Analysis of pediatric facial dog bites

A two-year retrospective cohort study investigating the occurrence and short-term outcomes of dog-bite injures in regional Western Australia

BACKGROUND

Dog bite injuries are a preventable yet common cause of animal related hospitalisation. Dog bites in metropolitan areas have been well characterised however there is limited information regarding dog bites in regional areas. This study sought to describe the demographics, clinical presentation and short-term outcomes of patients presenting with dog bite related injuries to Broome Regional Hospital (BRH).

METHODS

A retrospective cohort study examined all dog bite related injuries presenting to BRH Emergency Department (ED) between July 1st 2021 - June 30th 2023, with the terms "dog" AND "bitten OR bite" in ED triage note. Chart review was performed to extract demographics, clinical presentation and short-term outcomes of dog bite related injuries.

RESULTS

After exclusions, 207 patients were identified during the 2-year study period; approximately four dog-bites per week. Median age was 32 (IQR: 32, range 1-97 years old) with 46 % of patients being female. Residents of the Kimberley represented 78 % of presentations for dog bites. Dogs that belonged to or were known to patients were involved in 74 % of cases. The lower limb below the knee (42 %) was most commonly bitten, followed by the distal upper limb (30.5 %) and then face (13 %). Most patients presented on the same-day (67 %), were treated with antibiotics (79 %) and 83 % were discharged on the day of presentation. There were 43 (23 %) patients who required repair in the ED or operating theatre. Thirty-three patients were admitted to BRH. Seven patients required transfer for subspecialty tertiary level care.

CONCLUSION

Dog-bite trauma is common and consumes significant health resources associated with ED presentations, hospital admissions, theatre usage and transfer in severe cases. A multifaceted approach encompassing education, engineering, and enforcement is required to prevent dog bites.

Facial dog bites in children: A public health problem highlighted by COVID-19 lockdown

BACKGROUND

Stay-at-home injunction during COVID-19 pandemic led to new dynamics in households and increased the risk of domestic accidents involving pets. The aim of the study was to demonstrate an increase of facial dog bites in children during first lockdown period in France, compared to the same period in 2018 and 2019. Secondary objective was to investigate the demographics and circumstances in which dog bites occurred.

METHODS

A retrospective multicentric study was conducted nationwide. Patients under 18 years old managed in fifteen oral and maxillofacial surgery departments for a dog bite were included.

RESULTS

Eighty-seven patients were included. A significant increase of the number of children managed for facial dog bite was noticed in 2020 (p=0.0005). The male-to-female ratio was significantly reversed in 2020 with more bites in girls than boys (p=0.02). In 2020, children were mostly bitten to cheeks (28.6 %), lips-and-chin region (26.2 %), and eyelids (23.8 %). Severe bites increased in 2020, in comparison with 2018 and 2019. Dog bites occurring while petting or playing significantly increased in 2020 (31 %) (p=0.03).

CONCLUSION

The process leading to bites is highly dependent on the balance of dog-owner relationship. This was strongly disrupted during COVID-19 pandemic, resulting in the increase of dog bites in households. Regarding dog bites, face is the most vulnerable area in children. Its injury has lots of esthetic and functional consequences and maxillofacial surgeons have a key role to play in their prevention. Reminders of some of these management and prevention strategies are presented in this article.

Incidence of facial fractures in association with facial laceration from dog bites in the pediatric patient

INTRODUCTION

Dog bite injuries occur in approximately 102 of every 100,000 population. Pediatric facial injuries due to dog bites are more common than in the adult largely due to height difference and ease of access for the dog to the head and neck region. Although majority are soft tissue injuries, pediatric facial fractures from dog bites are estimated at approximately 5%, with the true incidence unknown. We hypothesize that depth and facial subsite of laceration can indicate likelihood of facial fracture presence in pediatric patients with dog bite injuries.

METHODS

This single-institution retrospective study included 162 patients 18 years or younger (n = 162) who had an ICD-9 code of E906.0 or ICD-10 code of W54.0 for dog bites in the head and neck region between 1/1/2015 and 12/31/2019 and were treated in the emergency department by either an emergency department, otolaryngology, or plastics surgery provider. Multivariable logistic regressions were used to examine the association between patient age, sex, and dog size, and the outcomes: laceration depth (epidermis, dermis, muscle, bone), and facial subsite (upper, middle, lower third).

RESULTS

Males had a lower laceration penetration at the epidermis level (aOR = 0.36; 95% CI 0.19, 0.69) but a higher laceration penetration at the muscle level (aOR = 2.29; 95% CI 1.04, 5.04) compared to females. No significant findings were observed for the levels of dermis and bone. In the multivariable analysis, there were no significant associations to suggest facial fractures found between facial subsites and age, sex and dog size.

CONCLUSION

No significant associations between depth or facial subsite of facial injury from dog bites and the presence of facial fractures in pediatric patients except with regard to male sex and laceration level of epidermis and muscle.

Epidemiological pattern and management of dog bite injuries in Karachi, Pakistan: A cross-sectional study

BACKGROUND

Dog bite injuries are a common problem globally; however, little is known about the epidemiology of dog bite injury from a low-and-middle-income country like Pakistan. This study aims to determine the epidemiology of dog bite injuries among children and adults from a tertiary care hospital in Karachi, Pakistan.

METHODS

We conducted a cross-sectional study on dog bite patients visiting the emergency department from November 2015 to August 2016 of a major public tertiary care hospital. Data was collected using a structured questionnaire on demographic details, bite history, and management of dog bite victims. Descriptive analysis was reported. Chi-square test was applied to check the associations between age-specific dog bite cases and independent variables.

RESULTS

2178 participants were included in the analysis. 715 (38.8%) were children less than 18 years old, and 1463 (61.2%) were adults over 18 years. A majority of the patients were males (1909, 87.7%). Results show that most dog bite injuries (2052, 94.2%) tend to occur outside the house by stray dogs biting without provocation. People aged 18 years and above (61.2%) and males (children: 84.6%, adults: 89.1%) tend to be bitten more often. Lower limbs are most frequently bitten (children: 69.5%, adults: 85.8%). Free-roaming stray dogs (children: 73.4%, adults: 74.9%) were involved in reported biting cases. Many of the patients did not receive appropriate first aid and instead just washed the wound with soap and water (children: 45.1%, adults: 43.7%). 99% of the victims received Tetanus toxoid, Rabies vaccine, and immunoglobulins while in the emergency department.

