Dengue Fever in Children
A Comprehensive Guide for Nursing Students
Table of Contents
Introduction to Dengue Fever
Dengue fever is a mosquito-borne viral disease that has rapidly spread across tropical and subtropical regions worldwide. It’s particularly concerning in pediatric populations where the clinical presentation can range from mild flu-like symptoms to life-threatening complications. As nursing students, understanding how to identify, manage, and prevent dengue in children is crucial for providing effective care.
Key Facts About Dengue:
- Caused by four serotypes of dengue virus (DENV-1, DENV-2, DENV-3, and DENV-4)
- Transmitted primarily by female Aedes aegypti mosquitoes
- Nearly 95% of dengue cases globally are in children under 15 years of age
- Not directly contagious from person to person (except from pregnant woman to child)
- No specific antiviral treatment exists, making supportive care critical
Why Dengue Matters to Nurses
As frontline healthcare providers, nurses play a vital role in the early detection and management of dengue cases in children. Your vigilance in recognizing warning signs can prevent progression to severe dengue, while your expertise in fluid management and patient monitoring is essential for successful outcomes.
Epidemiology
Global Burden
- Approximately 390 million dengue infections occur annually worldwide
- Around 96 million manifest clinically (with symptoms)
- Endemic in over 100 countries, particularly in Asia, the Americas, and Africa
- Rising global incidence due to climate change, urbanization, and international travel
Pediatric Vulnerability
Children are particularly vulnerable to dengue for several reasons:
- Less developed immune systems
- Higher baseline capillary permeability
- Difficulty in articulating symptoms
- Greater risk of severe disease with secondary infections
- Faster progression from mild to severe disease
Transmission Cycle
- An infected mosquito bites a human, injecting virus with saliva
- The virus replicates in human cells (incubation period: 4-10 days)
- The infected person develops viremia (high levels of virus in blood)
- An uninfected mosquito bites the viremic person, becoming infected
- After an extrinsic incubation period of 8-12 days, the mosquito can transmit the virus to other humans for the rest of its lifespan (3-4 weeks)
The Aedes aegypti mosquito feeds primarily during daylight hours, especially at dawn and dusk. Unlike many other mosquitoes, it can bite multiple people during a single blood meal, making it an especially efficient disease vector.
Pathophysiology
Understanding the pathophysiology of dengue is crucial for anticipating complications and implementing appropriate nursing interventions. The disease progression in dengue infections involves complex interactions between the virus and the host’s immune system.
Viral Invasion and Replication
- The dengue virus enters the human body through a mosquito bite
- It initially replicates in local dendritic cells
- The virus then spreads through the lymphatic system
- It infects and replicates in monocytes, macrophages, and other cells
- Viremia develops, with virus present in the bloodstream
Immune Response
The immune response in dengue can be protective but can also contribute to pathology, especially in secondary infections.
Mnemonic: “ABC” of Dengue Pathophysiology
- Antibody-Dependent Enhancement
- Bleeding due to thrombocytopenia
- Capillary leakage causing plasma extravasation
Important Note
In children, the pathophysiological changes can develop more rapidly than in adults, and the clinical deterioration can be sudden. This makes vigilant monitoring crucial in pediatric dengue management.
Key Pathophysiological Mechanisms
Antibody-Dependent Enhancement (ADE)
In secondary infections with a different dengue serotype, pre-existing antibodies may bind to the virus but not neutralize it. Instead, these complexes enhance viral entry into cells, leading to increased viral replication and more severe disease.
Vascular Leakage
Inflammatory mediators released during infection increase vascular permeability, causing plasma leakage into extravascular spaces. This leads to hypovolemia, reduced circulation, and potentially shock.
Hemorrhagic Manifestations
Multiple mechanisms contribute to bleeding in dengue, including thrombocytopenia (low platelet count), platelet dysfunction, and coagulopathy. The virus can directly affect bone marrow and interfere with platelet production.
Clinical Manifestations
Children with dengue infection may present with a wide spectrum of clinical manifestations, from mild symptoms to severe disease. The presentation can vary significantly by age, immune status, and dengue serotype.
