Dengue in Children: Early Recognition, Progression to Severe Disease, and Timely Hospitalization

Dengue remains one of the fastest-growing mosquito-borne viral infections, with children being particularly vulnerable to the disease. Nearly half of the global population is at risk, while Asia accounts for about 70% of the disease burden (1). India experiences recurrent monsoon and post-monsoon outbreaks, leading to significant paediatric hospitalizations. A Delhi cohort study involving 984 children reported the highest burden among 5–10-year-olds, with DEN-3 as the dominant serotype (2). Urbanization, climate change, poor vector control, and water stagnation continue to drive dengue transmission in endemic regions (3)

Dengue progresses through four clinical phases: incubation, febrile, critical, and recovery. The febrile phase presents with high fever, headache, myalgia, rash, and mild bleeding. Around defervescence, some patients enter the critical phase characterized by plasma leakage, thrombocytopenia, and risk of shock or severe bleeding. During recovery, fluid reabsorption and platelet improvement occur. Early recognition of warning signs is essential to avoid severe dengue complications (1).

Recent evidence suggests that dengue progression is not explained by thrombocytopenia alone; it reflects an early interaction between viral burden, immune activation, and endothelial injury. Higher day-3 viremia has been associated with severe dengue (4), while febrile-phase vascular and inflammatory markers such as syndecan-1, angiopoietin-2, IL-8 and ferritin correlate with later stages of dengue (5). These markers are linked with vascular leakage, organ dysfunction, ICU admission and mortality (6).

Figure- Clinical Progression of Dengue

Warning Signs and Complications of Dengue

Warning signs include persistent vomiting, severe abdominal pain, mucosal bleeding, lethargy, restlessness, hepatomegaly, and clinical fluid accumulation such as pleural effusion or ascites (1). Severe complications include dengue shock syndrome, severe bleeding, acute liver injury, encephalopathy, myocarditis, acute kidney injury, and multiorgan failure (7). Critically ill children may also develop secondary bacterial co-infections, which can worsen outcomes and increase ICU stay and mortality risk (8).

A systematic review published in The Nature highlighted that children in endemic countries face repeated dengue exposure, increasing the risk of secondary infections, since the immunity developed after infection with one serotype is type-specific (9).

Severe neurological complications may persist after recovery, with 39.3% of children with dengue encephalitis developing neurological sequelae (10).

Diagnosis and Management in Children

Early diagnosis is essential for appropriate monitoring and management. NS1 antigen testing during the early febrile stage and IgM antibody testing later in the illness are commonly used diagnostic tools (1).

Hospitalized children with dengue require serial hematocrit (HCT) monitoring as the primary objective indicator for plasma leakage, alongside serial platelet counts to track disease progression. For severe cases, diagnostic checks must include accurate urine output via indwelling catheters, central venous pressure (CVP), and DIC studies if uncontrolled bleeding is suspected. Additionally, bedside ultrasound or chest X-rays are valuable for identifying "hidden" fluid accumulations, such as pleural effusion or ascites, which are hallmark signs of critical-phase plasma leakage in pediatric patients (11).

Supportive Treatment Remains the Cornerstone

There is currently no specific antiviral therapy for dengue (1,7,12). Management includes:

• Adequate fluids (oral/ intravenous)
• Monitoring haematocrit and platelet counts
• Fever management
• Avoidance of NSAIDs (ibuprofen and aspirin) (1)

The IAP guidelines emphasize cautious intravenous crystalloid therapy, as excessive fluids during the capillary leak phase may worsen respiratory distress and fluid overload (13). Supportive treatment remains the cornerstone of dengue management in children, in the absence of specific antiviral therapy.

National MoHFW- GOI guidelines stress early recognition of warning signs, adequate hydration, careful intravenous fluid therapy, and close monitoring of hematocrit, platelet count, urine output, and vital signs to prevent progression to shock and organ dysfunction. Children with severe dengue often require intensive monitoring to balance timely fluid resuscitation while avoiding complications such as pulmonary edema and fluid overload (11).

When is Hospitalization Needed?

Hospitalization is needed when a child with dengue develops warning signs such as abdominal pain, persistent vomiting, mucosal bleeding, fluid accumulation, lethargy/restlessness, rising hematocrit with falling platelets, or reduced urine output (13,14)

Children with dengue shock, severe bleeding, respiratory distress due to fluid accumulation, or organ involvement should be managed urgently, preferably in a PICU (13).

Post Dengue Recovery

Post-dengue recovery in children requires careful follow-up, as clinical improvement may continue even after fever resolution and hospital discharge. In the recovery phase of paediatric dengue, Indian data suggest that rising platelet count is an important marker of clinical improvement. In a Chennai study including 80 hospitalized children, immature platelet fraction significantly correlated with subsequent platelet recovery, helping guide follow-up and avoid unnecessary platelet transfusion(15).