Dengue among children in India: Clinical Complexity, Unfavourable Outcomes and the Role of Comorbid Conditions- Dr S. Balasubramanian

National Dengue Day, observed every year on May 16, marks the Ministry of Health and Family Welfare's nationwide push to strengthen dengue awareness, prevention, and community participation. Dengue fever has evolved into a year-round public health issue in India, rather than a seasonal occurrence. According to official National Centre for Vector Borne Diseases Control (NCVBDC) data, more than 1 million dengue cases and 1,572 deaths were reported in India over the last five years (2021–2026). In partial data available for 2026 alone, 6,927 cases and 10 deaths have already been reported. (1)

Data in the pediatric age group from Delhi, a cohort of 984 children between the ages of 6 months and 15 years had an acute dengue incidence of 37.9 per 1,000 person-years, with children between the ages of 5 and 10 having the highest burden at 50.4 per 1,000 person-years. (2) With dengue seroprevalence of 30.9% among 9–12-year-olds and 24.6% among 5–8-year-olds, Sero surveillance from Kerala further reveals hidden childhood exposure. About, parents of 90% of seropositive children were unaware of prior infection, indicating that routine reporting significantly underestimates the true burden. (3)

Dengue in children is becoming a growing public health challenge

A 2025 published retrospective study from Puducherry evaluated 632 dengue admissions in pediatric age group over a 5-year period at a tertiary-care women and child hospital. The study found that 54% of children had dengue with warning signs, while 3.5% progressed to severe dengue. Fever was reported in 99% of children, vomiting in 51.3%, and abdominal pain in 37.3% of cases. (4)

Another Karnataka-based prospective observational cohort involving 100 serologically confirmed dengue patients aged 1–15 years reported that 23% progressed to severe dengue. Persistent vomiting, abdominal pain, hepatomegaly, positive tourniquet test, and altered vital signs at admission were identified as early predictors of severe disease. (5) Among children aged <15 years, the median cost for hospitalised laboratory-confirmed dengue cases was INR 14,800. (6)

These findings highlight that dengue often presents variably and may worsen rapidly despite initially mild symptoms.

Hyperendemic Dengue Transmission and Multi-Serotype Co-Circulation in India

India shows clear evidence of hyperendemic dengue transmission, with widespread exposure beginning in childhood and increasing with age. In a nationally representative serosurvey conducted across 240 clusters in 60 districts from 15 states, tested 12,300 individuals and reported an overall dengue virus seroprevalence of 48.7% in India. Seroprevalence was already substantial among children, rising from 28.3% in those aged 5–8 years to 41.0% in those aged 9–17 years, indicating early and repeated exposure during school-age years. Regionally, dengue transmission was highly heterogeneous but particularly intense in southern India, where overall seroprevalence reached 76.9%, followed by western India at 62.3% and northern India at 60.3%. These findings demonstrate sustained and intense dengue transmission across India, with children experiencing significant exposure early in life and contributing substantially to the country’s expanding dengue burden. (7)

India also reports circulation of all four dengue virus serotypes — DENV-1, DENV-2, DENV-3, and DENV-4. A 2024 tertiary-care study from Northern India analysing dengue samples from earlier this decade confirmed circulation of multiple serotypes, reinforcing India’s hyperendemic pattern. (8)

The co-circulation of multiple serotypes increases the risk of secondary dengue infections, which may predispose children to severe disease due to antibody-dependent enhancement.

Co-morbidities Augment Dengue Severity in Children

Comorbidities are increasingly recognised as important contributors to severe dengue among pediatric population. Children with chronic illnesses such as asthma, congenital heart disease, malnutrition, haematological disorders, and metabolic abnormalities may also face increased risk of severe disease and complications.