Common Symptoms
- High fever (40°C/104°F), typically sudden onset
- Severe headache, often with retro-orbital pain
- Muscle and joint pain (sometimes called “breakbone fever”)
- Nausea and vomiting
- Rash appearing 3-4 days after fever onset
- Pain behind the eyes that worsens with eye movement
- Mild bleeding manifestations (e.g., petechiae, easy bruising)
Warning Signs (Require Immediate Medical Attention)
- Severe abdominal pain or tenderness
- Persistent vomiting (≥3 episodes in 24 hours)
- Clinical fluid accumulation (pleural effusion, ascites)
- Mucosal bleeding (gums, nose, etc.)
- Lethargy or restlessness
- Liver enlargement >2 cm
- Laboratory: Increasing hematocrit with rapidly decreasing platelet count
Mnemonic: “DENGUE” Clinical Features
Diarrhea & Dehydration
Exanthem (Rash)
Nausea & Vomiting
Gum & nasal bleeding
Unbearable headache
Excruciating joint pain
Age-Specific Presentations in Children
| Age Group | Common Presentations | Special Considerations |
|---|---|---|
| Infants (<1 year) |
• Fever • Irritability • Feeding difficulties • Maculopapular rash |
• May present with undifferentiated febrile illness • Poor feeding is a key warning sign • Higher risk of plasma leakage |
| Toddlers (1-3 years) |
• High fever • Irritability • Vomiting • Petechial rash |
• May not verbalize symptoms • Watch for behavioral changes • May be misdiagnosed as other viral illnesses |
| School-age (4-12 years) |
• Classic “triad” of fever, rash, headache • Abdominal pain • Joint pain • Epistaxis (nosebleeds) |
• Better able to describe symptoms • Often present with more typical symptoms • Abdominal pain can be confused with appendicitis |
| Adolescents (13-18 years) |
• Similar to adults • Severe myalgia • Retro-orbital pain • More pronounced rash |
• May downplay symptoms • Higher incidence of severe muscle pain • Menstrual bleeding may be heavier in females |
Phases of Dengue Infection
The clinical course of dengue infection typically progresses through three distinct phases. Understanding these phases is crucial for appropriate nursing management and monitoring.
Febrile Phase
Duration: 2-7 days
Clinical Features:
- Sudden onset high fever (often >39°C/102.2°F)
- Facial flushing and skin erythema
- Generalized body ache
- Headache and retro-orbital pain
- Anorexia and nausea
- Minor bleeding (petechiae, epistaxis)
Nursing Priorities:
- Fever management with acetaminophen
- Monitor for warning signs
- Ensure adequate hydration
- Daily CBC to monitor platelet count
Critical Phase
Duration: 24-48 hours (days 3-7 of illness)
Clinical Features:
- Defervescence (temperature drops to 37.5-38°C)
- Increased capillary permeability
- Plasma leakage (pleural effusion, ascites)
- Progressive thrombocytopenia
- Increasing hematocrit
- Shock may develop in severe cases
Nursing Priorities:
- Close monitoring of vital signs
- Strict fluid management
- Hourly urine output monitoring
- Frequent hematocrit checks
Recovery Phase
Duration: 2-3 days
Clinical Features:
- General improvement in condition
- Stabilization of vital signs
- Reabsorption of extravascular fluid
- Improved appetite
- Bradycardia may occur
- Itchy convalescent rash (white patches on red background)
Nursing Priorities:
- Monitor for fluid overload
- Gradual discontinuation of IV fluids
- Nutritional support
- Support for fatigue and weakness
Critical Nursing Alert
The transition from febrile to critical phase is a crucial period where close monitoring is essential. The disappearance of fever does NOT indicate improvement—in fact, this is when most severe complications are likely to occur. Watch for warning signs including severe abdominal pain, persistent vomiting, lethargy, and bleeding.
Diagnosis and Identification
Early and accurate diagnosis of dengue is crucial for appropriate management. Nurses should be familiar with the diagnostic approach to support timely identification of cases.
