Consensus Statement on the Management of Dengue Infection

in the Paediatric Population

Chapter of Paediatrics, Academy of Medicine of Malaysia
Contents

Page

1. Definition , Scope of the Problem and Morbidity Issues . 2

2. Clinical Spectrum of Dengue Infection . 3
2.1 Pointers to Clinical Diagnosis of Dengue Infection
2
3

Atypical Presentations

3
4

2.2 Dengue Fever vs. Dengue Haemorrhagic Fever

2.3 WHO Case Definition of DHF

3. Management .. 6
3.1 Management of a Child with Suspected Dengue Infection

3.2 Management of Grades I and II DHF

3.3 Management of Dengue Shock Syndrome (Grades III and IV DHF)

3.4 WHO Management Guidelines for DSS

3.5 Blood Transfusion

10

3.6 Special Notes

10

3.7 Criteria for Discharging Patients Hospitalised with DF / DHF

11

4. Laboratory Diagnosis 11
5. Advice for Parents on Source Reduction in the Home and Vicinity 12
6. References ..13
7. Members of Committee 15

Figure 1 : Manifestations of the Dengue Syndrome 3

Figure 2 : Volume replacement flow-chart in Dengue Haemorrhagic Fever .. 8
Figure 3 : Treatment of dengue shock syndrome, grades III and IV ... 9

1. DEFINITION
Dengue virus infections cause a spectrum of illness ranging from asymptomatic, mild
undifferentiated fever to classical dengue fever (DF), and dengue fever with
haemorrhagic manifestations, or dengue haemorrhagic fever (DHF) and the dengue shock
syndrome (DSS). The classification of severe dengue has been complicated by the
variation in clinical picture, for which the underlying pathophysiology may be different.
1.1 Scope of the problem
There are four strains of the dengue virus. The virulence pattern is different in different
regions and spontaneous mutation in the viral strain can cause variation in the virulence
pattern. The presence of all 4 viral strains in Malaysia in the recent years has made the
infection endemic and a threat to the population. All age groups are being affected. As
there is no specific treatment available it is imperative to assist all clinicians to recognize
the varied clinical spectrum seen and start symptomatic treatment early. Many clinicians
are unaware of the unusual modes of presentation and multisystem involvement being
seen now.
1.2 Morbidity Issue
Some facts about the dengue situation in the country:
1. Prevailing virus strains are predominantly DEN 1 followed by DEN 2 in 1996 and
1997.
2. Case fatality rate (CFR) for DHF is higher in Malaysia than the neighbouring
countries. The Ministry of Health Vector Borne Disease Control Section (Cawangan
Penyakit Bawaan Vektor) recorded a total number of dengue fever cases in 1998 as
26,240 with 5 deaths. There were 53 deaths out of a total of 1,133 cases of dengue
haemorrhagic fever in the same year. Taking the latter numbers, the CFR is 4.67%.
Cambodia has the highest CFR of about 10%. The CFR in Thailand and Indonesia
are only 0.3% and 0.5% respectively. Intensive public health education, education of
frontline practitioners, and early recognition of the disease pattern in patients have
resulted in reduction of severe cases of DSS (Grade IV).
3. Unfamiliarity with the WHO Classification of dengue infection could result in cases
of DHF being reported as DF, and hence the relatively small number of notified cases
of DHF, resulting in the high CFR.
DF and DHF is a notifiable disease in this country since 1974. It is compulsory for all Medical
Officers to notify the disease under the Prevention and Control of Infectious Diseases Act, 1988.
All cases diagnosed clinically are to be notified by the attending Physicians / Medical Officers to
the nearest district health office within 24 hours. One should not wait for laboratory confirmation
of the case before notification. Early notification is very essential for control measures to be
instituted immediately. Delay in notification will lead to delay in control measures taken by
health personnel, which will further lead to occurrence of outbreaks. Confirmation of a case by
laboratory diagnosis depends very much on the time the specimen is taken and the type of test
used. Also normally two specimens are required for confirmation in most cases.

