Severe Dengue in Children: Pathogenesis, Early Recognition, and Evidence-Informed Management.

Severe dengue remains an important cause of pediatric hospitalization, morbidity, and mortality in tropical and subtropical regions, particularly where rapid triage and pediatric critical-care capacity are limited. This structured narrative review synthesizes the evidence on the epidemiology, pathogenesis, early recognition, diagnosis, management, and prevention of severe dengue in children. Severe disease reflects interactions among viral factors, pre-existing immunity, dysregulated host responses, and microvascular endothelial injury. Antibody-dependent enhancement, inflammatory mediators, dengue nonstructural protein 1, and endothelial glycocalyx disruption contribute to vascular hyperpermeability, plasma leakage, shock, severe bleeding, and organ impairment. Because deterioration often occurs abruptly around defervescence, serial clinical assessment, hematocrit trends, urine-output monitoring, and timely recognition of warning signs are central to risk stratification. Molecular assays and NS1 antigen testing are most useful during the early febrile phase, although diagnostic performance varies with illness timing and immune status. Carefully titrated isotonic crystalloid therapy remains the cornerstone of treatment; both delayed resuscitation and excessive fluid administration may worsen outcomes. Reducing mortality requires integrated clinical and public-health strategies combining standardized pediatric management, accessible diagnostics, effective referral systems, vaccination where appropriate, surveillance, and vector control.