Pediatric Dog Bites: A Review of 1422 Cases Treated at a Level One Regional Pediatric Trauma Center

Abstract

Background:
Children under the age of 14 account for over 40% of the almost 900,000 annual hospital visits associated with dog bites. Care for dog bites ranges from simple wound irrigation to complex surgical reconstruction. Due to a number of factors, children frequently sustain dog bites to highly vulnerable regions, often necessitating intervention by plastic surgeons.

Methods:
This retrospective study analyzed data from the 1422 pediatric patients who sustained dog bites and presented to the Le Bonheur Children's Hospital Emergency Room from January 2011 to May 2017.

Results:
The typical pediatric dog bite case was male (63.5%), African-American (57.4%), and less than 10 years old (69.4%). The head and neck were the most commonly affected areas (64.7%). Of the head and neck regions, the cheeks and lips were the most frequently injured structures (34.5%). Hospital admission was required for 188 patients (13.2%) and operative repair was deemed necessary in 16.9% of all cases. Of the patients requiring inpatient operative repair, most (78.3%) were discharged in less than 24 hours. Operative complications occurred in 5.8% of all cases, with infections accounting for the majority (92.9%). No fatal dog bites occurred in this study.

Conclusions:
Age, bite location, and number of bites sustained are several factors of significance, which may aid the novice plastic surgeon in identifying, which pediatric dog bite cases will require surgical intervention.

Full text

Pediatric Dog Bites: A Review of 1422 Cases Treated at a
Level One Regional Pediatric Trauma Center
Louisa C. Boyd, MD,

Jeremy Chang, MD,
y
Sonia Ajmera, MD,
z
Robert D. Wallace, MD,
§
Sonia M. Alvarez, MD,
§
and Petros Konofaos, MD, PhD
§
Background: Children under the age of 14 account for over 40% of
the almost 900,000 annual hospital visits associated with dog bites.
Care for dog bites ranges from simple wound irrigation to complex
surgical reconstruction. Due to a number of factors, children
frequently sustain dog bites to highly vulnerable regions, often
necessitating intervention by plastic surgeons.
Methods: This retrospective study analyzed data from the 1422
pediatric patients who sustained dog bites and presented to the Le
Bonheur Children’s Hospital Emergency Room from January 2011
to May 2017.
Results: The typical pediatric dog bite case was male (63.5%),
African-American (57.4%), and less than 10 years old (69.4%). The
head and neck were the most commonly affected areas (64.7%). Of
the head and neck regions, the cheeks and lips were the most
frequently injured structures (34.5%). Hospital admission was
required for 188 patients (13.2%) and operative repair was
deemed necessary in 16.9% of all cases. Of the patients
requiring inpatient operative repair, most (78.3%) were
discharged in less than 24 hours. Operative complications
occurred in 5.8% of all cases, with infections accounting for the
majority (92.9%). No fatal dog bites occurred in this study.
Conclusions: Age, bite location, and number of bites sustained are
several factors of significance, which may aid the novice plastic
surgeon in identifying, which pediatric dog bite cases will require
surgical intervention.
Key Words: Animal bite injury, dog bites, pediatric trauma,
reconstructive surgery, surgical management
(J Craniofac Surg 2022;33: 1118–1121)
Census data from 2018 reports that within the United States,
there are currently 89.7 million dogs kept by 60.2 million
households, in addition to an unknown number of stray dogs.
1
Although no current studies have been done to assess nationwide
statistics on dog bites, a 2001 Centers for Disease Control and
Prevention report estimated 4.4 million dog bites occurred in the
USA annually, resulting in 885,000 associated hospital visits.
Children under the age of 14 accounted for over 40% of this
statistic.
2
Dog bites are not without mortality risk.
3
The severity of dog
bites and subsequent interventions required vary greatly, with
multiple known characteristics such as the patient age, location
of the dog bite, and size/depth of the lesion playing a role. Dog bites
can cause significant trauma to soft tissue and often damage vital
dermal and subdermal structures. Even after successful defect
repair, the healing process may result in lasting contraction and
scarring, compromising aesthetic outcomes. Furthermore, dog bites
carry a potentially lethal infectious disease risk, as the canine oral
cavity may be colonized by Methicillin-Resistant Staphylococcus
Aureus, Pasteurella, C. tetani, or rabies virus.