2. CLINICAL SPECTRUM OF DENGUE INFECTION

Dengue virus infections can cause a spectrum of illness ranging from the asymptomatic
mild undifferentiated fever, to classical dengue fever (DF), dengue fever with
haemorrhagic manifestations, and dengue haemorrhagic fever (DHF)
Dengue Virus Infection

Asymptomatic

Undifferentiated
Fever
Without
Haemorrhage

Symptomatic

Dengue Fever
Syndrome

Dengue Haemorrhagic Fever

(Plasma Leakage)

Unusual
Haemorrhage

No Shock

Dengue Shock
Syndrome

Figure 1 : Manifestations of the Dengue Syndrome

The clinical course of classic dengue fever has been well described in adults by Siler
(1926)2 and Sabin (1959)3
2.1 Pointers to Clinical Diagnosis of Dengue Infection
1.
2.
3.
4.
5.
6.

High continuous fever of 3 days or more

Abdominal pain
Petechial haemorrhage and/or other spontaneous bleeding
Rash generalised flushing/maculopapular
Hepatomegaly
Fall in platelet count that precedes or occurs simultaneously with a rise in
haematocrit
7. Normal WBC or leucopaenia with relative lymphocytosis
8. Normal ESR (< 20mm per hour)
9. Shock
NB: All criteria need not be present at the same time
Be aware of atypical presentations.
3

Atypical presentations
Acute abdominal pains, diarrhoea, severe gastrointestinal haemorrhage 5,6
Severe headache, convulsions, altered sensorium 7

Encephalitic signs associated with or without intracranial haemorrhage 7

Irregular pulse and heart rate 6,7

Respiratory distress 8

Fulminant hepatic failure, obstructive jaundice, raised liver enzymes 9, Reye

syndrome

Acute renal failure, haemolytic uraemic syndrome 6

Disseminated intravascular coagulation (DIC)

Vertical transmission in newborns (described in 2 infants in Malaysia in 1996/97) 10

Dengue virus has been isolated from CSF suggesting direct involvement of the brain.
Multisystem involvement is increasingly being documented during the last 10 years.
2.2 Dengue Fever vs. Dengue Haemorrhagic Fever
Thrombocytopaenia with concurrent haemoconcentration differentiates Grades I and II
DHF from classic DF. Increased capillary permeability is the main pathophysiology that
differentiates DHF/DSS from DF. Therefore your notification has to be either DF or
DHF. Case fatality rate is calculated only for DHF cases. The clinical differentiation
between Grades I and II DHF from dengue fever may not be as clear cut because of the
variation in the baseline haematocrit in the paediatric population.
Normal haematocrit values for age
Age
2 weeks
3 months
6 months 6 years
7 years 12 years
Adult
Male
Female

Range (%)
42 66
31 41
33 42
34 40

Mean (%)
50
36
37
38

42 52
37 47

47
42

Source : Nelson Textbook of Pediatrics, 15th edition, p 1379

If the baseline haematocrit is not available, the average haematocrit appropriate for age
can be used. An initial haematocrit of > 40% warrants close monitoring.

2.3 WHO Case Definition of DHF (WHO 1975, 1986)4

All of the following criteria must be present :
1. Fever (high and continuous of 2-7 days duration)
2. Haemorrhagic diathesis (at least a positive tourniquet test (except in shock))
3. Thrombocytopaenia (less than 100,000/mm3)
4. Haemoconcentration (20% or more relative to baseline or evidence of increased
capillary permeability) or evidence of plasma leakage (i.e. pleural effusion, ascites
and/or hypoproteinaemia)
Other clinical manifestations suggestive of DHF are:
1. Hepatomegaly (which may be tender)
2. Circulatory disturbances (restlessness, cool extremities, capillary refill time > 2 sec.,
tachycardia)
3. A fall in haematocrit following volume replacement
These along with a platelet count below 100,000/mm3 can justify notification of the case
as DHF.
Haemoconcentration may be absent during early fluid replacement or in cases where
bleeding has occurred.
Role of Tourniquet Test
In children above 4 years of age this is a useful test, as a positive reading alerts the
clinician about dengue infection. In Thailand, the tourniquet test is claimed to have a
positive predictive value of 90% for dengue 11. Appropriate sized blood pressure cuff
should be used and a positive reading is taken as > 20 petechiae per 2.5cm 2 area.12 If the
test is positive the child should be sent to a centre which can provide good observation
and investigation facilities. If the test cannot be done or is negative, then a full blood
count with the white cell count, platelet count, haemoglobin and haematocrit should be
done. A low white cell count with relative lymphocytosis suggests a viral infection.
Admit the child if the platelet count is less than 100,000/mm 3, or if the haematocrit is
high for the age group.
2.4 WHO grading of DHF
Grade I
In the presence of haemoconcentration, fever and non-specific constitutional symptoms, a
positive tourniquet test is the only haemorrhagic manifestation
Grade II
Spontaneous bleeding in addition to the manifestation of Grade I
Grade III *
Circulatory failure, pulse pressure less than 20 mmHg but systolic pressure is still normal
Grade IV *
Profound shock, hypotension or unrecordable blood pressure.
5

