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Animal Bite Injuries in Children: Review of Literature and Case Series
International Journal of Clinical Pediatric Dentistry, January-March 2017;10(1):67-72
67
IJCPD
Animal Bite Injuries in Children: Review of Literature
and Case Series
1Aviral Agrawal, 2Pradeep Kumar, 3Ruchi Singhal, 4Virendra Singh, 5Amrish Bhagol
IJCPD
REVIEW ARTICLE
10.5005/jp-journals-10005-1410
1,3Senior Resident, 2Dental Surgeon, 4Professor and Head
5Assistant Professor
1Department of Oral and Maxillofacial Surgery, Kalpana Chawla
Government Medical College, Karnal, Haryana, India
2,4,5Department of Oral and Maxillofacial Surgery, Postgraduate
Institute of Dental Sciences, Rohtak, Haryana, India
3Department of Pedodontics, Postgraduate Institute of Dental
Sciences, Rohtak, Haryana, India
Corresponding Author: Aviral Agrawal, Senior Resident
Department of Oral and Maxillofacial Surgery, Kalpana Chawla
Government Medical College, Karnal, Haryana, India, Phone:
+919336618558, e-mail: aviral2011@yahoo.co.in
ABSTRACT
Introduction: Maxillofacial region in children is particularly
vulnerable to animal bite injuries. These injuries may range
from insignicant scratches to life-threatening neck and facial
injuries. Children are the common victims, particularly of
dog bites.
Materials and methods: Three cases of animal bite injuries in
children with their clinical presentation and their management
are being presented along with review of literature. Surgical
management included cleansing and primary closure of the
wound. Rabies and tetanus prophylaxis were given.
Discussion: The most common site of injury was the face. For
the facial injuries, the most frequently affected area was the
middle third (55%), also called as the “central target area.” The
small stature of children, the disproportionate size of the head
relative to the body, their willingness to bring their faces close
to the animal, and limited motor skills to provide defense are
believed to account for this. The resulting soft-tissue injuries
can vary in relation to their extent. Treatment involved initial
surgical exploration, and secondary repair later depending on
the severity of the injury.
Conclusion: Prompt assessment and treatment can prevent
most bite wound complications. Early management of such
injuries usually guarantees satisfactory outcome. Prevention
strategies include close supervision of child–dog interactions,
better reporting of bites, etc.
Keywords: Animal bite injuries, Dog bites, Facial trauma.
INTRODUCTION
Facial trauma in children represents a significant medical
and public health issue.1-4 A considerable proportion of
skeletal and soft-tissue injuries of the face results from
animal bite injuries, mostly due to dog bites.5 In the UK,
it is estimated that dog attack injuries are responsible for
an average of 250,000 minor injuries and emergency unit
attendances each year,6 and in the USA, an average of
4.7 million dog bites occur each year7; many bites prob-
ably go unreported. Children, in particular, are more
likely to experience dog bite injuries compared with
adults, with children aged between 5 and 9 years con-
sidered to be the most at risk.6,8 Being the most exposed
part of the body, the face is particularly vulnerable to
such injuries.9-12 Among the victims of dog attacks, most
studies showed a male preponderance.10,13,14 The types of
wounds encountered range from insignificant scratches to
life-threatening neck and facial injuries. The tissue defects
may be superficial, but they can even cause amputations,
including severe vascular and nerve or bony destruction.
We present three cases of dog bite attacks in young chil-
dren and their management.
CASE REPORTS
Case 1
A 3-year-old girl reported to the emergency department
following an attack by a stray dog. She was otherwise fit
and well, and had no relevant medical history or known
allergies. A deep laceration wound was present extend-
ing from the left side of lower lip to the lower border
of mandible (Fig. 1). A small laceration was present on
the right nasolabial fold. Intraoral examination revealed
that maxillary deciduous central incisors were slightly
extruded and mobile. Her soft-tissue wounds were thor-
oughly debrided and irrigated with normal saline and
hydrogen peroxide. The laceration was sutured with
4-0 round body vicryl and 4-0 reverse cutting prolene
suture material (Fig. 2). The luxated maxillary incisors
were stabilized with composite splinting. The parents
were informed about the postoperative wound manage-
ment. Tetanus and rabies prophylaxis were evaluated.
The child was reviewed after 1 week and sutures were
removed (Fig. 3). The patient was kept on regular follow-
up for 3 months.
How to cite this article: Agrawal A, Kumar P, Singhal R, Singh V,
Bhagol A. Animal Bite Injuries in Children: Review of Literature
and Case Series. Int J Clin Pediatr Dent 2017;10(1):67-72.
Source of support: Nil
Conict of interest: None
Aviral Agrawal et al
68
Case 2
A 13-year-old boy reported to the emergency department
following an attack by a stray dog. He was otherwise fit
and well and had no relevant medical history or known
allergies. A deep laceration wound was present on the left
side of face extending 1 cm below and lateral to lower lip
up to the lower border of mandible in the midline of face
(Fig. 4). His soft-tissue wounds were thoroughly debrided
and irrigated with normal saline and hydrogen peroxide.
