Prevention

70. Prevention

71. Prevention

72. Prevention

73. Prevention

74. Prevention

75. Prevention

76. Prevention

77. Prevention

78. Prevention

79. WHO position on the vaccine
 Dengvaxia vaccine
 attenuated dengue vaccine
 vaccine is targeted for persons living in endemic areas,
 ranging from 9-45 years of age,
 VACCINE has been shown in clinical trials to be effective and safe in
persons
 who have had at least 1 documented dengue virus infection
previously.
 vaccine carries an increased risk of severe dengue in
 those who experience their first natural dengue infection after
vaccination
 those who were seronegative at the time of vaccination.