4
Care for dog bites may range from simple wound irrigation to
laceration repair within the Emergency Room (ER) to complex
surgical interventions. Depending on the extent of damage sus-
tained, procedures such as skin grafting and nerve repair may be
required.
4
Plastic surgeons remain at the forefront of care for
traumatic dog bite patients. In 2017 alone, dog bites represented
approximately 28,000 reconstructive procedures. To put this in
perspective, dog bites amounted to more reconstructive cases
annually than either lower extremity reconstruction or burn care.
5
Numerous studies nationwide report a higher prevalence of
pediatric dog bites victims than adults.
2,6
Children are found to
have an increased risk of head and neck bites, with this anatomical
location having been linked with increased need for invasive repair
and morbidity.
7
Increased awareness towards this injury is neces-
sary for both the lay and medical community to potentially decrease
occurrences and morbidities from child dog bites.
8,9
Although studies exist investigating dog bite occurrence, few
investigations focus exclusively on the pediatric population.
1,2,6,7,10
In the recent literature, even fewer studies include over 1000
pediatric patients.
1,2
To the best of the authors knowledge, there
is a paucity in the literature regarding predictors of cases, which will
require surgical intervention in excess of surgical closure within the
ER and which will have a higher incidence of complications. The
aim of this review is to provide the novice plastic surgeon with
predictors of these 2 aspects of care in the management of pediatric
dog bite patients.
PATIENTS AND STUDY DESIGN
A retrospective review of 1422 pediatric patients who sustained dog
bites and presented to Le Bonheur Children’s Hospital ER from
January 2011 to May 2017 was performed. Initial filtering of
patients was performed by ER diagnostic code. Charts were subse-
quently analyzed for patient demographics, bite location, dog
From the Division of Plastic and Reconstructive Surgery, Saint Louis
University School of Medicine, Saint Louis, MO; yDepartment of
Surgery, University of Iowa Hospitals and Clinics, Iowa City, IA;
zDepartment of Neurosurgery, Hospital of the University of Pennsylva-
nia, Philadelphia, PA; and §Department of Plastic Surgery, University of
Tennessee Health Science Center, Memphis, TN.
Received July 11, 2021.
Accepted for publication August 24, 2021.
Address correspondence and reprint requests to Petros Konofaos, MD,
PhD, Department of Plastic Surgery, University of Tennessee Health
Science Center, 1068 Cresthaven Road, Suite 500 Memphis, TN 38119;
E-mail: pkonofao@uthsc.edu
Presented at the Plastic Surgery The Meeting (ASPS), 2019, in San Diego.
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL
citations appear in the printed text and are provided in the HTML and
PDF versions of this article on the journal’s Web site (www.jcraniofa-
cialsurgery.com).
Copyright #2021 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000008209
CLINICAL STUDY
1118 The Journal of Craniofacial Surgery Volume 33, Number 4, June 2022
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demographics, interventions, and outcomes. Additional visits relat-
ed to the same initial injury were all entered under the same patient.
Inclusion and Exclusion Criteria
Inclusion criteria consisted of the following: (1) presentation to
our ER for evaluation and treatment of dog bite injury; (2) age of
less than or equal to 18 years; (3) no interventions had been
performed at other institutions before presentation. Patients were
excluded if the bite source was not canine or if no true bite occurred
(ie, animal scratch with no skin break or laceration/abrasion sec-
ondary to animal activity).
Treatment and Management Algorithm
Before evaluating the wound, ensure that the patient is stablefrom
both respiratory and hemodynamic perspectives. Both appropriate
antibiotic coverage and tetanus/rabies prophylaxis underlie all care.
Abrasions may be treatedwith simple irrigation, applicationof wound
dressing, and follow-up. Puncture wounds may require primary
closure in addition to the previously mentioned interventions. Super-
ficial lacerations require the previously mentioned treatment with the
exception of tetanus prophylaxis. More extensive lacerations, such as
partial flap avulsions, require appropriate antibiotic therapy in addi-
tion to hospital admission for wound monitoring. If necessary,
debridementwith subsequent vacuum assisted closureor skin grafting
may ensue. Finally, injury involving vital structures, vulnerable
anatomical locations, large surface areas, or complete tissue loss
require antibiotics and hospital admission. Consultation of appropri-
ate subspecialists may be necessary. Surgical intervention is likely
warranted. The treatment algorithm is provided in Figure 1.