A recent Indian meta-analysis of 21 studies including 186,901 children reported a pooled childhood obesity prevalence of 8.4% and overweight prevalence of 12.4%, indicating that nearly 1 in 10 Indian children are obese. (9) A systematic review and meta-analysis of 15 paediatric studies, found that obese children had 38% higher odds of developing severe dengue compared with non-obese children (OR 1.38; 95% CI 1.10–1.73). (10) Indian hospital data, further highlights the severe clinical spectrum of dengue in children, reporting outcomes among 151 admitted children aged 1 month to 16 years. (11) Together, these findings suggest that the growing burden of childhood obesity may increase the pool of children at risk for severe dengue outcomes in India.

Clinicians are therefore increasingly recognising obesity and metabolic dysfunction as important risk factor of dengue requiring close monitoring in children

Expanded Dengue Syndrome

A 2026 Indian scoping review highlighted “expanded dengue syndrome” as a severe multisystem form of dengue involving neurological, cardiac, hepatic, renal, respiratory, and haematological complications.

 

Fig.1: Potential Complications in an Expanded Dengue Syndrome

Predicting Unfavorable Outcomes in Dengue among Pediatrics

Recent Indian studies have highlighted the importance of liver involvement and laboratory abnormalities in severe dengue among pediatric population. A 2024 observational study from Pune evaluated 151 children aged one month to 16 years admitted with dengue fever over a 3-year period. The study reported 4.8% mortality and observed hepatomegaly in 34% of children. Elevated SGOT, SGPT, bilirubin, APTT, and PT levels were significantly associated with PICU admission and mortality. (11)

A prospective study from New Delhi evaluated 78 children with laboratory-confirmed severe dengue fever admitted to a tertiary-level PICU. The study reported 20 deaths, corresponding to a 25.6% mortality rate. Non-survivors had significantly higher disease-severity and organ-dysfunction scores, along with elevated transaminases, blood lactate, and serum creatinine. The study also noted that children who died required more intensive interventions within the first 24 hours of admission, suggesting that early organ dysfunction and need for aggressive support may predict poor outcomes in pediatric severe dengue. (12)

Preventive measures such as elimination of stagnant water, sanitation improvement, vector control through fumigation, mosquito repellents, window screens, and use of full-sleeve clothing remain important for reducing dengue exposure in children. (1)

However, despite repeated awareness campaigns and vector-control measures, outbreaks continue to occur because of rapid urbanisation in cities, poor sanitation in villages, overcrowding, and climatic conditions favourable for mosquito breeding. Currently, no universally effective preventive strategy is available to completely control dengue transmission.

Parents and caregivers should be educated regarding warning signs such as persistent vomiting, severe abdominal pain, lethargy, bleeding manifestations, breathing difficulty, reduced urine output, and inability to tolerate oral fluids. Early diagnosis and timely referral remain critical in preventing severe disease and mortality.

Fig 2: Dengue in children

Take Home Messages

• Dengue in children is becoming a major public health challenge, driven by rising hospitalisations, silent transmission, hyperendemic serotype circulation, obesity, and severe inflammatory complications.
•  Indian studies suggest that warning signs, plasma leakage, liver dysfunction, childhood obesity, and laboratory abnormalities are important predictors of severity apart from platelet count alone, highlighting the need for early clinical assessment, severity stratification, and timely supportive care.
• Stronger surveillance, caregiver awareness, vector-control measures, timely referral, and future dengue vaccination strategies will be essential to reduce severe paediatric dengue transmission, complications, and mortality in India.

Disclaimer: The information contained herein is based on the published medical literature and international recommended guidelines. It is not intended to substitute the consultation with a healthcare provider/ registered medical practitioner and shall not be used for diagnosing or treating a health problem or disease. The information provided is aimed at increasing awareness on Dengue and it is not meant for promotion of any specific product. Registered Healthcare Practitioner / Registered Medical Practitioner shall apply their independent medical judgement for assessing or diagnosing or treating any patient. Takeda makes no representation or warranty concerning the information/content provided. The user/presenter of this presentation at his discretion may modify the contents as may be required in accordance with applicable references, laws and regulations. Any liability resulting from modification of slide set shall be the sole responsibility of user/presenter.

Document Number: C-ANPROM/IN/QDE/0167; Date of Preparation: May 2026