Animal bite injuries in pediatric population: a systematic review

Abstract

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.

Full text

Systematic Review
Animal bite injuries in pediatric population: a systematic
review
Ruchi Singhal
1,*
, Neha Sikka
2
, Ritu Namdev
1
1
Department of Pedodontics, PGIDS, Rohtak, India
2
Department of Dental Materials, PGIDS, Rohtak, India
(Received: 4 May 2022, accepted: 6 July 2022)
Keywords:
Animal bite /
injury / child /
adolescent / dog
Abstract -- 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.
Introduction
Animals are an indispensable part of the human ecosystem.
The animals might display many kinds of behavioral traits
towards humans like loyalty, affection or aggression. Animal
bite injuries in children of all ages represent an unsatisfactorily
understood but significant medical and public health issue.
Unaesthetic soft-tissue and skeletal injuries, scars and
disfigurements are outcome of such incidents [1]. It is
estimated that 50% of population in the United States
experience an animal or human bite wound at least once in
their lifetime, and 45% ofchildren had been bitten during their
lifetimes [2–4]. These types of injuries are ever-growing burden
for public health, especially in developing and third world
countries. Amongst bites caused by domestic animals, dog
bites account 80–90% [5,6], whereas cat bites account for 5%
and 15% [7,8], as second common cause. Children are
especially susceptible to dog bite injuries of the head and
neck region [4,9–12]. The kind of wounds afflicted span from
insignificant scratches to fatal injuries and/or infections [13].
These injuries are considerably preventable by studying the
attributes of the children who are traumatized, the character-
istics of biting animals and the detailed features of biting
incident. Accurate reporting of animal bites to authorities is
important for framing appropriate prevention strategies,
identifying the traumatic load and development of a more
efficacious planning of resource allocation and to provide care
[14–16]. Various studies have been conducted in different
regions of the world to elucidate and characterize injuries
resulting from animal-inflicted bites [17–20]. However, there
are significant scientific controversies in literature, and no
consensus on risk factors and optimal management. Therefore,
this systematic review aims to explore the literature to
understand the nature and severity of outcomes of bites from
animals, and identify the risk factors for injuries among young
victims of animal bite.
Method
Preliminary search
The databases PROSPERO, the Cochrane Database of
Systematic Reviews, the JBI Database of Systematic Reviews
and Implementation Reports and MEDLINE were searched and
no systematic reviews (completed or in process) on this topic
were identified.
*Correspondence: singhal84.ruchi@gmail.com
J Oral Med Oral Surg 2022;28:37
©The authors, 2022
https://doi.org/10.1051/mbcb/2022021
https://www.jomos.org
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
1