The laceration was sutured with vicryl and prolene suture
material (Fig. 5). The parents were informed about the
postoperative wound management. Tetanus and rabies
prophylaxis were evaluated. The child was reviewed after
1 week and sutures were removed (Fig. 6). The patient
was kept on regular follow-up for 3 months.
Case 3
A 6-year-old girl reported to the department with infected
suture wound. Parents gave history of an attack by a stray
dog, which was sutured by some private practitioner. The
wound showed sign of infection with pus collection. She
was otherwise fit and well and had no relevant medical
history or known allergies. An infected laceration wound
was present below the left eye extending up to the middle
of the cheek. The sutures were removed and the margins
Fig. 1: Deep lacerated wound in a 3-year-old girl Fig. 2: Sutured lacerated wound
Fig. 3: Follow-up picture after removal of sutures Fig. 4: Lacerated wound in a 13-year-old boy
Fig. 5: Sutured lacerated wound with vicryl and prolene
Animal Bite Injuries in Children: Review of Literature and Case Series
International Journal of Clinical Pediatric Dentistry, January-March 2017;10(1):67-72
69
IJCPD
of wound were refreshed with surgical blade (Fig. 7).
Her soft-tissue wounds were thoroughly debrided and
irrigated with normal saline and hydrogen peroxide. The
laceration was sutured with vicryl and prolene suture
material (Fig. 8). The parents were informed about the
postoperative wound management. Tetanus and rabies
prophylaxis were evaluated. The child was reviewed after
1 week and sutures were removed. The patient was kept
on regular follow-up for 3 months.
DISCUSSION
Animal bites have been a major public health problem.
Children are the most common victims, particularly of
dog bites.15 The most common site of injury was the face.9-
12 For the facial injuries, the most frequently affected area
was the middle-third (55%).13 This reflects the findings
of Palmer and Rees who called this the “central target
area.”16 The small stature of children, the disproportion-
ate size of the head relative to the body, their willing-
ness to bring their faces close to the animal, and limited
motor skills to provide defense are believed to account
for this.4,17
A study showed that the risk factors for dog attacks
include school-aged children (but highest rate of serious
injury from dog bite is in children under 5 years of age),18
male, households with dogs, certain breeds (German
shepherds, bull terriers, blue/red heelers, dobermans,
and rottweilers), and male dogs. Most of the cases involve
a known dog (friends, neighbors) and family pet.19
Dog bites are commonly associated with soft-tissue
injury to the face, but rarely result in facial fractures.1,4,19,20
The injuries to the soft tissues are designated into three
categories: Lacerations, punctures, and avulsions (tissue
loss). The resulting soft-tissue injuries can vary consid-
erably in relation to their extent and depth.20 The actual
incidence of facial fractures relating to dog attacks is cur-
rently unknown. Schalamon et al.,1 Karlson,3 and Palmer
and Rees16 documented no maxillofacial fractures in their
review of facial dog bite injuries, and Tu et al20 suggested
that facial fractures may occur in less than 5% of dog
attack incidents.1,3,16,20 When a maxillofacial fracture is
encountered, the most frequent bones to be fractured
are the orbital, nasal, and maxillary bones, constituting
78% of the documented dog bite facial fractures.20,21 The
mechanism of injury in cases of maxillofacial fracture
is thought to be the consequence of the mandible (or
involved bone) being physically held by the dogs jaws,
which is capable of delivering immense force to the area
of bone contacted by the dog’s teeth. In some breeds of
dog, the force produced has been measured to be in the
region of 31,790 kPa.6,22,23 The resultant force generated
creates a crush-type injury and fracture of the alveolar
bone. Young children are especially vulnerable to this
type of crush injury, since the maxillofacial skeleton is
not completely mineralized, is thinner, and, therefore,
considerably weaker compared with during adulthood.20
Fig. 6: Follow-up picture showing healed wound Fig. 7: Lacerated wound in a 6-year-old girl
Fig. 8: Sutured lacerated wound with vicryl and prolene material
Aviral Agrawal et al
70
Additional injuries due to animal bite included facial
nerve damage, lacrimal duct damage requiring stenting
and reconstruction, ptosis from levator transection, and
blood loss requiring transfusion.19
The severity of the wounds was assessed by Lack-
mann’s classification9:
I. Superficial injury without involvement of muscle.
II. Deep injury with involvement of muscle.
III. Deep injury with involvement of muscle and tissue
defect.
IVa. Stage III in combination with vascular or nerve
injury.
IVb. Stage III in combination with bony involvement or
organ defect.