Statistical Analysis
Chi square test was utilized to assess associations between the
following categorical variables with a significance level of 0.05:
age, gender, anatomical location of bite, number of bites, dog breed
demographics, type of surgical intervention, need for surgical
intervention, and complications. Student ttest and analysis of
variance were used to analyze measures of central tendency with
a significance level of 0.05.
RESULTS
A total of 1422 patients were identified over a 6.5 year-period,
averaging 1 bite every 1.6 days. The typical patient was male
(63.5%) and African-American (57.4%). Younger children were
more frequently bitten, with the highest incidence of bites occurring
in patients who were less than 10 years old (69.4%) (Supplementary
Digital Content, Table 1, http://links.lww.com/SCS/D315). The
head and neck were the most commonly affected areas (64.7%)
in this study (Supplementary Digital Content, Table 2, http://links.
lww.com/SCS/D315) (Fig. 2A-G). Hospital admission was required
for 188 patients (13.2%) and operative repair, entailing repair either
in the operating room or under sedation in the ER, was deemed
necessary in 16.9% of all patients. Of the patients requiring hospital
admissions most (78.3%) were discharged in less than 24 hours. No
fatal dog bites occurred in this study.
Rabies and Tetanus Prophylaxis
Most patients did not receive vaccinations, whereas in the ER
(n ¼1245). Those that did received either the tetanus, diphtheria
and acellular pertussis vaccine (n ¼154), the rabies vaccine/immu-
noglobulin (n ¼19), or both (n ¼4). No cases of rabies or tetanus
were reported.
FIGURE 1. Treatment algorithm.
FIGURE 2. A 9-year-old Caucasian male involved in an incident with his aunt’s
Labrador where he sustained a complex posterior scalp avulsion along with
multiple lacerations of his face and left upper extremity. Following initial
debridement and irrigation with antibiotic solution, the lacerations on the left
arm and face were primarily closed whereas the scalp wound was partially
closed with a remaining 107 cm defect, which temporally covered with a
wound vacuum-assisted closure. The later was reconstructed with dermal
substitute and then with a split thickness skin graft (STSG). A year and a half
following application of the STSG, the patient underwent placement of a
smooth rectangle tissue expander with remote injection dome, 550 mL for
restoring cosmesis. The expander placement was performed through a left
temporal incision, 5 cm, and a minimal right temporal incision, 2 cm. Five
months later, final reconstruction was performed with removal of the expander
and advancement of the expanded hair-bearing scalp over the defect. An
aesthetically pleasing result was achieved. (A) The scalp defects. (B) The final
defect following debridement of devitalized tissues and repairing parts of the
wounds. (C) View of the wound following application of dermal substitute. (D)
Lateral view of the patient’s scalp following application of a 550 mL tissue
expander through a 5 cm left temporal incision. (E) Lateral view of the patient
with the final expansion volume. (F) Final outcome, 1 year after final
reconstruction; posterior view of the patient. (G) Final outcome, 1 year after final
reconstruction; lateral view of the patient.
The Journal of Craniofacial Surgery Volume 33, Number 4, June 2022 Pediatric Dog Bites
#2021 Mutaz B. Habal, MD 1119
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Anatomic Distribution of Bites
The majority of bites were located in various areas of the head
and neck (64.7%). Of these areas, the cheeks and lips were the most
frequently injured structures (34.5%). The extremities were the
second most frequently bitten location, with the upper extremities
(30.1%) being slightly more common than the lower extremities
(28.9%). Bites to the trunk were much less numerous (9.5%). Three
patients sustained bites to the genitals (Supplementary Digital
Content, Table 2, http://links.lww.com/SCS/D315).
