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Dengue Hemorrhagic Fever Management in Infants

The principle of Dengue Hemorrhagic Fever Management in infants must be understood because the risk of mortality is higher than in pediatric groups. According to WHO, the infant is included in the high-risk group for severe dengue infection. Dengue infection in infants is often experienced by the 4-9 months age group.

Dengue Hemorrhagic Fever Management in Infants

Differences in Dengue Severity in Infants, Children, and Adults

A study of 118 infants aged <12 months in Vietnam found that almost all infants affected by dengue had manifestations of bleeding in the form of petechiae (99%). This study also reported that 97.1% of patients had manifestations of hepatomegaly, splenomegaly in 6.5%, gastrointestinal bleeding in 7.4%, and dengue shock syndrome in 20.5%. Dengue encephalopathy was found in 10 patients (9.3%), in which seizures occurred in 7 patients, lethargy in 4 patients, and coma in 4 patients. Pneumonia was also found in 4 patients, bronchitis and bronchiolitis in 4 patients, and shigellosis in 2 patients.

Another study in Nicaragua reported that the infant had more severe clinical manifestations than both children and adults (infant 64%, children 55%, adults 36%). Severe clinical manifestations can include dengue shock syndrome, plasma leakage, severe thrombocytopenia, and internal bleeding, which is more common in infants aged 6 months.

The WHO guidelines for dengue management states that the infant has fewer respiratory reserves and is more susceptible to liver damage and electrolyte imbalance. On the other hand, the infant also responds more quickly to fluid resuscitation and has a shorter duration of plasma leakage, therefore in the management of dengue in infants can be examined urine output and fluid intake more frequently than adults.

Problems Commonly Faced in Dengue Hemorrhagic Fever Management in Infants

Problems that are often faced in the management of cases of dengue in infants include the assessment of clinical manifestations, difficulty detecting shock, installing intravenous access, fluid selection, and an increased risk of hypoglycemia.

Difficulty Assessing Clinical Manifestations

Difficulties in the management of dengue in infants start from establishing the diagnosis. Fever in infant, which certainly has many differential diagnoses.
Symptoms that appear in infants are not as clear as pediatric or adult patients. For example, pediatric and adult patients can complain of bone and joint pain, while in infants, these manifestations may appear in the form of fussy children.

Doctors can suspect the possibility of dengue infection if the patient lives or has a history of travel to the endemic area of ​​dengue, or if there are individuals around the patient's environment who get dengue fever.

In the fever phase, some diseases manifest like dengue, especially diseases with flu-like symptoms such as common cold, influenza, chikungunya, measles, and typhoid fever.

Difficulty Detecting Shock

Another difficulty often encountered is in assessing shock. Untreated plasma volume permeation can cause shock to death.

Shock is characterized by pulse pressure (difference in systolic and diastolic blood pressure) ≤20 mmHg or signs of decreased peripheral perfusion. Shock is classified as compensated if there are signs of decreased peripheral perfusion, but systolic blood pressure remains normal. Shock is classified as decompensated if there are signs of reduced peripheral perfusion accompanied by hypotension or unmeasured blood pressure.

In fact, blood pressure measurements in infants often experience problems. Often the infant sphygmomanometer cuffs used are of the inappropriate size or even not available. To overcome this, the doctor can assess other signs of shock such as decreased consciousness and decreased peripheral perfusion characterized by prolonged capillary filling times, weak pulses, heart rate significantly increased or decreased, and cold acral.

Another way to assess infant shock is to compare body weight before illness with current body weight, see oliguria to anuria, assess muscle tone, see hydration of mucous membranes, and check fontanelle.

Difficulties in Installing Intravenous Access

Installation of intravenous access to infants is often difficult, especially if the infant is in shock. Veins in the infant are smaller and are less supported by the surrounding soft tissue. The most commonly chosen peripheral veins are the cephalic veins in the hands, the dorsal arcus veins in the legs, or superficial temporalis veins on the scalp.

Another alternative is the administration of fluid through a nasogastric tube (NGT) if having difficulty installing access to the peripheral veins. Installation of intraosseous access in the upper third of the anteromedial tibia or distal femur (about 2 cm above the lateral condyle) also an alternative to giving fluids and taking blood samples. Even central venous catheters can be installed in the femoral, jugular and subclavian veins.

Risk of Hypoglycemia

Hypoglycemia can appear in infants infected with dengue because of the neurohormonal stress response. Periodic monitoring of blood glucose levels needs to be performed.

If hypoglycemia develops, give glucose 0.1-0.5 g / kg body weight to normal blood sugar levels. Furthermore, maintain sugar levels by administering isotonic liquids that contain maintenance glucose levels, for example, 5% dextrose in normal saline fluid or ½ saline liquid of 1-3 ml/kg/hour.

Appropriate Liquid Selection

The recommended fluids for resuscitation are crystalloids (0.9% NaCl or Ringer lactate) or colloids (dextran, hydroxyethyl starch, and gelatin) given an initial bolus of 10-20 ml/kg in 10 minutes and repeated if necessary.

The choice of fluids for maintenance recommended by WHO is Ringer lactate, Ringer acetate, and NaCl 0.9%. Other guidelines suggest maintenance fluids are NaCl 0.9% + Dextrose 5% +/- 20 mmol / L KCl. Provision of hypotonic fluid with lower sodium content than plasma is not recommended because of the risk of hyponatremia


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References
1. WHO. Handbook for clinical management of dengue. WHO. 2012: 30-37
2. Hung NT, Lei HY, Lan, NT, et al. Dengue hemorrhagic fever in infants: a study of clinical and cytokines profile.J Inf Disease, 2004. 189:221-32.
3. Hammond SN, Balmaseda A, Perez L, et al. Differences in dengue severity in infants, children, and adults in a 3 year hospital based study in Nicaragua. Am J Trop Med Hyg, 2005. 73(6):1063-70.
4. WHO. Dengue. In : Pocket book of hospital care for children, 2nd ed. WHO. 2013: 188.
5. Haas NA. Clinical review: Vascular access for fluid infusion in children. Critical Care. 2004;8(6):478-484. doi:10.1186/cc2880.
6. Intravenous fluids. (https://www.rch.org.au/clinicalguide/guideline_index/Intravenous_fluids/#this-guideline-has-been-adapted-for-statewide-use-with-the-suppo)
7. Disque K. Pediatric Advanced Life Support. Satori Continum Publishing. 2015:47
8. Standards for pediatric intravenous fluids: NSW Health, 2nd ed. 2015:6 (https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2015_008.pdf)

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