CONCLUSION

There is a high burden of dog bite injuries from stray dogs in Karachi, Pakistan. Efforts should be made to create awareness among the general public on the risks of dog bites and on seeking appropriate first aid and medical attention for a dog bite injury.

Incidence and Characteristics of Facial and Ophthalmic Injuries From Domestic Mammal Bites: Parts of the data in the manuscript were presented at the American Academy of Ophthalmology Annual Meeting, 2022

PURPOSE

To determine population-based incidence and characteristics of facial and ophthalmic injuries from domestic mammal bites in Olmsted County, Minnesota.

DESIGN

Retrospective, population-based cohort study.

METHODS

The Rochester Epidemiology Project (REP) was used to identify all potential cases of facial injuries from domestic mammal bites in Olmsted County, Minnesota from January 1, 1999, to December 31, 2015. Subjects were categorized into 2 cohorts: the ophthalmic cohort, which included persons with ocular and periocular injuries with or without facial injuries, and the non-ophthalmic cohort, which included persons with facial injuries only. The incidence and characteristics of facial and ophthalmic injuries from domestic mammal bites were assessed.

RESULTS

There were 245 patients with facial injuries, 47 ophthalmic and 198 non-ophthalmic. The overall age- and sex-adjusted incidence of facial injuries was 9.0 (CI = 7.9-10.1) per 100,000 persons per year, 1.7 (CI = 1.2-2.2) ophthalmic and 7.3 (CI = 6.3-8.3) non-ophthalmic. Rates of facial injuries were highest in patients younger than 5 years and lowest in patients 50 years or older, 49.1 (CI = 41.3-61.6) and 1.3 (CI = 0.7-2.5), respectively (P < .001). All facial injuries were caused by either dog (92%) or cat (8%) bites. Patients with ophthalmic injuries received more intravenous prophylactic antibiotics (18% vs 1%, P < .001), wound closure (83% vs 58%, P < .001), and hospital admission (6% vs 0%, P = .007) than patients with non-ophthalmic injuries. Facial injury complications were infrequent (14, 6%) and included soft tissue infection and prominent scar.

CONCLUSIONS

Although domestic mammal bites to the face are quite common, ocular injury occurs in a minority of cases.

Legal epidemiology of paediatric dog bite injuries

BACKGROUND

Dog bite injuries cause over 100 000 paediatric emergency department visits annually. Our objective was to analyse associations between regional dog ownership laws and incidence of paediatric dog bites.

METHODS

This observational study used an online search to locate local dog-related policies within Ohio cities. Data collected by Ohio Partners For Kids from 2011 through 2020 regarding claims for paediatric dog bite injuries were used to compare areas with and without located policies and the incidence of injury.

RESULTS

Our cohort consisted of 6175 paediatric patients with dog bite injury encounters. A majority were white (79.1%), male (55.0%), 0-5 years old (39.2%) and did not require hospital admission (98.1%). Seventy-nine of 303 cities (26.1%) had city-specific policies related to dogs. Overall, the presence of dog-related policies was associated with lower incidence of dog bite injury claims (p=0.01). Specifically, metropolitan areas and the Central Ohio region had a significantly lower incidence when dog-related policies were present (324.85 per 100 000 children per year when present vs 398.56 when absent; p<0.05; 304.87 per 100 000 children per year when present vs 411.43 when absent; p<0.05).

CONCLUSIONS

The presence of city-specific dog-related policies is associated with lower incidence of paediatric dog bite injury claims, suggesting that local policy impacts this important public health issue. There are limited dog-related policies addressing dog bite prevention, with inconsistencies in breadth and depth. Creating consistent, practical requirements among policies with vigorous enforcement could ameliorate public health concerns from paediatric dog bite injuries.

Tracheal injury from dog bite in a child

BACKGROUND

Dog bites associated with the head and neck area in children are a common problem. Most of the lacerations are found in the upper lip and the nose region, and tracheal injury is rare [1]. Tracheal injury requires prompt and accurate diagnosis and treatment to rescue the patient. Especially in children, securing the airway is often more difficult than in adults because of their short neck and narrow trachea. In this report, we experienced a pediatric case of multiple dog bites with tracheal injuries in the neck.

CASE PRESENTATION

We report the case of a 3-year-old girl who presented with multiple dog bites. There were multiple wounds on the head, face, neck, and anterior chest, and air leakage was observed from the cervical wound at the time of transfer. It was difficult to perform oral endotracheal intubation, therefore, we extended the neck wound, probed the trachea with finger, and inserted a tracheal tube directly from the cervical wound in the emergency room. Tracheoplasty and another wound cleansing were performed in the operating room. The patient was discharged on the 18th day after surgery, without further complications.

CONCLUSION

Tracheal injury from a dog bite is rare. It is important to prompt and accurate diagnosis and treatment. Children should be especially careful because of their short necks and narrow tracheas.

Management of Dog Bite Injuries: Procedural Sedation, Infection, and Operative Indications at a Single-Institution Level I Pediatric Trauma Hospital

BACKGROUND

Dog bite injuries are common within the pediatric population. Currently, there are inconclusive data on best sedation practice, antibiotic regimen, and need for plastic surgery referrals for treatment of dog bite injuries in the emergency department (ED) versus operating room (OR). This study set out to determine sedation practice, infection management, and necessity for plastic surgery referral at a level I pediatric trauma center.

METHODS

A retrospective review of all pediatric (0-18 years old) dog bites documented in electronic medical records from January 1, 2010, to December 31, 2019, was performed. Bitten by dog encounters were identified by International Classification of Diseases, Ninth Revision and Tenth Revision codes E906.0 and W54.0, W54.0XXA, and W54, respectively. Data gathered included age, gender, month of injury, circumstance of injury, injury characteristics, location of repair, person performing repair, sedation (if used, then length of sedation), inpatient admission, antibiotics prescribed, dog characteristics (breed, size, sex, age, relationship to patient), and complications. Summary statistics were calculated as mean ± SD. Comparisons for nominal variables were performed using the χ2 test. All analyses were performed using Stata v.16. 1.