* Grades III and IV are classified as Dengue Shock Syndrome (DSS).

3. MANAGEMENT
3.1 Management of a child with suspected dengue infection
A child with continuous fever for 3 or more days with no focus of infection identified
Criteria for admission (any of the following) in the presence of suspicion of dengue
fever :
Restlessness or lethargy
Cold extremities or circumoral cyanosis
Bleeding in any form
Oliguria or reluctance to drink fluids
Rapid and weak pulse
Capillary refill time > 2 seconds
Narrowing of pulse pressure (< 20mmHg) or hypotension
Haematocrit of 40, or rising haematocrit
Platelet count of less than 100,000/mm3
Acute abdominal pain
Evidence of plasma leakage, e.g. pleural effusion, ascites
If patient refuses admission, parent should be advised to :
Encourage child to drink fluids
Observe for coldness / blueness of extremities
Administer Paracetamol for fever 10-15mg/kg/dose 4-6 hourly (limit to 5 doses in 24
hours)
Tepid sponging as necessary
Avoid aspirin and non-steroidal anti-inflammatory drugs
Parents must bring the child back immediately to the nearest hospital in the presence
of any one of the following situations:
Not drinking / Feeding poorly
Passing less urine than usual
Abdominal pain
Bleeding in any form
In older children, inability to sit up, giddiness
Irritability, drowsiness, restlessness
Child continues to be unwell
Pointers for early diagnosis of DHF:
Frequent vomiting during first one or two days of febrile illness
Leucopaenia on day 2

3.2 Management of Grades I and II DHF

All cases are to be admitted

Encourage patient to drink fluids, ORS, fruit-juices
Start intravenous fluid (1/5 dextrose saline initially) for those with poor oral intake.
Paracetamol for high fever
Daily capillary haematocrit determination (haematocrit will rise before pulse or blood
pressure changes)
Rise in haematocrit of 20% or more reflects a significant plasma loss and also
indicates need for intravenous fluid therapy
Monitor urine output, vital signs

3.3 Management of Dengue Shock Syndrome (Grades III and IV DHF)

This is a medical emergency, and every minute counts towards a favourable outcome.
Prompt and adequate fluid replacement for the rapid and massive plasma losses through
increased capillary permeability is required. Delayed or inadequate fluid resuscitation
can cause multisystem organ dysfunction that may lead to death. Electrolyte (sodium,
calcium) and acid base disturbances may occur and there is a high potential for
developing disseminated intravascular coagulopathy (DIC) in cases with prolonged
shock.
Intravenous fluid therapy should be adjusted after close monitoring at 1-2 hourly
intervals, throughout the 24-hour period. Establishment of central venous pressure may
be necessary in the management of severe cases that are not easily reversible. Colloidal
fluid is indicated in patients with massive plasma leakage and in whom a large volume of
crystalloid has been given. In cases with persistent shock despite a decline in haematocrit
after initial fluid replacement and resuscitation with plasma or plasma expanders, internal
bleeding should be suspected. Blood transfusions may then be indicated.
(Refer to flow-chart on page 8)

Initial IV fluid
5% D/NS (5%D/0.45%saline in younger children)
@ 6 ml/kg/hr
Follow up haematocrit at least 6 hourly / hourly vital signs / urine output
IMPROVEMENT

NO IMPROVEMENT

Hct.
Stable pulse & BP
Urine output

Hct. Pulse
Pulse pressure < 20 mmHg
Urine output

Reduce iv rate to 5 ml/kg/hr

VITAL SIGNS WORSEN

OR HAEMATOCRIT

IMPROVEMENT

IMPROVEMENT

*Increase iv rate to 10 ml/kg/hr

NO IMPROVEMENT
*Increase iv rate to 15 ml/kg/hr

Reduce iv rate to 3 ml/kg/hr

Monitor PCV and vital signs hourly

FURTHER
IMPROVEMENT

UNSTABLE VITAL
SIGNS
Urine output
Signs of shock

Central venous access

Urinary catheter
Rapid fluid bolus

Stop iv infusion after 24-48 hr

(see Figure 3)

VITAL SIGNS & Hct.