Clinical Diagnosis
Clinical diagnosis is based on the WHO criteria:
Probable Dengue
Live in/travel to endemic area, fever, and 2+ of the following:
- Nausea, vomiting
- Rash
- Aches and pains
- Positive tourniquet test
- Leukopenia
- Any warning sign
Mnemonic: “FEVeR TLC”
For probable dengue diagnosis:
- Fever
- Endemic area (living or travel)
- Vomiting and nausea
- Rash
- Tourniquet test positive
- Leukopenia
- Clinical warning signs
Laboratory Diagnosis
| Test Type | Timing | Nursing Considerations |
|---|---|---|
| NS1 Antigen Test | Days 0-5 of illness |
• Rapid diagnostic test • Most useful in early phase • Explain purpose to child/parents |
| PCR (Viral RNA) | Days 0-7 of illness |
• Highly specific • Can identify serotype • Explain blood draw procedure |
| Serology (IgM/IgG) | IgM: After day 5 IgG: After day 7 |
• Paired samples may be needed • Can differentiate primary/secondary infection • Document timing of symptoms |
| Complete Blood Count | Daily during illness |
• Watch for thrombocytopenia • Monitor leukopenia • Track hematocrit changes |
Tourniquet Test Procedure
- Inflating a blood pressure cuff to a point midway between systolic and diastolic pressure for 5 minutes
- Mark a 2.5 cm × 2.5 cm (1 inch × 1 inch) square on the ventral surface of the forearm
- Count the number of petechiae in this area
- A positive test has 10 or more petechiae per square inch
- The test is often positive in children with dengue, but may be negative in adults
Nursing Tips:
- Explain the procedure to child and parents
- Ensure comfort during the 5-minute cuff inflation
- Use distraction techniques for younger children
- Document results accurately
Differential Diagnosis
Several conditions can mimic dengue infection in children:
- Influenza
- Measles
- Rubella
- Zika virus
- Typhoid fever
- Leptospirosis
- Meningococcemia
- Malaria
- Acute appendicitis
- Juvenile rheumatoid arthritis
Nursing Management in Hospital
Hospital management of pediatric dengue focuses on close monitoring, appropriate fluid management, and vigilance for early detection of complications. Nurses play a critical role in all aspects of this care.
Assessment & Monitoring
- Vital signs every 1-4 hours (more frequently in critical phase)
- Monitor fluid intake and output hourly
- Daily weight to assess fluid status
- Assess for warning signs every shift
- Capillary refill time, peripheral pulse volume
- Abdominal examination for tenderness, hepatomegaly
- Neurological status assessment
- Laboratory monitoring: CBC, hematocrit, platelets
Fluid Management
- Calculate maintenance fluid based on weight
- Use isotonic solutions (0.9% saline, Ringer’s lactate)
- Adjust rate based on clinical parameters
- In critical phase, give minimum volume required
- Monitor for signs of fluid overload
- Document intake/output meticulously
- If shock occurs, administer fluid bolus as per protocol
- Avoid hypotonic solutions
Symptom Management
- Fever management with acetaminophen only
- AVOID NSAIDs (aspirin, ibuprofen) due to bleeding risk
- Apply tepid sponging for high fever
- Position for comfort and to reduce respiratory effort
- Skin care to prevent pressure injuries
- Manage nausea with small, frequent meals
- Oral hygiene, especially with mucosal bleeding
- Age-appropriate pain assessment and management
Mnemonic: “FLUID CARE” for Dengue Hospital Management
Frequent monitoring
Lab values tracking
Urine output recording
Isotonic fluids only
Defervescence awareness
Comfort measures
Acetaminophen only
Reassess constantly
Educate family
Nursing Care Plan: Dengue Fever in Children
| Nursing Diagnosis | Interventions | Expected Outcomes |
|---|---|---|
|
Hyperthermia related to viral infection as evidenced by elevated body temperature |
|
|
|
Risk for Deficient Fluid Volume related to increased capillary permeability and plasma leakage |
|
|
|
Risk for Bleeding related to thrombocytopenia and coagulopathy |
|
|
|
Anxiety (Child/Parents) related to illness, hospitalization, and potential complications |
|
|
Severe Dengue: Emergency Nursing Management
If a child develops severe dengue with shock, rapid nursing intervention is crucial:
Immediate Actions:
- Call for emergency assistance
- Position child flat with legs elevated
- Administer oxygen
- Establish/maintain large-bore IV access
- Initiate fluid resuscitation as per protocol
- Monitor response to fluid therapy
Ongoing Management:
- Monitor vital signs every 15-30 minutes
- Continuous cardiac monitoring
- Reassess fluid status frequently
- Check hematocrit levels
- Prepare for blood product administration if needed
- Document all interventions and responses
Nursing Management at Home
Most children with dengue can be managed at home with proper nursing guidance and family education. Nurses have a critical role in preparing families for home care and teaching them to recognize warning signs that require immediate medical attention.