RESULTS

A total of 1438 pediatric patients were included in this study over a 10-year period. Of injuries requiring repair (n = 846), most repairs were performed in the ED (97.1% [822/846]), whereas 24 (2.8%) required repair in the OR. Of the bites that required repair (n = 846), 81.1% (686/846) were performed by an emergency medicine physician and 147 (17.4%) by plastic surgeons. Procedural sedation in the ED was performed in 146 repairs (17.3%). Documented sedation time ranged from 10 to 96 minutes. Most patients received a prescription for antibiotics (80.5%), usually amoxicillin/clavulanate (90.8%). Infection was the most common sequela (9.5%). There was no significant difference in infection rates between repairs performed in the ED versus those in the OR.

CONCLUSION

Our study indicates that pediatric patient dog bite injuries can be successfully managed in an ED. Procedural sedation has demonstrated no increased safety risks compared with the OR. Rates of infection are also not demonstrated to be significantly higher in repairs done in the ED versus those taken to operating theater.

Pediatric Dog Bite Injuries: A 5-Year Nationwide Study and Implications of the COVID-19 Pandemic

Although single institution studies have analyzed various animal attacks, there has not been multicenter investigation into dog bites in children. The purpose of this study was to characterize national trends and investigate the characteristics of pediatric dog bites.

Systematic review of dog bite prevention strategies

BACKGROUND

The prevention of dog bites is an increasingly important public health topic, as the incidence of serious injury continues to rise.

OBJECTIVES

To evaluate the effectiveness of interventions to prevent dog bites and aggression.

METHODS

Online databases were searched (PubMed, Cochrane Library, Embase and Google Scholar), using the search terms: dog/s, canine, canis, kuri, bite/s, bitten, aggression, attack, death, fatal, mortality, injury/ies, prevention, intervention, for studies between 1960 and 2021. All study designs were considered. Outcomes of interest were the incidence of dog bites or dog aggression. Non-English studies, and those without full-text access were excluded.

RESULTS

Forty-three studies met the review criteria, including 15 observational and 27 interventional studies. Fifteen studies investigating dog-control legislation, including leash laws, stray dog control and infringements indicated this can reduce dog bite rates. Breed-specific legislation had less of an effect. Six studies investigating sterilisation, showed while this may reduce dog bites through a reduction in the dog population, the effect on dog aggression was unclear. An alcohol reduction programme showed a significant reduction in dog bite rates in one study. Seven studies assessing educational approaches found that intensive adult-directed education may be effective, with one study showing child-directed education was not effective. Eight studies on dog training (two police-dog related), and six evaluating dog medication or diet were generally low quality and inconclusive.

CONCLUSIONS

Multiple strategies including effective engagement with indigenous communities and organisations will be required to reduce dog-bites and other incidents involving dog aggression. This review provides some evidence that legislated dog control strategies reduce dog bite rates. Available evidence suggests greater restrictions should be made for all dogs, rather than based on breed alone. Due to a burden of child injury, protection of children should be a focus of legislation and further investigations. Prevention strategies in children require redirection away from a focus on child-directed education and future research should investigate the effectiveness of engineering barriers and reporting strategies.

Paediatric dog bite injuries: a 10-year retrospective cohort analysis from Sydney Children's Hospital

BACKGROUND

Dog bite injuries are largely preventable yet present the most common animal related cause of hospitalisation. This study examines the demographics and clinical cost of patients with dog bite related injuries who presented to Sydney Children's Hospital (SCH) from 2010 to 2020. The results from our study will be used to raise awareness regarding the impact of dog bite injuries in our community.

METHODS

Data was obtained from the SCH database using ICD-10-AM code W54.0, which captures all patients presenting to SCH with dog bite injuries from 2010 to 2020. A chart review was then performed to retrieve demographic data for analysis. Data analysis was performed using SAS® software version 9.4 and cost for each patient retrieved from the SCH clinical costing department.

RESULTS

A total of 628 patients presented to SCH with dog bites during the study period. 273 (43.5%) patients received treatment in ED only with the remaining 355 (56.5%) patients admitted for treatment. The average age was 5.69 years old. There were 321 males (51.1%) and 307 females (48.9%). Facial and other head & neck injuries were most common (64.4%). Pitbull, Labrador and Rottweiler were the most commonly documented offending breeds (25%) with the family dog most likely to offend (49%). The mean clinical cost for per dog bite injury was $2968.

CONCLUSION

As part of the largest single centre study exploring dog bite injuries, we expect that this study will stimulate potential public health campaigns targeted at educating parents and children on interacting with dogs to minimise these injuries.

Pediatric dog bite injuries in the USA: a systematic review

Introduction

Dog bites are one of the leading causes of non-fatal emergency room visits in children. These injuries not only cause physical harm but can lead to long-term psychological stress. This study evaluated the current literature related to pediatric dog bite injuries to identify research gaps which should be prioritized to improve a major public health concern.

Methods

We performed a keyword search of PubMed, Scopus, and OVID Medline databases (January 1980– March 2020) for all published studies focused on dog bite injuries in the pediatric population (≤18 years of age) using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses.

Results

Out of 1859 abstracts screened, 43 studies involving 86 880 patients were included. Twenty-nine studies were retrospective chart reviews characterizing the epidemiology of dog bites and their associated treatment outcomes; six were prospective cohort studies; two were cross-sectional studies; and six were experimental studies. Synthesized results demonstrate that children <9 years of age suffer the greatest burden of injuries, with children <6 years of age at higher risk of more severe injuries involving the head, neck, and face.

Conclusion

Studies analyzing the prevention or psychosocial consequences of dog bites injuries are needed.

