Severe dengue in children: clinical spectrum, neurological complications, and contemporary management - A systematic review

Background: Dengue can progress rapidly in children to severe plasma leakage, bleeding, organ dysfunction, or disabling neurological disease. Objective: To synthesize evidence on the clinical spectrum, neurological complications, prognostic features, and contemporary management of severe pediatric dengue. Methods: PubMed/MEDLINE and Europe PMC were searched from January 1, 2010, through August 25, 2026, for pediatric severe dengue, neurological disease, critical care, organ dysfunction, prognosis, and outcomes. Studies involving patients aged 0–18 years or reporting separable pediatric data were eligible. One reviewer performed screening, extraction, and design-specific risk-of-bias assessment. Heterogeneous findings were synthesized narratively. Results: The searches identified 2,798 records; 1,324 duplicates were removed, 1,474 records were screened, and 495 full-text reports were assessed. After 414 exclusions, 81 studies were included: 74 addressing severe dengue or critical care and seven focused on neurological disease. Twenty-eight had high risk of bias and 53 had some concerns. Severe disease involved plasma leakage, shock, bleeding, and hepatic, cardiac, respiratory, renal, or multiorgan dysfunction. Serial perfusion, hematocrit, urine-output, respiratory, fluid-balance, and organ-function trends were more informative than isolated measurements. Neurological presentations included encephalopathy, encephalitis, seizures, acute necrotizing encephalopathy, demyelination, stroke or hemorrhage, and neuromuscular syndromes. Management remained supportive and phase-directed, emphasizing titrated isotonic crystalloid, reassessment, recognition of bleeding and organ dysfunction, avoidance of unnecessary fluid and prophylactic platelet transfusion, and targeted intensive care. Evidence supporting dengue-specific antivirals or routine immunomodulation was insufficient. Conclusions: Severe pediatric dengue is a time-sensitive multisystem disorder. Early recognition of the critical phase, serial hemodynamic assessment, judicious fluid therapy, and prompt treatment of bleeding and organ failure remain central. Altered consciousness or seizures require simultaneous evaluation for systemic encephalopathy and direct or immune-mediated neurological disease, followed by structured neurological and developmental surveillance when major involvement occurs.