Attacking Dog Breeds
In this study, 6 different dog breeds, plus mixed breeds, com-
prised the majority of known dog breeds. Most cases (64.1%)
remained unidentified by the patient or family members at ED
presentation. Most dog bite victims (57.9%) were familiar with the
dog that attacked them. Pit Bulls were the most frequently identified
breed (n ¼245, 47.9%) of the 511 cases in which the breed was
known and were the most commonly identified breed in cases
requiring operative repair (52.2%) (Supplementary Digital Content,
Table 3, http://links.lww.com/SCS/D315).
Nonoperative Management
Patients not requiring surgical intervention most commonly
underwent simple wound irrigation (n ¼496). Those requiring more
extensive treatment received laceration repair without sedation
(n ¼146).
Operative Management
For patients requiring operative repair (n ¼240, 16.9%), 198
laceration repairs were performed, with more complex procedures
such as nerve (n ¼3) or vessel (n ¼3) repair and fracture reductions
(n ¼11) rarely being required. Most patients (89.2%) underwent a
single operation and 78.3% were discharged in less than 24 hours
(Supplementary Digital Content, Table 4, http://links.lww.com/
SCS/D315).
Operative Complications
In general, operative complications were rare and occurred in
only 5.8% of cases (n ¼14). Of those that occurred, 92.8% were
accounted for by infections (n ¼13). One case required scar revi-
sion (Supplementary Digital Content, Table 5, http://links.lww.
com/SCS/D315).
Statistical Analysis
This study aimed to identify factors of importance that would aid
the plastic surgeon in assessing, which pediatric dog bite cases
should be managed operatively and which cases might be prone to
higher complication rates. Several factors of significance related to
operative intervention were identified. There was a significant
increase in operative need in children less than 10 years of age
(P <0.000001). Additionally, bites to the head and neck were
significantly associated with operative need as compared to both
the upper and lower extremities (P <0.00001) and the torso
(P <0.0001). The number of bites sustained further influenced
surgical intervention, with more than 2 bites being significantly
associated with operative need (P<0.0001). Gender was not
significantly associated with operative intervention (P¼0.28)
and had no association with operative complications (P¼0.84).
DISCUSSION
In Emergency Departments across the country, plastic surgeons are
frequently consulted on pediatric dog bite injuries, as the severity
and location of many bites warrant high level operative interven-
tion. Although many studies regarding the management and statis-
tical analysis of pediatric dog bites exist in the literature, none have
attempted to analyze this issue from a reconstructive surgery
perspective. Furthermore, very few studies of similar size have
been performed at a single institution in recent years.
2,11
Special Considerations in Pediatric Patients
Pediatric dog bites are difficult to manage due to a multitude of
factors. The majority of dog bite victims in this study and through-
out the country are under the age of 10, meaning that the plastic
surgeon must work on a much smaller scale than is optimal.
Delicate and aesthetically demanding structures commonly affected
in dog bites, such as the lips and nose, are challenging enough to
repair on a full sized patient, let alone a toddler. Additionally, the
extent of damage inflicted to a pediatric patient may far surpass that
of an adult suffering from a comparable bite. Finally, the surgeon
must be cognizant that the aesthetic outcome achieved at the time of
repair may be compromised as the patient undergoes later growth
and development.
Victim Demographics
The demographics of the typical dog bite case in this study vary
little from the majority of the published literature for the past 2
decades. Like most studies, the average dog bite patient in our study
was male and elementary school aged.
1,11,12
This uneven gender
distribution be accounted for by simple boyhood curiosity or by the
more physically aggressive styles of play seen in young boys, which
dogs may not take well to. The majority of victims were less than
10 years old
1,12,13
perhaps indicating that the size, strength, and
situational awareness that develop with age are all protective factors
against dog bites. Schalamon et al
14
previously reported an in-
creased incidence in children less than 1 year of age, which our data
did not support.
The Danger of Familiarity
The majority of both operative (69.6%) and nonoperative cases
(55.6%) were familiar with the attacking dog. This is in agreement
with other studies, in which the attacking dog is most frequently
either a household pet or neighbor’s dog.
1,3,6,1,14
Since familiarity
clearly does not protect children from being bitten, 1 can infer that
children are likely approaching these ‘‘known’’ and ‘‘friendly’’ dogs
closer and more intimately than they would a strange dog, resulting
in bites that are frequently more severe. This false sense of safety
may also account for the high volume of bites that occur on the head
and neck regions of many pediatric patients.