Animal bite injuries in pediatric population: a systematic review

Objectives: To assess the scientific literature pertaining the risk factors for injuries among victims of animal bite injuries. Data and sources: A systematic review of scientific literature published until May 2020 was carried out in the following databases: PubMed, Cochrane Library, Google Scholar and Journals@ovid. Study selection: A total of 924 records were found, of which 29 articles fulfilled the inclusion criteria and were analyzed. There was a male preponderance in most of the studies with male/female ratio ranging from 0.75:1 to 2.1:1. The age range varies from 0 to 19 years with the mean age varying from 3.6 to 8 years. Pitbulls, Rottweiler's, German shepherds, Bull terriers, Labradors and Dobermans were breeds with higher risk of attack. The animals were familiar to the victim (own, friends, neighbors) in 27–98% instances. Most cases of animal bite injuries were recorded during Summer and Spring months. Head and neck followed by extremities was found to be most inflicted area. Conclusions: The sociodemographic characteristics of victim as well as the biting animal affect the circumstances leading to biting episode. However, the results should be interpreted with caution due to the high heterogeneity among studies and moderate quality evidence.

Surgical Treatment of Pediatric Dog-bite Wounds: A 5-year Retrospective Review

Introduction

Dog bites are a significant health concern in the pediatric population. Few studies published to date have stratified the injuries caused by dog bites based on surgical severity to elucidate the contributing risk factors.

Methods

We used an electronic hospital database to identify all patients ≤17 years of age treated for dog bites from 2013–2018. Data related to patient demographics, injury type, intervention, dog breed, and payer source were collected. We extracted socioeconomic data from the American Community Survey. Data related to dog breed was obtained from public records on dog licenses. We calculated descriptive statistics as well as relative risk of dog bite by breed.

Results

Of 1,252 injuries identified in 967 pediatric patients, 17.1% required consultation with a surgical specialist for repair. Bites affecting the head/neck region were most common (61.7%) and most likely to require operating room intervention (P = 0.002). The relative risk of a patient being bitten in a low-income area was 2.24, compared with 0.46 in a high-income area. Among cases where the breed of dog responsible for the bite was known, the dog breed most commonly associated with severe bites was the pit bull (relative risk vs German shepherd 8.53, relative risk vs unknown, 3.28).

Conclusion

The majority of injuries did not require repair and were sufficiently handled by an emergency physician. Repair by a surgical specialist was required <20% of the time, usually for bites affecting the head/neck region. Disparities in the frequency and characteristics of dog bites across socioeconomic levels and dog breeds suggest that public education efforts may decrease the incidence of pediatric dog bites.

Management of Nasal Trauma

Facial trauma can have long-lasting physical and mental consequences. Trauma to the nose is commonly seen in the emergency department. Nasal lacerations account for 7% of all facial lacerations. Thorough examination and documentation including photographs is important for documentation and creating a reconstruction plan. Underlying damage to cartilage or bone must be reconstructed initially or in a delayed fashion to recreate the pretrauma anatomy and function. There are several options for soft tissue nasal reconstruction, including local flaps, skin grafts, pedicle flaps, and free flaps. At present there is no standard of care for postoperative facial trauma wound care.

Analysis of Pediatric Dog Bite Injuries at a Level 1 Trauma Center Over 10 Years

BACKGROUND

Dog bite injuries cause significant preventable patient morbidity and health care expenditure in children. This study aimed to characterize the patient and healthcare burden related to pediatric dog bite injuries at a level 1 trauma center.

METHODS

This is a retrospective review of 356 pediatric patients who presented to Virginia Commonwealth University Pediatric Emergency Department between July 2007 and August 2017 after sustaining dog bite injuries. Demographic information, injury details, management, outcomes, and financial information were analyzed.

RESULTS

Most pediatric dog bite injuries afflicted male children (55.6%), ages 6 to 12 years (45.7%), by a household dog (36.2%). The most common offending breed was a pit bull or pit bull mix (53.0%). Infants and grade schoolers were more likely to sustain bites to the head/face (P = 0.001). Usual management consisted of primary repair (75.9%), whereas approximately 25% of the patients required advanced reconstructive techniques. Most patients healed uneventfully, but prolonged antibiotics, additional wound care, or procedures were necessary in 8.4% of the patients. Hospital charges per patient averaged US $8830.70 and tended to be higher in the younger age groups. Insurance status was statistically associated with use of conscious sedation, surgical consult placement, and surgical repair.

CONCLUSIONS

Although most pediatric dog bite injuries in this study healed uneventfully from primary management in the emergency department, 25% required additional interventions. Furthermore, patient care for these injuries was associated with significant but potentially avoidable personal and financial burden to families. Our data reflect a need for safety education on animal care, behavior, and interaction.

Demographics and management of paediatric dental-facial trauma in the 'lockdown' period: A UK perspective

Background

The United Kingdom entered ‘lockdown’ on the 23 March 2020 due to the COVID‐19 pandemic. This resulted in school closures forcing children to remain at home. Dental‐facial trauma was still likely to be common place due to falls and injuries exercising. The aim of this study was to explore the impact of the COVID‐19 pandemic on clinical practice in a paediatric population in a tertiary care hospital and a linked Dental Institute.

Method

A proforma was designed to capture the demographics, presenting complaints, type of dental‐facial injury, treatment need and the treatment received for all paediatric patients presenting face to face with dental‐facial trauma to King's College Hospital during the ‘lockdown’ period (23 March‐ 14 June 2020).

Results

Four hundred and twenty calls were triaged, converting to 102 patients seen face‐to‐face for dental‐facial trauma. The remainder were able to be triaged ‘virtually’. Injuries seen included 56 (54.9%) dentoalveolar injuries, 37 (36.2%) lacerations, five (4.9%) suspected facial fractures and four (3.9%) dog bites. Males and females were equally affected. The majority of incidents occurred in the home environment (n = 60, 58.8%), with the remainder (n = 42, 41.2%) occurring outside the home environment. The main causes of dental‐facial trauma were falls (n = 47, 46.1%) and bicycles/scooters (n = 29, 28.4%). The most common type of dentoalveolar injury was lateral luxation (n = 15, 26.7%), followed by avulsion (n = 12, 21.4%). Only one child required treatment under general anaesthesia (GA).

Conclusion

The demographic, presenting complaints and treatment needs of patients who presented during the lockdown period with dental‐facial trauma were unusual. The overwhelming majority were able to be treated without the use of GA. The attendance protocol in a tertiary care setting and the use of ‘teledentistry’ ensured only the most severe trauma cases were seen. This highlights how more complex trauma can still occur during ‘lockdown’ and requires immediate management.