Protocol and registration
The systematic review was conducted following the PRISMA
Statement (Preferred Reporting Items for Systematic Reviews
and Meta-Analyses) and the Cochrane’s Guidelines. The
proposed systematic review was registered in PROSPERO under
registration number # CRD42020177845.
The primary review question was, “What is the epidemiology
of animal-inflicted injuries in children and associated risk
factors?”PECO strategy as proposed by Maia and Antônio was
followed instead of PICO [21]. The PECO used was Population
(patients 19 years of age), Exposure (animal bite), Compar-
ison (sociodemographic and bite wound characteristics) and
Outcome (injury pattern and characteristics).
Eligibility criteria
Inclusion criteria were observational studies (prospective
studies, retrospective, cohort, case-control and cross-sec-
tional) in which risk factors for animal bite in children and
adolescents (19 years) were reported. There was no
restriction of year, or publication status (Epub ahead of print).
Fig. 1. PRISMA flowchart.
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
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Exclusion criteria were: (1) review articles, opinion articles and
single case reports; (2) studies with no apparent aim of
studying risk factors for injuries caused by animals; (3) studies
on adults with age >19 years and injuries caused by human
bites; and (4) studies addressing other etiologies (e.g.,
interpersonal violence).
Sources of information and research
The primary study source, PubMed/MEDLINE, Cochrane
Library, Google Scholar and Journals @ Ovid were used. The
descriptors were searched in the MeSH database (Medical
Subject Headings). With the help of the Boolean operators
“AND”and “OR”, the research strategy was developed. The
keywords searched were (((((“maxillofacial injuries”OR ”facial
injuries”))) AND ((”wounds and injuries”OR bites and stings OR
trauma OR soft tissue injuries OR wounds OR lacerat* OR
injuries OR wounds))) AND ((animal OR mammal* ORdog OR cat
OR domestic OR non domestic OR pet OR stray OR wild))) AND
((infan* OR child* OR adolescen* OR pediatr* OR human)).
The search strategy was modified for each included
information source. In addition, reference lists of literature,
existing networks and websites, were scrutinized to enhance
procurement of documents. Following initial search, all the
citations were transferred to EndNote 9 (Clarivate Analytics)
and duplicates were removed.
Selection of studies
To minimize inter-examiner variability, 2 reviewers
applied the eligibility criteria to 20% of retrieved studies
as calibration exercise and a good agreement level was
achieved (x= 0.841). The studies were assessed in two main
phases: (1) two reviewers (RS and NS) systematically analyzed
titles and abstracts, and when they fulfilled the inclusion
criteria for the review, articles were selected for the next phase
and (2) full texts of eligible studies were obtained and
evaluated. Reasons for exclusion of full text studies that do
not meet the inclusion criteria were documented. Any
disagreements between the reviewers during selection
process were resolved through discussion, or with a third
reviewer. The whole procedure was presented stepwise in a
Preferred Reporting Items for Systematic Reviews and Meta-
analyses (PRISMA) flow chart.
Data collection and extraction process
Two evaluators (RS and NS) performed data extraction
independently using a spreadsheet specially created to extract
the necessary information including the following items:
article identification (author, location, duration of study,
source of information, type of study and case definition);
victim characteristics (age and sex); causative animal
characteristics (breed, familiarity, provoked/unprovoked) and
results (area and types of injuries and months of year when
incidence is at peak) and other relevant variables.
Methodological quality appraisal
After data extraction of all relevant articles, an objective
appraisal process was initiated. The process ofappraisal aims to
assess the quality of the study by evaluating the design and
methodology. The quality assessment of included studies were
independently rated by two reviewers using an adapted version
of the NIH Scale for case series and JBI prevalence critical
appraisal tool having 7 questions, assigning Y/N/U (Yes/No/
Unclear) for each question. The higher the score, the better was
the methodological quality of the study.
Synthesis of result
The variability among studies was appraised by parameters
such as the outcome analyzed, sample attributes, predictor
measures, statistical tests and summary variables. This
prevented the pooling of data for meta-analysis.
Results
Selected studies
A sum total of 924 potentially relevant articles were
recognized. Of the 924 articles, 842 were excluded after the
analysis of titles and abstracts. Full-text analysis was done for
eighty two articles, out of which twenty nine were included in