STABLE
Adequate diuresis

HAEMATOCRIT
(or distress)

HAEMATOCRIT

IV colloid infusion

Blood transfusion

IMPROVEMENT
Figure 2 : Volume replacement flow-chart in DHF with >20% increase in haematocrit 17
(Hct = Haematocrit, D/NS = Dextrose-saline solution)
* Exercise caution when administering iv fluids to children weighing > 30 kg
Adapted from Ref 12 : Nimmanitya S, 1997 & WHO95632

3.4 WHO Management Guidelines for DSS

Infuse 0.9% saline or Ringers lactate at 10-20ml/kg boluses as rapidly as possible until
vital signs return to normal. 2-3 boluses may be needed in profound shock. When vital
signs improve, change IV fluids to dextrose 5% and 0.45% saline at a reduced rate, 1-2 x
maintenance (3-6 ml/kg/hour), guided by haematocrit, urine output and vital signs
If there is no definite improvement in vital signs and if haematocrit remains high, use
plasma or haemaccel. If there is no definite improvement in vital signs and if
haematocrit is low, or has decreased, transfuse blood because this signifies haemorrhage,
occult or obvious. Sudden drop in haemoglobin level is also an indicator of occult
haemorrhage
Continue replacement of further plasma losses with Dextrose 5% and 0.45% saline over a
period of 24-48 hours.
Reduce or discontinue intravenous fluids between 24-48 hours after the onset of shock if
vital signs are stable. Reduce intravenous fluids earlier if patient has good urine output.
(Pulmonary oedema and massive pleural effusion will occur if excessive intravenous
fluids are given after this stage).
Hyponatraemia and acidosis occur commonly in DSS. These will correct with fluid
resuscitation with 0.9% saline. Periodic arterial blood gases and electrolytes should be
measured.
UNSTABLE VITAL SIGNS
Urine output
Signs of shock

Immediate rapid volume replacement

10-20 ml/kg (or as rapid bolus) normal saline or Ringers lactate solution iv
IMPROVEMENT

NO IMPROVEMENT

Adjust iv therapy

Oxygen
Correct acidosis
Haematocrit
Blood transfusion
10 ml/kg

Haematocrit
Colloid infusion
10-20 ml/kg iv
Plasma / Haemaccel / 5% albumin / Dextran
40

Figure 3 : Treatment of dengue shock syndrome, grades III and IV

9

Adapted from Ref 12 : Nimmanitya S, 1997 & WHO95633

3.5 Blood transfusion

1. Blood transfusion is indicated in significant clinical bleeding, most often
haematemesis and melaena
2. Persistent shock with rapidly declining haematocrit level despite adequate volume
replacement, indicates significant clinical bleeding which requires prompt treatment
with blood transfusion
3. It may be difficult to estimate and recognise the degree of internal blood loss in the
presence of haemoconcentration
4. Blood products like fresh frozen plasma, platelet concentrate, and cryoprecipitate
may be indicated in some cases, especially when consumptive coagulopathy causes
significant bleeding
5. Platelet concentrate is required if the platelet count is < 50,000 / mm 3 with bleeding.
In the absence of bleeding, prophylactic platelet concentrate is indicated when the
platelet count is less than 10,000 to 20,000 / mm3 (10-20 ml/kg of platelets or 4 u/m2)
6. In the presence of disseminated intravascular coagulation (DIC)18, supportive
therapy consisting of maintaining circulatory volume, correcting acidosis with sodium
bicarbonate and hypoxia with oxygen are required in addition to the use of blood
products. Cryoprecipitate (1 unit per 5 kg body weight) followed by platelets (4
units/m2 or 10-20 ml/kg) within one hour and fresh frozen plasma (FFP 10-20
ml/kg). Frequent clinical assessment and regular coagulation profile (PT, aPTT,
fibrinogen, platelet and FDP) are mandatory as indicated.
3.6 Special Notes
1. Insertion of nasogastric tube carries the risk of trauma and haemorrhage to nasal
passages and stomach. If a gastric tube is necessary, the oral route is preferable.
2. Transfusion of blood and blood products to correct thrombocytopaenia or deranged
coagulopathy carries the risk of transmission of diseases. These should be given with
caution and under close supervision.
3. Insertion of intercostal drains carries the risk of trauma and haemorrhage to the lung.
Careful titration of intravenous fluids to achieve stable vital signs, with reduction of
intravenous fluid intake once stable vital signs are achieved, will limit the
accumulation of large pleural effusions, ascites and positive fluid balance in children.
Large pleural effusions during the recovery phase after 48 hours may need small
doses of frusemide (0.25-0.5mg/kg 6 hourly for 1 to 2 doses). With these methods it
may be possible to avoid insertion of intercostal drains and tracheal intubation.
10