Home Care Instructions
Fluid Management
- Encourage oral rehydration solution (ORS)
- Offer frequent small amounts of fluids
- Suitable fluids: water, ORS, fresh fruit juices, coconut water
- Avoid carbonated drinks and caffeine
- Monitor urine output (frequency, amount, color)
- Keep a fluid intake chart
Fever Management
- Use acetaminophen (paracetamol) only
- NEVER give aspirin or ibuprofen
- Follow recommended dosage by weight
- Apply tepid sponging for high fever
- Lightweight clothing and comfortable room temperature
- Monitor temperature regularly
Nutrition
- Offer small, frequent meals
- Provide easily digestible foods
- Include fruits rich in vitamin C
- Avoid spicy, oily or heavy foods
- Monitor appetite as an indicator of recovery
When to Seek Immediate Medical Care
Instruct families to return to the hospital immediately if ANY of these signs occur:
- Severe abdominal pain or persistent vomiting
- Bleeding from nose, gums, or in vomit/stool
- Excessive sleepiness, irritability, or confusion
- Cold or clammy skin
- Difficulty breathing
- No urination for 4-6 hours
- Refusal to drink fluids
Mnemonic: “DENGUE RED FLAGS”
Nursing Education for Families
Monitoring at Home
- Teach temperature measurement technique
- Demonstrate fluid intake/output recording
- Explain signs of dehydration
- Show how to check for skin rash or bleeding
- Instruct on keeping a symptom diary
Medication Administration
- Explain proper acetaminophen dosing by weight
- Demonstrate use of medication syringe/cup
- Emphasize avoiding aspirin and NSAIDs
- Teach timing of antipyretic administration
- Explain how to document medication given
Comfort Measures
- Demonstrate tepid sponging technique
- Explain positioning for comfort
- Suggest age-appropriate distraction activities
- Advise on skin care for rashes
- Recommend rest periods throughout the day
Follow-up Care After Discharge
- Schedule follow-up visit within 24-48 hours after discharge
- Arrange for laboratory follow-up as needed (CBC, platelet count)
- Provide written home care instructions
- Give emergency contact numbers
- Discuss gradual return to normal activities
- Arrange for home visits if available
- Educate on preventing reinfection
The 3 Golden Questions
Teach families to ask these questions daily:
- How much has the child been drinking?
- How often has the child been urinating?
- Has the child’s activity level changed?
Prevention and Control Strategies
Prevention of dengue focuses on vector control and personal protection measures. As nurses, educating communities and families about prevention is a key responsibility.
Vector Control Strategies
Environmental Management
- Eliminate mosquito breeding sites around homes
- Cover water storage containers
- Remove standing water from flower pots, tires, etc.
- Clean roof gutters and drains regularly
- Dispose of solid waste properly
- Maintain clean surroundings
Chemical Control
- Use of larvicides in water containers
- Space spraying during outbreaks
- Residual spraying of surfaces
- Use of temephos (Abate) in water storage
- Biological control with larvivorous fish or bacteria
Personal Protection Measures
Preventing Mosquito Bites
- Use insect repellents containing DEET, picaridin, or IR3535
- Wear long-sleeved shirts and long pants
- Use permethrin-treated clothing
- Install and use window/door screens
- Use bed nets, especially during daytime naps for children
- Use air conditioning when available
- Be especially vigilant during peak mosquito hours (early morning and late afternoon)
Mnemonic: “PROTECT” from Dengue
- Prevent breeding sites around home
- Repellents should be applied regularly
- Optimize screening on windows and doors
- Treat standing water with larvicides
- Eliminate containers that collect water
- Cover skin with appropriate clothing
- Take special care during peak mosquito hours
Nursing Role in Community Prevention
Health Education
- Conduct awareness sessions in schools
- Develop educational materials
- Teach about dengue transmission
- Demonstrate vector control methods
- Address misconceptions about dengue
Community Surveillance
- Participate in case detection
- Report suspected cases
- Help identify outbreak clusters
- Conduct home visits in affected areas
- Monitor vector breeding sites
Advocacy & Support
- Advocate for environmental improvements
- Support community clean-up campaigns
- Coordinate with local authorities
- Mobilize community volunteers
- Promote sustainable prevention practices
Dengue Vaccines and Future Directions
Vaccination can be an additional tool for dengue prevention in some contexts, though it does not replace vector control efforts.