Can This Dog Be Rehomed to You? A Qualitative Analysis and Assessment of the Scientific Quality of the Potential Adopter Screening Policies and Procedures of Rehoming Organisations

Unwanted dogs are an international problem, and rehoming organisations are tasked with finding many of them appropriate homes. Whilst the processes involved in assessing dogs' suitability for rehoming have received considerable academic attention, the policies and procedures organisations employ for screening potential adopters, which are equally as important to dogs' outcomes, appear to be largely overlooked. Therefore, the aim of this study was to conduct a qualitative analysis of rehoming organisations' adopter screening processes in order to gain insight into what is being done, the extent to which this appears to have any scientific rationale, and what other factors might be driving the process. A written enquiry was sent to organisations in the UK; topics addressed included whether they use a standardised screening process, whether they interview potential adopters and what information is gathered during the interview, and how they score responses. Information was received from 82 respondents. Pre-adoption home visits were the most commonly used method. Self-administered questionnaires were the most standardised method. Using a thematic analysis, ten themes emerged from the types of information gathered during the screening process; 31 characteristics could lead an adopter being deemed unsuitable to adopt a dog. Evidence to potentially support these was found for only eight of them in the academic literature relating to risk factors for relinquishment and human safety risk. The inclusion of some of the characteristics considered important was thought to be for the purpose of ensuring a good quality of life for a dog, but there is a lack of relevant research investigating this. Organisations seem to invest considerable resources into screening potential adopters, but there is limited scientific, and sometimes logical, rationale for this. A further concern relates to the quality of the assessment processes, which show little evidence of quality control measures. Until the necessary research is conducted, it could be argued, from a pragmatic perspective, that organisations should relax their strict screening criteria, and focus their resources on ensuring owners are fully prepared for the changes in their life associated with the inclusion of a new dog in their home and supporting them as necessary.

Massive Dog Bite Injury of the Scalp in One-year Old Boy

A one-year-old boy was referred to our Department of Pediatric Surgery with extensive scalp injury. He was bitten by a neighbour's mixed-breed dog. The wound of the forehead is primary closed while scalp is reimplanted. Due to non-acceptance on the eighth day a necrectomy of devitalized tissue was done. Before applying Integra®, for 2 days, the wound was treated with a V.A.C.® system. After 14 days, Integra® was accepted and split-thickness skin graft (STSG) was transplanted from left upper leg. After 3 months the local status is satisfactory. A hair transplant is planned in the future.

Dog Bites in the United States from 1971 to 2018: A Systematic Review of the Peer-Reviewed Literature

BACKGROUND

Surgical specialists in plastic, head and neck, hand, trauma surgery, and emergency medicine physicians bear the burden of treating the most serious injuries caused by animals. Most of these incidents result from an attack by a known dog, and breed has been proposed, but not proven, to be a controllable factor. The authors summarize the peer-reviewed literature on dog bites in the United States, specifically as related to the breeds implicated.

METHODS

A systematic review of all peer-reviewed publications reporting on dog bites in the United States was performed. MEDLINE, Embase, Scopus, Google Scholar, and Cochrane Library searches were conducted through May 8, 2018, for studies from the United States implicating a specific dog breed as responsible.

RESULTS

Forty-one articles met inclusion criteria, the majority of which were single-institution retrospective reviews. Main outcomes were any dog bite reported in the peer-reviewed literature where a specific breed was implicated. Secondary measures included dog bites reported in areas where breed-specific legislation was enacted. The most common pure breed identified was German Shepherd, followed by Pit Bull-type breeds (i.e., American Staffordshire Terrier, American Pit Bull Terrier, Staffordshire Bull Terrier, American Bully), Labrador, Collie, and Rottweiler, respectively. Pit bull-type and German Shepherd breeds are consistently implicated for causing the most serious injuries to patients in the United States across heterogeneous populations, and this remained consistent across multiple decades.

CONCLUSIONS

The authors' results indicate that German Shepherd and Pit Bull-type breeds account for the largest subset of pure breeds implicated in severe dog bites inflicted on humans in the medical literature. The role and complexity of mentioning breed in relation to human injuries are also discussed.

A One Health Perspective on the Human-Companion Animal Relationship with Emphasis on Zoonotic Aspects

Over time the human-animal bond has been changed. For instance, the role of pets has changed from work animals (protecting houses, catching mice) to animals with a social function, giving companionship. Pets can be important for the physical and mental health of their owners but may also transmit zoonotic infections. The One Health initiative is a worldwide strategy for expanding collaborations in all aspects of health care for humans, animals, and the environment. However, in One Health communications the role of particularly dogs and cats is often underestimated.

OBJECTIVE

Evaluation of positive and negative One Health issues of the human-companion animal relationship with a focus on zoonotic aspects of cats and dogs in industrialized countries.

METHOD

Literature review.

RESULTS

Pets undoubtedly have a positive effect on human health, while owners are increasing aware of pet's health and welfare. The changing attitude of humans with regard to pets and their environment can also lead to negative effects such as changes in feeding practices, extreme breeding, and behavioral problems, and anthropozoonoses. For the human, there may be a higher risk of the transmission of zoonotic infections due to trends such as sleeping with pets, allowing pets to lick the face or wounds, bite accidents, keeping exotic animals, the importation of rescue dogs, and soil contact.

CONCLUSIONS

One Health issues need frequently re-evaluated as the close human-animal relationship with pet animals can totally differ compared to decennia ago. Because of the changed human-companion animal bond, recommendations regarding responsible pet-ownership, including normal hygienic practices, responsible breeding, feeding, housing, and mental and physical challenges conforming the biology of the animal are required. Education can be performed by vets and physicians as part of the One Health concept.

An Epidemiological Analysis of Pediatric Dog Bite Injuries Over a Decade

BACKGROUND

An estimated 800,000 dog bites require medical attention every year. The purpose of this study is to review the characteristics of dog bite injuries in children and examine temporal trends.

METHODS

The Kids' Inpatient Database was used to identify pediatric patients with dog bite injuries over a 10-y period. Demographic data, primary payer, injury characteristics, length of hospitalization, and treatments were recorded. Statistical analysis was performed in SAS 9.3 (SAS Institute Inc, Cary, NC).