4. Insertion of central venous line carries the risk of haemorrhage. The intraosseous
route is acceptable in the child with profound shock.
5. The use of corticosteroids in the treatment of shock has failed to show any benefits
13,14

6. The efficacy of heparin in DIC and the use of intravenous immunoglobulin in dengue
shock syndrome have not yet been documented.
3.7 Criteria for discharging patients hospitalised with dengue/DHF 15
All of the following six criteria must be met before a patient is discharged :
.
Absence of fever for 24 hours without the use of antipyretics, and a return of appetite
Visible improvement in clinical picture
Stable haematocrit
Three days after recovery from shock
3
Platelet count greater than 50,000/mm and rising
No respiratory distress
4. LABORATORY DIAGNOSIS 16
There are three approaches in the laboratory diagnosis of dengue infection. These are:
1) Serology
2) Virus isolation
3) Detection of dengue ribonucleic acid
4.1 Serology
This is by far the most practical method for the laboratory diagnosis of dengue infection.
Although the haemagglutination inhibition (HI) test has been traditionally employed, it is
labour-intensive, requires 3 days to perform and is only available in 3 centres; the
Institute for Medical Research, University of Malaya and University Malaysia Sarawak
The serological test of choice is the detection of dengue IgM by enzyme immunoassay.
This test, which takes only a few hours, is available in the same 3 centres mentioned.
The following commercial tests are available for the detection of dengue IgM:
a) Dengue IgM Dot Enzyme Immunoassay (Venture Technologies, Malaysia)
b) Pan Bio Dengue IgM ELISA
c) Pan Bio Dengue Rapid (5 min) Immunochromatographic Test
All these commercial tests have been evaluated by the WHO Collaborating Cenre for
DF/DHF and found to have high sensitivity and specificity
11

The Ministry of Health has made available the dengue IgM Dot Enzyme Immunoassay in
all central laboratories in each state
The interpretation of serological results must be carefully considered against clinical
suspicion and not taken in isolation.
Serological results may be negative in early acute blood specimen and a second
specimen should be tested to confirm or exclude dengue infection.
4.2 Virus isolation:
Although this is the most definitive method for the diagnosis of dengue infection, it is
only performed in very few research laboratories. Its usefulness is in virus surveillance
and the prediction of outbreak severity
4.3 Detection of dengue ribonucleic acid
The use of polymerase chain reaction to detect dengue RNA is not a routine procedure
and should be considered more of a research tool. It is indicated when there is a
diagnostic problem.
5. ADVICE FOR PARENTS ON SOURCE REDUCTION IN THE HOME AND
VICINITY
Instructions as recommended by Health Division, Ministry of Health, Malaysia
1. Cover all water containers such as pails, urns or drums tightly or add larvicide (eg. 1
tablespoon (10gm) of ABATE 1% SG to 20 gallons of water) every 3 months
2. Add 2 teaspoons of salt to each ant trap to prevent mosquitoes from breeding
3. Change the water in flower vases every week
4. Remove the water and clean the flower pot trays weekly
5. Check roof gutters weekly and clear leaves or other debris that block the water flow
6. Clean the surrounding area of your house. Throw all containers which can collect
water such as empty cans and bottles into plastic bags and place them into the
appropriate bins
7. Use an insecticide spray (aerosol) in the house to kill adult mosquitoes
8. Allow the authorities to fog the interior of the house
9. Use mosquito repellants and/or mosquito nets to avoid mosquitoes from biting
12