Current Vaccine Status
- The FDA has approved a dengue vaccine (Dengvaxia) for children ages 9-16 who have laboratory-confirmed previous dengue infection and live in endemic areas
- The CDC recommends the vaccine for children ages 9-16 years who live in Puerto Rico and other endemic U.S. territories
- TAK-003 (Qdenga) is another dengue vaccine approved in some countries
- Vaccination is most effective for those with prior dengue infection
Nursing Considerations
- Stay updated on vaccine recommendations
- Provide accurate information to families
- Understand the importance of serological testing before vaccination
- Be aware of potential adverse effects and contraindications
Important Vaccine Considerations
The dengue vaccine is NOT recommended for:
- Children without previous dengue infection
- Individuals with compromised immune systems
- Pregnant or breastfeeding women
- People with allergies to vaccine components
- Travelers or those living in non-endemic areas
Complications and Key Points
Potential Complications
Severe Dengue Complications
-
Dengue Hemorrhagic Fever (DHF)
Characterized by increased vascular permeability, thrombocytopenia, and hemorrhagic manifestations
-
Dengue Shock Syndrome (DSS)
Circulatory failure due to plasma leakage, narrow pulse pressure, hypotension
-
Organ Impairment
Including hepatic, neurological, cardiac, and renal complications
-
Encephalopathy/Encephalitis
Altered consciousness, seizures, focal neurological signs
-
Metabolic Abnormalities
Acidosis, hypoglycemia, electrolyte imbalances
Prognostic Factors
Risk Factors for Severe Disease
Host Factors
- Young age (<5 years)
- Female gender
- Secondary dengue infection
- Specific HLA types
- Chronic diseases (diabetes, asthma)
Viral Factors
- Virus serotype (DENV-2 and DENV-3 associated with greater severity)
- Viral load
- Viral genotype
Mnemonic: “ABCS” of Dengue Complications
- Acidosis
- Bleeding
- Calcium (hypocalcemia)
- Sugar (hypoglycemia)
Key Points for Nursing Students
Assessment Pearls
- The disappearance of fever (defervescence) is a critical time for monitoring, not a sign of improvement
- Capillary refill time is a sensitive indicator of circulatory status
- Rising hematocrit with falling platelets is a key warning sign
- The tourniquet test can help identify capillary fragility early
- Persistent vomiting is a significant warning sign
Treatment Essentials
- Fluid management is the cornerstone of dengue treatment
- Acetaminophen is the ONLY recommended antipyretic
- Judicious fluid administration prevents both shock and fluid overload
- Most cases recover completely with appropriate supportive care
- Early recognition and treatment of warning signs prevents severe disease
Prevention Priorities
- Community education is the most sustainable prevention strategy
- The Aedes mosquito bites during day time, especially early morning and late afternoon
- Personal protection is especially important for children
- Regular environmental surveys can identify breeding sites
- Integrated vector management approaches are most effective
Self-Assessment Questions
1. Which of the following is the most critical nursing intervention during the critical phase of dengue?
- Administering NSAIDs for pain relief
- Monitoring fluid balance and vital signs
- Encouraging ambulation to prevent stasis
- Administering prophylactic antibiotics
Answer: b. Monitoring fluid balance and vital signs
2. A 6-year-old child with dengue has a temperature of 38.5°C and is complaining of headache. What is the most appropriate medication to administer?
- Aspirin
- Ibuprofen
- Acetaminophen (Paracetamol)
- Naproxen
Answer: c. Acetaminophen (Paracetamol)
3. Which of the following is NOT a warning sign of severe dengue?
- Persistent vomiting
- Severe abdominal pain
- Low-grade fever for 2 days
- Mucosal bleeding
Answer: c. Low-grade fever for 2 days
4. What laboratory finding is most concerning in a child with dengue entering the critical phase?
- Rising hematocrit with falling platelet count
- Mild leukocytosis
- Slightly elevated liver enzymes
- Mild hypokalemia
Answer: a. Rising hematocrit with falling platelet count
5. Which of the following should be included in discharge education for the family of a child recovering from dengue?
- Continue ibuprofen for pain control
- Return to hospital if fever returns
- Limit fluid intake to prevent fluid overload
- Resume normal activities immediately
Answer: b. Return to hospital if fever returns