RESULTS

A total of 6308 patients were identified. Average age at time of injury was 6.4 ± 4.3 y. Children under age 5 y were the most affected subgroup (39.3% in 2000 versus 44.7% in 2009, P < 0.001). Most bites were to the head/neck and significantly increased from 53.9% in 2000 to 60.1% in 2009. Cellulitis complicated many injuries (33.7% in 2000 versus 44.8% in 2009, P < 0.001). Overall, 50% of patients underwent a procedure; 31% had an invasive surgical procedure; and 5.1% of patients required skin grafts or flaps.

CONCLUSIONS

Dog bites are a common cause of pediatric injuries and are a significant burden on families and the health care system. Evaluating the characteristics of these injuries can guide educational efforts.

Children Have an Increased Risk of Periorbital Dog Bite Injuries

PURPOSE

Dog bites to the head, neck, and face (HNF) disproportionately affect children. It is unclear if specific facial regions are uniquely at risk in this population. Both the periorbital region and the central target area (CTA; nose, lips, and cheeks) have been proposed as being at increased risk. This study addressed the following question: Among individuals sustaining a dog bite injury to the HNF, are children, when compared with adults, at greater risk of injury to the periorbital region or CTA?

PATIENTS AND METHODS

Using a retrospective cohort design, we enrolled a sample composed of patients presenting with HNF dog bite injuries. The predictor variable was age category: pediatric or adult (≥18 years). The primary outcome variable was injury location: isolated periorbital, isolated CTA, both periorbital and CTA, or other HNF location (neither periorbital nor CTA). Other variables included specific facial structures injured, demographic characteristics, injury circumstances, and clinical course. Descriptive and bivariate statistics were calculated.

RESULTS

The sample consisted of 183 pediatric (58.5%) and 130 adult (41.5%) patients. Isolated periorbital injuries were more common in the pediatric group (relative risk [RR], 2.2 [95% confidence interval (CI), 1.3 to 3.7]; P = .003), as was injury to both periorbital and CTA regions (RR, 2.0 [95% CI, 1.2 to 3.5]; P = .01). Isolated CTA injury was the most common injury pattern overall in both children and adults, but children were at significantly less risk than adults (RR, 0.7 [95% CI, 0.5 to 0.9]; P = .002). Children were also less likely to sustain an injury to other HNF regions (RR, 0.6 [95% CI, 0.3 to 0.97]; P = .038).

CONCLUSIONS

Children were twice as likely as adults to incur a periorbital dog bite, but no such increased risk was observed for the CTA. This may reflect unique anatomic risks in children or targeting of their eyes by attacking dogs, contributing to higher rates of HNF injury in this population. Public health measures should recommend against children being at eye level with dogs, even if familiar or under adult supervision.

Pediatric Dog Bite Prevention: Are We Barking Up the Wrong Tree or Just Not Barking Loud Enough?

OBJECTIVES

The objectives of this study were (1) to evaluate dog bite-related injuries and associated medical documentation and (2) to compare these results with a study of dog bites from the same institution 10 years prior.

METHODS

Data were retrospectively collected from a pediatric emergency department from July 2007 to July 2011 for patients treated for dog bites. These data were then compared with data from the same institution from 10 years prior.

RESULTS

A total of 1017 bite injuries were treated (average, 254.25 bites/year), which represents a 25% increase compared with 10 years prior. Comparing the 1997 and 2007 to 2011 cohorts, patient demographics, bite rate among children less than 5 years old, rate of dog breed documentation, and setting of injury were similar. Dog breed was reported in 47% (95% confidence interval [CI], 40.2-53.9) and 41% (95% CI, 38.0-44.0) of cases, respectively, in the 2 cohorts. Bites to the craniofacial region were most common (face only reported for 1997: 43.2%; 95% CI, 36.4-50 versus 2007-2011: 66.1%; 95% CI, 63.2-69.0). In both cohorts, the child's home was the most frequent setting, accounting for 43% of bites (1997: 95% CI, 30.2-55.9 and 2007-2011: 95% CI, 39.3-46.7).

CONCLUSIONS

Pediatric dog bites continue to occur frequently, and the associated factors did not change over the 10-year period: young age of child, bites to the craniofacial region, and dogs familiar to the child. Although accurate medical documentation of dog bites is a prerequisite to develop effective prevention strategies, current medical documentation of dog bites may be misguided.

Dog bite injuries to the face: Is there risk with breed ownership? A systematic review with meta-analysis

INTRODUCTION

Dog bite injuries to the face are a serious, yet modifiable public health concern. This study explores the relationship between dog breed and the risk of biting and injury. The objective of this study is to determine the relative risk and severity of dog bite injuries to the face by breed.

METHODS

Retrospective chart review of facial dog bite injuries presenting to the University of Virginia Health System and Nationwide Children's Hospital. Additionally, descriptive data was collected from 240 patients over the last 15 years. Bite risk by breed was assessed by a literature search from 1970 to current. A composite measure was used to determine the severity of injury, and characterize each patient into an ordinal scale of bite severity. An average of each breed bite rate within each study was calculated and combined to create an empiric bite risk by breed. Dog breeds were also further characterized morphologically.

RESULTS

Bite risk by breed from the literature review and bite severity by breed from our case series were combined to create a total bite risk plot. Injuries from Pitbull's and mixed breed dogs were both more frequent and more severe. This data is well-suited for a bubble plot showing bite risk on the x-axis, bite severity on the y-axis, and size of the bubble by number of cases. This creates a "risk to own" graphic for potential dog owners.

CONCLUSIONS

Breeds vary in both rates of biting and severity. The highest risk breeds had both a high rate of biting and caused significant tissue injury. Physical characteristics can also help determine risk for unknown or mixed dog breeds. Potential dog owners can utilize this data when assessing which breed to own.

Dog Bites in Children: A Descriptive Analysis

Objective

To describe characteristics of dog bites and their treatment in a pediatric population including infection, medical specialties involved, rates of admission, and need for surgery.