The optimal management of these wounds is contro-
versial. The management of dog bite injuries has evolved
over the years. In the past, accepted surgical practice
involved delayed closure or healing by secondary inten-
tion. It was thought that because of the risk of infection,
dog bite msinjuries should not be closed primarily.9,24
Pinsolle et al25 reviewed their series of dog bite injuries
between 1979 and 1980. Treatment involved initial surgi-
cal exploration, followed by daily dressing with hydrogen
peroxide and secondary repair 2 to 7 days later depend-
ing on the severity of the injury. More recently, there has
been a move to more early and definitive treatment, with
authors advocating early washout and debridement of
wounds and primary closure.13,15,26-29 These changes have
arisen from findings that the infection rate increased if
treatment was delayed following injury,30 that debride-
ment reduced the incidence of infection by as much as
30-fold,30 and that primary treatment produced the best
cosmetic and functional results.9,10,26,30,31 Current opinion
advocates early surgical treatment with irrigation of
the wound, minimal debridement, and direct closure
where possible.9,10,13,16,32,33 Postoperatively, attention to
patient counseling, dressings, ointment, cleaning, and
scar revision help assure an optimal outcome for the
traumatized tissue. Avulsive injuries with significant
tissue loss represent the most difficult cases for definitive
management and are also those most likely to require
hospitalization.34 For traumatic avulsion involving the
lip vermilion and the perioral composite soft tissue, even
with injuries including delicate anatomic landmarks,
healing by secondary intention can be instituted as the
initial treatment of choice in younger patients, often
providing optimal results.35
Our regimen of primary closure after careful debride-
ment of necrotic tissue has been the favored procedure in
almost all recent publications.15,26-29 Wound cleansing is
essential. We irrigated wounds with hydrogen peroxide
and saline.15 Topical antibiotics and iodine solutions are
no longer recommended.5 The use of water-based, rather
than alcohol-based antiseptic solutions that cannot be
used without local anesthesia solutions, is suggested by
other authors.36
Wound infection is the most common complication
following these injuries. Some authors estimate an infec-
tion rate of up to 30% following animal bite injuries to the
extremities.37,38 Most infections caused by mammalian
bites are polymicrobial, with mixed aerobic and anaerobic
species. Bacteriology of infected dog and cat bite wounds
includes Pasteurella multocida, Staphylococcus aureus,
Viridans streptococci, Capnocytophaga canimorsus,
and oral anaerobes.19 Presenting symptoms are usually
wound site pain with cellulitis and purulent drainage.19
In addition to local wound infection, other complications
may occur, including lymphangitis, local abscess, septic
arthritis, tenosynovitis, and osteomyelitis. Rare compli-
cations include endocarditis, meningitis, brain abscess,
and sepsis with disseminated intravascular coagulation,
especially in immunocompromised individuals.19
Management of infection can be divided into cleansing
of the wound, antibiotic prophylaxis, and antibiotic treat-
ment.15 Antibiotic therapy is indicated for infected bite
wounds and fresh wounds considered at-risk for infec-
tion, such as extremely large wounds, large hematoma,
and cat bites, that appear to be more infected than dog
bites (37.5 and 14.9% respectively) and immunocompro-
mised patients.19 Antibiotic therapy (a combination of
amoxicillin and clavulanic acid) and other combinations
of extended-spectrum penicillins with beta-lactamase
inhibitors offer the best in vitro coverage of the patho-
genic flora.39 In patients with allergy to penicillins,
monotherapy with azithromycin seems to be an effective
alternative.39 Amoxycillin–clavulanic acid at a dose of 875
+ 125 mg, twice a day, by mouth, for adults and 25 mg/
kg, twice a day, by mouth, for children seems to be the
best regimen for prophylaxis in bite wound. Alternatively,
azithromycin by mouth can be used (for adults 500 mg
on day 1 and 250 mg a day for the next 4 days; for infants
more than 6 months old, 10 mg/kg on day 1 followed by
5 mg/kg for the next 4 days).15 In case of slow recovery
or no improvement, simultaneous lymphadenopathy, or
pneumonia, S. aureus or Francisella tularensis should be
suspected; ciprofloxacin is recommended.19 Prophylactic
antibiotics are recommended for 5 to 7 days.15,40 Tetanus
and rabies prophylaxis must be evaluated in all dog bites.
Metzger et al36 proposed the use of antibiotic prophy-
laxis for patients with comorbidities, high-risk injuries
including cat bites, puncture wounds, bites older than
6 hours, extensive trauma to soft tissue, and bites in
babies and infants. No antibiotic prophylaxis is neces-
sary for scratch wounds or excoriations.14,41 Correira40
Animal Bite Injuries in Children: Review of Literature and Case Series
International Journal of Clinical Pediatric Dentistry, January-March 2017;10(1):67-72
71
IJCPD
suggested the use of antibiotic prophylaxis also for
patients with an edema at the site of the bite and for
patients older than 50 years. Nearly all the patients in
the study from Kountakis et al28 were given prophy-
lactic antibiotics without regard to the severity of their
injuries. Another study that focused on bacteriological
background proposed antibiotic prophylaxis after bites
by horses and birds.39
Prompt assessment and treatment can prevent most
bite wound complications.19 Early management of such
injuries usually guarantees satisfactory outcome. Preven-
tion strategies include close supervision of child–dog
interactions, public education about responsible dog
ownership and dog bite prevention, stronger animal
control laws, better resources for enforcement of these
laws, and better reporting of bites.19 Anticipatory guid-
ance by pediatric health care providers should attend to
dog bite prevention. The need to improve community
knowledge of rabies and the availability and affordability
of rabies vaccine must be highlighted.19
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