Dengue in Children

M Priyanka

ALTERNATIVE NAMESHemorrhagic dengueDengue shock syndromePhilippine hemorrhagic feverThai hemorrhagic feverSingapore hemorrhagic feverBreakbone fever

Dengue Hemorrhagic Fever is an acute infectious viral disease usually affecting infants and young children. This disease used to be called break-bone fever because it sometimes causes severe joint and muscle pain that feels like bones are breaking.is a severe, potentially deadly infection spread by certain species of mosquitoes (Aedes aegypti).Philippine Hemorrhagic Fever was first reported in 1953. in 1958, hemorrhagic fever became a notifiable disease in the country and was later reclassified as Dengue Hemorrhagic Fever.

ETIOLOGIC AGENT

Flavivirus, Dengue Virus Types 1, 2, 3, & 4Chikungunya Virus

SOURCE OF

INFECTION

Vector mosquito Aedis Aegypti , Aedis albopictus,

The infected person

INCUBATION PERIODUNCERTAIN. Probably 6 days to 1 week

PERIOD OF COMMUNICABILITYUnknown. Presumed to be on the first week of illness when virus is still present in the blood.

SUSCEPTIBILITY, RESISTANCE AND OCCURRENCE

All persons are susceptible. Both sexes are equally affected. Age groups predominantly affected are the preschool age and school age. Adults and infants are not exempted. Peak age affected 5-9 years.Occurrence is sporadic through out the year. Epidemic usually occur during the rainy seasons June – November. Peak months are September and October.Occurs wherever vector mosquito exists. Susceptibility is universal. Acquired immunity may be temporary but usually permanent.

SIGN and SYMPTOMS

An acute febrile infection of sudden onset with clinical manifestation of 3 stages:

First 4 days – Febrile or Invasive Stage

Saddble back fever (alteration febrile and afebrile period of 2-3 days each)

Abdominal pain and headache Later flushing which may

accompanied by vomiting, conjunctival infection and epistaxis

4th-7th days – Toxic or Hemorrhagic Stage

Lowering of temperatureSevere abdominal painVomiting and frequent bleeding from gastrointestinal tract in the form of hematemesis or melenaUnstable BPNarrow pulse pressureshock

7th-10th day – Convalescent or Recovery stage

Generalized flushing with intervening areas of blanching appetite regainedBlood pressure already stable

CLASSIFICATION

Severe, frank type – with flushing, sudden high fever, severe hemorrhage, followed by sudden drop of temperature, shock and terminating in recovery or death.Moderate – with high fever, but less hemorrhage, no shockMild – with slight fever, with or without petechial hemorrhage but epidemiologically related to typical cases usually discovered in the course of investigation of typical cases.

PETECHIAE

BRUISES

RASHThe rash of dengue fever in the acute stage of the infection

blanches when pressed.

Exams and Test

Physical Examination may reveal the following:Low BPA weak, rapid pulseRashRed eyesRed throatSwollen glandsEnlarged liver (hepatomegaly)

Warning signsWorsening abdominal painOngoing vomitingLiver enlargementMucosal bleedingHigh hematocrit with low plateletsLethargy or restlessnessSerosal effusions

DHF is currently defined by the following fourWorld Health Organization (WHO) criteria:

• Fever or recent history of fever lasting 2–7 days. • Any hemorrhagic manifestation (a positive tourniquet test, skin hemorrhages (petechiae, hematomas), epistaxis (nose bleed), gingival bleeding (gum bleed), and microscopic hematuria, vaginal bleeding, hematemesis, melena, and intracranial bleeding). • Thrombocytopenia (platelet countof <100,000/mm3). • Evidence of increased vascular permeability (elevated hematocrit ≥20%; decline in hematocrit after volume-replacement treatment of ≥20%; pleural effusion or ascites; hypoproteinemia or hypoalbuminemia).

Dengue shock syndrome (DSS) is defined as any case that meets the four criteria for DHF and has evidence of circulatory failure manifested by (1) rapid, weak pulse and narrow pulse pressure (≤20 mmHg [2.7 kPa]) or (2) hypotension for age, restlessness, and cold, clammy skin.

Test may iclude the following:HematocritPlatelet countElectrolytesCoagulation studiesLiver enzymesBlood gasesTorniquet test (causes petechiae below the torniquet)X-ray of the chest (may demonstrate pleural effusion)Serologic studies (demonstrate antibodies to Dengue viruses - IgG and IgM)Serum studies from samples taken during acute illness and convalescence (High in titer to Dengue antigen - NS1)

Antibodies & Antigens in Dengue

COMPLICATIONS

Most people who develop DHF recover completely within 2 weeks. Some, however, may go through several weeks to months of feeling tired and/or depressed. Others develop severe bleeding problems. This complication, DHF, is a serious illness which can lead to shock (very low BP) and is sometimes fatal especially to children and young adults.

Other complications are the following:ShockEncephalopathyResidual brain damageSeizuresLiver damage

MANAGEMENT

Supportive and symptomatic treatment should be providedFor fever, give paracetamol for muscle pains. For headache, give analgesic. DON’T give ASPIRIN.Rapid replacement of body fluids is trhe most important treatmentIncludes intensive monitoring and follow-up.Give ORESOL to replace fluid as in moderate dehydration at 75 ml/kg in 4-6 hours or up to 2-3L in adults. Continue ORS intake until patient’s condition improves.

Nursing Care

1. For hemorrhage – keep the px at rest during bleeding episodes. For nose bleeding, maintain an elevated position of trunk and promote vasoconstriction in nasal mucosa membrane through an ice bag over the forehead. For melena, ice bag over the abdomen. Avoid unnecessary movement. If transfusion is given, support the patient during the therapy. Observe signs of deterioration (shock) such as low pulse, cold clammy perspiration, prostration..

2. For shock – prevention is the best treatment. Dorsal recumbent position facilitates circulation. Adequate preparation of the patient,

mentally and physically prevents occurrence of shock.

Provision of warmth-through lightweight covers (overheating causes vasodilation which aggravates bleeding).

3. Diet – low fat, low fiber, non-irritating, non-carbonated. Noodle soup may be given.

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