Method

Patients presenting with a dog bite to the emergency department of a tertiary care pediatric hospital between January 1, 2015, and June 30, 2017, were included. Details related to demographics, complications, consultations, and treatment were extracted from the patients' records. Descriptive statistics were performed and binary logistic regression was used to assess potential predictors of infection.

Results

One hundred fifty-eight dog bite patients were identified. Most patients were male (53.8%) and less than 5 years of age (50%). Bites occurred most frequently in June (13.3%) and July (16.5%). The face was most commonly involved (42.9%), followed by the hands (12.6%) and the scalp (26.6%). Pit bulls (11.4%), Labrador retrievers (7.0%), and German shepherds (4.4%) were the most common offending breeds. Most bites were superficial (91.1%). Half were treated conservatively with dressings and petrolatum-based ointment, with 41.1% requiring simple primary closure. Ten (6.3%) cases necessitated primary repair in the main operating room under general anesthesia. More than half of patients were treated with prophylactic systemic antibiotics (55.1%). Plastic surgery was the most common service involved (24.7%). Seven (4.4%) patients developed an infection and there were no mortalities or long-term complications. Rates of infection did not differ between patients who did or did not receive prophylactic systemic antibiotics (P = .88). Regression analysis revealed no significant predictors of infection.

Conclusions

Most dog bites are superficial and involve the head and hands. Infection rate is low, with no significant difference in infection rates between patients treated with or without prophylactic antibiotics.

Dog Bite Injuries in the Head and Neck Region: A 20-Year Review

Dog bite-related wounds seem to have become a common problem, especially when they relate to the head and neck region. According to Overall and Love, up to 18 per 1,000 people sustain a dog bite every year, of whom 3 need medical attention. Approximately 1 to 2% of bite injuries require hospitalization of the victims. Most of the lacerations are found in the upper lip and the nose regions and they are classified according to severity and concomitant damage to other organs. Bite wounds are considered "dirty" wounds and are prone to infection. When dealing with bite wounds, there is always an indication for antibiotic treatment. Broad-spectrum antibiotics like amoxicillin-clavulanate and/or moxifloxacin cover most of the pathogenic flora and should be administered in every bite wound case at risk of infection. This article would like to present a medical record review: a retrospective analysis of all bite wounds sustained in the head and neck region, treated at the University Hospital of Leuven over the past 20 years. Furthermore, it provides an overview of the current literature and its standings on the treatment of dog bite injuries in the maxillofacial region. We assessed both surgical and medical treatment options, as well as primary management, which includes infection prevention strategies, closure management, and additional vaccination requirements. Secondary management or scar revision methods will be mentioned. After conducting a UZ Leuven database search using keywords such as "dog," "dog bite," "face," "head," "lip," and others, 223 patients were included. Age at the time of injury, location of the injury, treatment method used, and whether secondary infection was present or not were documented. All patients have been divided in age groups. We concluded that 21.52% was 5 years old or younger. Almost half of our patients (49.33%) were 18 years old or younger. Of all patients, 79 were hospitalized (35.43%). Primary closure was the treatment of choice. In 141 patients, the wounds were closed primarily (63.23%), resulting in only 2.24% reported secondary infections. Only one fatality was reported in our center over the course of 20 years (0.45%), a 6-year-old girl who had been attacked by her father's Rottweilers. Most patients who sustained dog bite injuries in the head and neck region seem to be children, specifically toddlers. Due to their height, it is possible they are more prone to dog bite injuries in the head and neck region. It is essential to optimize management of these injuries due to the impact they have on patients. This article provides the epidemiological data and clinical outcome of the approach at our center.

Pediatric dog bites: a population-based profile

BACKGROUND

Previous studies have identified risk factors for dog bites in children, but use data from individual trauma centers, with limited generalizability. This study identifies a population risk profile for pediatric dog bites using the National Trauma Data Bank. We hypothesized that the population at risk was younger boys, that such bites occur at home, are moderately severe, and are on the face or neck.

METHODS

For this retrospective cross-sectional study, a sample of 7912 children 17 years old and younger with International Classification of Diseases (ICD)-9 event code E906.0, for dog bites, were identified. Datasets from 2007 to 2014 were used. Data included patient's gender, age, ICD-9 primary and location E-codes, AIS body region and AIS severity.

RESULTS

Most children were 6-12 years old and female, but a similar number fell into the narrower range of 0-2 years old. Injuries in the younger group frequently occurred at home, on the face and head, and with minor severity. Age of the child predicts the location of incident (P<0.001), the severity of injury (P<0.001) and the body region of the injury (P<0.001). Body region of the injury predicted its severity (P<0.001).

DISCUSSION

Younger children are more likely to receive dog bites, and bites incurred are likely of greater severity. Children this young cannot yet be taught how to properly interact with a dog.

CONCLUSIONS

Dog bites are a significant source of morbidity for children. Based on the population risk factors profile generated, this study recommends targeting live dog education towards the parents of young children.

An Algorithmic Approach to Operative Management of Complex Pediatric Dog Bites: 3-Year Review of a Level I Regional Referral Pediatric Trauma Hospital

Background:

Incidence of dog bites continues to rise among the pediatric population and serves as a public health threat for the well-being of children. Plastic surgeons are at the forefront of initial management and eventual outcome of these devastating injuries. This study set out to determine the nature of dog bite injuries treated over a 3-year period at a large level 1 pediatric trauma center.

Methods:

A retrospective review of emergency room records of all pediatric patients (age, 0–18 years old) who sustained dog bites between January 2012 and December 2014 were gathered. All details about age of patient, location and severity of dog bites, type of dog breed, antibiotics given, and emergency versus operative treatment were recorded and analyzed.

Results:

One hundred eight patients aged 5 months to 18 years old were treated in the emergency department after suffering dog bite injuries during the study period. The highest incidence of dog bites occurred in preschool children. The mean age for patients who required operative repair was lower than the mean age for patients who underwent primary closure in the emergency department. The location of injury was most commonly isolated to the head/neck region. Of the 56 cases that had an identified dog breed, pit bulls accounted for 48.2% of the dog bites, and 47.8% of pit bull bites required intervention in the operating room.

Conclusion:

Children with large dog bite injuries require more immediate care in a level 1 pediatric trauma hospitals in order to optimize their hospitalization course and eventual outcome.