References
1. WHO (1986) Dengue Haemorrhagic Fever: Diagnosis, Treatment, Control. World
Health Organisation.Geneva
2. Siler JF (1926) Dengue: Its history, epidemiology, mechanism of transmission,
etiology, clinical manifestations, immunity and prevention. Philippine Journal of
Science 29 : 170-210
3. Sabin AB (1959)Dengue: In Rivers TM and Horsfall FL (eds) Viral and Rickettsial
Infections of Man. Lipincott. Philadelphia pp556-568
4. WHO (1975) Technical Guides for Diagnosis, Treatment,Surveillance, Prevention and
Control of dengue Haemorrhagic Fever. World Health Organisation. Geneva
5. Sumarmo, Wulur H. Jahja E, Gubler DJ Sutomenggolo TS,Saroso JS (1983) Clinical
observations on virologically confirmed fatal dengue infections in Jakarta, Indonesia.
Bulletin of the World Health Organisation 61: 693-701
6. George R, Liam CK, Chua CT, Lam SK, Pang T, Geethan R, Foo LS (1988): Unusual
clinical manifestations of dengue virus infection. Southeast Asian Journal of Tropical
Medicine and Public Health. 19: 585-590
7. Lum LCS, Lam SK,Choy YS, George R, Harun F (1996). Dengue Encephalitis: a true
entity? American Journal of Tropical Medicine and Hygiene. 54: 256-259
8. Lum LCS, Thong MK, Cheah YK and Lam SK (1995) Dengue- associated adult
respiratory distress syndrome. Annals of Tropical Paediatrics 15 : 335-339
9. Lum LCS, Lam SK, George R and Devi S (1993). Fulminant hepatitis in dengue
infection . Southeast Asian Journal of Tropical Medicine and Public Health 24: 467471
10. Chye JK, Lim CT, Ng KB, Lim JMH, George R, Lam SK (1997). Vertical
transmission of Dengue Clinical Infectious Diseases 25: 1374-1377
11. Teeratkul A, Limpakarnjanarat K, Nisalak A, Nimmanitya S (1990). Predictive value
of clinical and laboratory findings for early diagnosis of dengue and dengue
haemorrhagic fever (Abstract). Southeast Asian Journal of Tropical Medicine and
Public Health. 21: 696-697
12. Nimmanitya S (1997) Dengue haemorrhagic fever diagnosis and management
Chapter 7. Dengue and Dengue Haemorrhagic fever. LAB International. Editors DJ
Gubler and G Kuno
13. Sumarmo, Talogo W, Asrin A, IsnahandojoB and Sabudi A (1982). Failure of
hydrocortisone to affect outcome in dengue shock syndrome. Paediatrics 69: 45-49
13

14. Tassaniyom S, Vasanawathana S, Chirawatkul A and Rojanasuphot S (1993). Failure

of high dose methylprednisolone in established dengue shock syndrome: A placebo
controlled double blind study. Paediatrics 92: 111-115
15. Dengue and Dengue Haemorrhagic fever in the Americas: Guidelines for Prevention
and Control 1997
16. Lam SK. Application of Rapid Laboratory Diagnosis in Dengue Control. Asia Pacific
Journal of Molecular Biology and Biotechnology.1995; 3: 351-355
17. WHO (1997) Dengue Haemorrhagic Fever: Diagnosis, Treatment and Control 2nd
edition. World Health Organisation.Geneva
18. Medical Consensus Development Panel, Kementerian Kesihatan Malaysia and
Academy of Medicine of Malaysia (1994). Guidelines for the Rational Use Blood
and Blood Products.