Vulnerable Locations and Structures
Our data indicate that the head and neck were the most com-
monly bitten areas (64.7%) in pediatric dog bite injuries. More
specifically, the cheeks and lips were the prime sites of injury. This
finding is consistent with existing literature, which also indicates
that bites are most commonly sustained to the central structures of
the face.
6,13,15
Palmer and Rees
15
previously deemed the cheeks,
lips, and nose the ‘‘central target zone’’ in pediatric dog bite injuries
due to the high incidence of bites that occur on these delicate and
central structures.
Predictors of Surgical Intervention
Surgical intervention was necessary in 16.9% of dog bite cases
in our study and was statistically significant in relation to several
variables. Head and neck bites accounted for 54.2% of all operative
cases and were statistically associated with surgical intervention,
Boyd et al The Journal of Craniofacial Surgery Volume 33, Number 4, June 2022
1120 #2021 Mutaz B. Habal, MD
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indicating that these areas suffered more severe damage than the
extremities (P<0.00001) or torso (P<0.0001).
5,16
Children are of
short stature and are, therefore, more easily bitten on these critical
areas than their adult counterparts.
6
Furthermore, children are less
aware of dangerous situations and lack both the gross motor skills
and strength necessary to protect themselves from harm, perhaps
also accounting for the severity of injuries occurring in these
regions. Based on the high frequency of head and neck bites seen
in our study and others,
6,13
children are likely approaching dogs at a
very close range to hug, kiss, pet, or play with them, whereas
leaving their head and neck regions susceptible to injury.
3
High Risk Dog Breeds
Although great controversy surrounds the idea of singling out
certain breeds as ‘‘problem’’ breeds, this study, in the company of
many before it, has identified a few breeds that bite children with a
greater frequency than others. The authors have no intention of
entering the political debate over whether or not certain breeds
should be banned or considered high risk, but, rather, to comment
on whether or not certain breed bites have a higher propensity to
send a patient to the operating room or not.
Although any dog can bite a child, countless studies from across
the country have identified Pitt Bulls, Mastiffs, German Shepherds,
and Dobermans as the most frequently identified breeds resulting in
visits to the ER.
1,5,6,14
Likewise, Pit Bulls comprised the majority of
identified dog breeds in this study (47.9%), followed by mixed
breeds and German Shepherds. Of the cases requiring operative
intervention, Pit Bulls were the most frequently identified attackers.
Clearly, the catchment area of the ER plays a role in this data, as dog
breed demographics may vary between urban and rural areas.
Limitations
Although this study has its limitations, no other studies are of
comparable size in the recent literature and lack the ability to fully
analyze, which factors may influence the need for operative interven-
tion. That being said,our hospital is the largest pediatric traumacenter
for a relatively large catchment region and as a result, the cases
presenting to the ER may reflect more severe injuries that local care
providersdid not feel comfortable treating. Bothpatient and dog breed
demographics seen in this study may not be applicable to other
similarly sized citiesacross the USA. This study, and its predecessors,
are further limited by the self-reported nature of dog demographic
data. The majority of data regarding breed identification, relationship
to the victim, andif the attack was provoked remain unreported during
ER presentation. Whether or not Pitt Bulls are in fact the most
frequently attacking dogs is left to be determined due to the sheer
volume of unreported breeds. Pit Bulls may be more memorable than
other breeds, resulting in confounding of the data from recall bias.
Finally, this retrospective chart review suffered in that the charts were
not written for research purposes and lacked standardization.
CONCLUSIONS
Children frequently sustain dog bites to highly vulnerable regions,
often necessitating surgical intervention. Although great debate
remains as to how to best decrease our nation’s pediatric dog bite
epidemic, plastic surgeons can help to minimize the devastating
physical and psychological effects of these injures through effective
and timely management of cases requiring surgical intervention.
Analysis of data from our high-volume pediatric trauma center can
hasten this triage process for the reconstructive surgeon, by analysis
of repeated gender, age, and bite location patterns observed in
our study.
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The Journal of Craniofacial Surgery Volume 33, Number 4, June 2022 Pediatric Dog Bites
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