Dog-Bite-Related Craniofacial Fractures among Pediatric Patients: A Case Series and Review of Literature

Dog bites in the pediatric population commonly cause injuries to the head and can be associated with fractures, often leading to prolonged hospital stays, multiple surgical interventions, and long-term complications. Our goal was to evaluate our experience with dog-bite-related craniofacial fractures, understand frequency and demographics of these fractures, identify common fracture patterns, and provide recommendations based on management and complications encountered. The institution's electronic medical record was reviewed. A review of the English literature for the past 20 years was also conducted. A retrospective chart review was conducted using ICD-9 codes to include all patients with head and neck dog bites and craniofacial fractures. Fractures resulting from canine bites to the face and scalp were rare, occurring in our study in less than 1% of total facial dog bites (1,069 cases) and 1.5% of pediatric facial dog bites (462 cases). Ages ranged from 5 months to 9 years at the time of presentation. A total of seven patients, all pediatric, were documented. All seven patients required operative intervention for their wounds, and five patients required at least two operative interventions. Midface and skull fractures were the most commonly encountered fracture sites. Dog bite injuries to the face in young children, especially when severe, should raise suspicion for fracture of underlying bone. Management of these injuries should include a multidisciplinary approach and focus on repair of soft tissue and skeletal deformities. Furthermore, it is prudent to follow up patients who require operative management after injury to monitor for long-term complications, given the significant proportion of complications and operative takebacks in this study.

Soft Tissue Management in Facial Trauma

The management of soft tissue injury after facial trauma poses unique challenges to the plastic surgeon, given the specialized nature of facial tissue and the aesthetic importance of the face. The general principles of trauma management and wound care are applied in all cases. The management of severe injuries to the face is discussed in relation to the location and the mechanism of injury. Facial transplants have arisen in the past decade for the management of catastrophic soft tissue defects, although high morbidity and mortality after these non-life-saving operations must be considered in patient selection.

Characteristics of 1616 Consecutive Dog Bite Injuries at a Single Institution

Dog bite injuries remain a common form of pediatric trauma. This single-institution study of 1616 consecutive dog bite injuries over 4 years revealed a much higher prevalence of dog bites as compared with other similar centers. Though inpatient admission was rare (9.8%), 58% of all patients required laceration repair, primarily in the emergency department. Infants were more than 4 times as likely to be bitten by the family dog and more than 6 times as likely to be bitten in the head/neck region. Children ≤5 years old were 62% more likely to require repair; and 5.5% of all patients required an operation. Pit bull bites were implicated in half of all surgeries performed and over 2.5 times as likely to bite in multiple anatomic locations as compared to other breeds. The relatively high regional prevalence and younger age of injured patients as compared with other centers is a topic of further study but should draw attention to interventions that can minimize child risk.

Practices and Perceptions of Animal Contact and Associated Health Outcomes in Pregnant Women and New Mothers

Companion animals play an important role in our society. However, pregnant women and new mothers might have specific concerns about animal-associated health outcomes because of their altered immune function and posture as well as their newborn babies. The study was conducted to collect baseline data for developing an evidence-based intervention for pregnant women and new mothers to help them adopt certain behaviors to prevent adverse animal-associated health outcomes. A survey, using the Health Belief Model as the theoretical framework, was developed and administered to 326 women attending the Women, Infants, and Children programs in Illinois and Indiana in 2015. Prevalence of dog and cat ownership was estimated to be 39% (95% CI: 33–45%) and 26% (95% CI: 21–31%), respectively. Regardless of pet ownership, 74% of the respondents reported having some type of animal contact in the past month. Pregnancy or the birth of a child altered some animal contact practices among the study participants; particularly a discontinuation or decrease in cleaning cat litter boxes. Reports of diseases contracted from animals were low (4%) in this study. By contrast, animal-associated injuries were prevalent (42%), and the majority were caused by animals the respondents owned (56%). Overall, respondents indicated that they appreciated the benefits of a program addressing animal-associated health outcomes and did not indicate strong resistance to adopt certain behaviors. The majority recognized human health-care providers as a source of information about animal contact and associated health outcomes but less frequently identified veterinarians as a source for such information. In addition, although most of the respondents felt that health-care providers and veterinarians should initiate discussions about preventing animal-associated illness and injuries, only 41% among those who had visited doctors or prenatal care services reported that their health-care providers discussed these issues with them. The results indicate the importance of an intervention concerning animal contact and associated health outcomes for the target population and provide insights to the potential implications of program implementation.

Morbidity of pediatric dog bites: a case series at a level one pediatric trauma center

BACKGROUND

Pediatric dog bite injuries are common and vary in severity. We sought to characterize predisposing factors, required interventions, and morbidity.

METHODS

A prospective clinical database at a level one pediatric trauma center was reviewed for dog bite injuries over 74 consecutive months ending December 2013. This included all patients brought in by ambulance and/or seen by the trauma team.

RESULTS

Of 650 dog bite incidents, 282 met the criteria for inclusion in the trauma database. Median age was 5 years (range, 2 months to 17 years) and 55% (154/282) of patients were male. Pit bulls were most frequently responsible, accounting for 39% (83/213) of incidents in which dog breed was documented. Fifty-three percent (150/282) of dogs belonged to the patient's immediate or extended family. Sixty-nine percent (194/282) of patients required operative intervention: 76% laceration repairs, 14% tissue transfers, and 2% neurosurgical interventions. The most severe injuries were depressed skull fractures, intracranial hemorrhage, laryngotracheal transection, and bilateral orchiectomy. Median length of stay was 1 day (range, 0 to 25 days). There were no mortalities.

CONCLUSIONS

Pediatric dog bites span a wide range of ages, frequently require operative intervention, and can cause severe morbidity. Dog familiarity did not confer safety, and in this series, Pit bulls were most frequently responsible. These findings have great relevance for child safety.

SUMMARY STATEMENT

Pediatric dog bites are common and can vary in severity from superficial wounds to life-threatening injuries. Dog familiarity may confer a false sense of safety. A national dog bite prevention and education campaign should be developed with the goal of decreasing the incidence of pediatric dog bites.