14

This guideline was formulated by :

Chief Coordinator
Rebecca George FRCP (London), FAMM
Associate Professor of Paediatrics
Universiti Malaya

Lucy Lum Chai See MRCP (UK)

Associate Professor of Paediatrics
Universiti Malaya

Lim Nyok Ling FRCP (Edin), FAMM

Consultant Paediatrician
Hospital Kuala Lumpur

Zulkifli Haji Ismail M.Med (Paed) UKM

Associate Professor of Paediatrics
Universiti Kebangsaan Malaysia

Nur Atiqah Abdullah MRCP (UK)

Paediatric Clinical Specialist
Hospital Kuala Lumpur

Noor Khatijah MRCP (UK)

Consultant Paediatrician
Hospital Kangar

Pyar Kaur MRCP (UK)

Consultant Paediatrician
Hospital Pulau Pinang

HSS Amar Singh MRCP (UK), MSc Comm. Paeds

(Lond)
Consultant Paediatrician
Hospital Ipoh

Mohd Sham Kasim FRCP (Edin), FAMM

Consultant Paediatrician
Hospital Kuala Lumpur

Fong Siew Moy MRCP (UK)

Paediatric Clinical Specialist
Hospital Klang

Bee Boon Peng MRCP (UK)

Paediatric Clinical Specialist
Hospital Seremban

Jimmy Lee Kok Foo DCH (Lon),MRCP (UK)

Consultant Paediatrician
Hospital Trengganu

Kok Juan Loong MRCP (UK)

Paediatric Clinical Specialist
Hospital Kuching

Zainah Saat MSc Med. Microbiology (Lond)

Consultant Virologist
Institute of Medical Research

Chia Yook Chin MRCP (UK)

Associate Professor of Primary Medicine
Universiti Malaya

Khoo Ee Ming MRCGP (UK)

Lecturer in Primary Medicine
Universiti Malaya

Koh Mia Tuang FRCP (Edin)

Associate Professor of Paediatrics
Universiti Malaya

Lam Sai Kit FRC Path, FASc

Professor of Medical Microbiology
Universiti Malaya

Bilkis A Aziz M.Med (Paeds) UKM

Lecturer in Paediatrics
Universiti Kebangsaan Malaysia

Tan Poh Tin MRCP (UK)

Associate Professor of Paediatrics
UNIMAS, Sarawak

Lee Eng Lam FRACP (Edin), FAMM

Consultant Paediatrician
Subang Medical Centre

M.Paranjothi DCH (Lon), FRCP (Edin)

Consultant Paediatrician
Hospital Assunta

Noorizan Abdul Majid M. Med (Paeds) USM

Lecturer in Paediatrics
Universiti Sains Malaysia

Tang Swee Fong M. Med (Paed.) UKM, MRCP

Lecturer in Paediatrics
Universiti Kebangsaan Malaysia

15

Appendix # 1

Outpatient Flow Chart

Fever > 380C
(for < 7 days)
Tourniquet test
Check platelet count
& haematocrit
Collect acute serum
Bleeding or
Restlessness
Signs of shock

Yes

Admit to Hospital
(see Appendix # 2)

No
High Haematocrit
Platelets < 100,000 / mm3

Yes

No
Give Oral Rehydration Solution (ORS)
and Paracetamol.
Monitor haematocrit, tourniquet test and
platelet count daily
Rising haematocrit
Platelets < 100,000 / mm3

Yes

No
Continue to monitor
-Clinical condition
-Platelet count
-Haematocrit

DETERIORATION
(unstable vital signs,
shock, rising haematocrit)

Yes

No
Discharge
Collect convalescent serum
2 weeks later
Adapted from WHO95634

16

Appendix # 2

Hospital Flow Chart

ADMISSION
IV Therapy (Figure 2)
where indicated
Oral fluids ad lib
Collect acute serum
Monitor
- haematocrit
- fluid intake/output
BLEEDING OR
RESTLESS
(signs of shock)

Yes

No

IV fluid bolus
(Figure 3)
Monitor :
- electrolytes
- blood gases

IMPROVEMENT
(pulse pressure > 20mmHg,
haematocrit normal)

Yes

No
Continue iv therapy
(follow Figure 2)

Administer iv colloid
therapy
(follow Figure 3)
Yes

DETERIORATION

RISING
HAEMATOCRIT

Yes

No
No
Stop iv therapy
Discharge when indicated
Collect convalescent serum

Stop iv drip
Discharge when indicated
Collect convalescent serum

Search for haemorrhage

Transfuse blood

Yes
IMPROVEMENT
No
? FLUID OVERLOAD ?
(Pulmonary oedema, raised JVP,
crepitations, rapidly enlarging liver,
heart rate > 120 / min)

Yes
Consider frusemide

Note : Figure 2 is on page 8

Figure 3 is on page 9
Adapted from WHO95635

17