the systematic review according to the eligibility criteria.
Figure 1 shows the stepwise process of searching, evaluation,
inclusion and exclusion of articles.
Characteristics of included studies
The prime characteristic features of eligible studies are
summarized in Tables I–III. The time span assessed in the
studies ranged from 1985 to 2017 [4,9,11,22–47]. Majority of
the included studies in the review were retrospective studies
except 4 studies (2 were prospective studies [11,25] and 2 were
cross-sectional questionnaire-based surveys [38,43]). The
animals involved in the biting episode were dogs in all the
included studies. The male/female ratio ranged from 0.75:1 to
2.1:1. Most of the included studies depict males are more prone
to animal bite injuries except only 3 studies which showed
female preponderance [22,33,47]. The age range varies from 0
to 19 years with the mean age varying from 3.6 to 8 years
[25,26]. The usual age in all studies analyzed corresponded to
preschool and grade school children being the most affected
group [22,24,25,27–33,37,40,43,46]. The list of breeds
commonly causing ABI are given in Table II. 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. Provocation was seen to be a risk factor for animal
bite. Most cases of animal bite injuries were recorded during
summer and spring months. Head and neck in younger children
followed by extremities in older children was found to be the
most inflicted area [22,24,25,27–33,37,46]. Among head and
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
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Table I. Demographic characteristics of patients included in studies.
Author/Country Duration of study Source Design Number of
patients
Age Gender Case definition Age
Classification
1 Abraham JT et al.
2019/ USA
5 Y (October 2011 to
October 2016)
Pediatric trauma registry
Texas A&M University
Health Science Center,
Temple, Texas.
RS 102 3 D 16 Y
Mean 5.84 Y
43:57 (0.75:1) Individuals 18
years who sustained
a dog bite and
presented to the ED
directly or as a
transfer from a
regional center for
continued care.
0–1Y: 11, 2–5 Y: 44,
6–12 Y : 42, >13Y :
5
2 Akhtar N et al. 2006/
UK
5 Y (1998–2002) Plastic Surgery Department
at the Sheffield’s Children
Hospital, UK
RS 118 1 15 Y Mean
6.6 Y
70:48
(1.4:1)
Patients with a dog
bite injury admitted
under the care of the
Plastic Surgery
Department at the
Sheffield’s Children
Hospital.
3 Alizadeh K et al.
2017/ USA
3 Y (January 2012–
December 2014)
Maria Fareri Children’s
Hospital of Westchester
Medical Center, USA
RS 108 0 18 Y
Mean 6.5 ± 4.9
Y
61:47 (1.30:1) All the pediatric
patients (age, 0–18
years old) who
sustained dog bites
Infant : 17.5%,
Preschool : 33.3%,
Grade School :
31.4%, Teenage :
17.5%
4 Avner RJ et al. 1991/
USA
1 Y (January 1989–
December 1989)
The Children’s Hospital of
Philadelphia
Emergency Department
PS 168 7 Mo 17 Y,
Mean 8 Y
60:40 (1.5:1) Children younger
than 19 years of age
who presented to ED
for evaluation of dog
bite injuries
5Y:54
>5 Y : 114
5 Bernardo LM et al.
1998/ USA
6 Y (January 1990–
December 1995)
Registry of the
Pennsylvania Trauma
Outcome Study (PTOS)
RS 183 <18 Y Mean 3.6
Y
106:77 (1.38:1) Individuals 18 years
of age or younger
whose injuries were
associated with a
dog bite
6 Bernardo LM et al.
2000/ USA
1 Y (January 1997–
December 1997)
ED records of Children
Hospital of Pittsburg
RS 204 2 D 19 Y
Mean 6.8±4.2
49%
<5Y
124:80 (1.55:1) (1) the biting
episode was caused
by a dog, and (2)
the dog bite occurred
less than 24 hours
before the ED visit.
5 Y: 49%
7 Bernardo LM et al.
2002/ USA
2 Y (January 1999–
December 2000)
Patient records from ED of
Children’s Hospital of
Pittsburgh
(CHP)
RS 386 7 Mo to 19 Y
Mean 6.7 Y
200:186
(1.07:1)
1) the biting episode
was caused by a dog,
and 2) the dog bite
<6 Y : 52.8%, >7Y
: 47.2%
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Table I. (continued).
Author/Country Duration of study Source Design Number of
patients
Age Gender Case definition Age
Classification
occurred less than 24
hours prior to the ED
visit.
8ChenHHet al. 2013/
USA
5 Y (January 2003–
December 2008)
Children’s Hospital
(Denver, CO)
RS 537 0.5 17 Y
Mean 4.59±3.36
Y
52:48
(1.08:1)
Patients with a
diagnosis of dog bite
were identified by a
search for medical
records containing
Code E906.0. Each
record was evaluated
to identify children
with bites to the
face
0–5 Y : 68%, 6–12 Y
: 28%, 13–17 Y : 4%
9 Chiam SC et al.
2014/ Australia
2 Y (January 2009–
December2011)
Women’s and Children’s
Hospital, Adelaide,
Australia.
RS 277 1 Mo 17 Y,
Mode 2 Y,
Median 5 Y
160:117
(1.37:1)
Children aged0–17
years presenting with
dog bites
0–4 Y : 120, 5–8Y:
67, 9–12 Y : 58, 13–
17 Y : 32
10Daniels DM et al.
2009/ USA
7 Y (1999–2006) Two Level I Trauma
Centers
RS 1347 <18 Y
Mean age 7.28
±4.44 Y
1.32:1 The study population
included all visits by
children younger
than 18 years who
were evaluated and
treated for dog bite
related injuries
<5 Y: 34%, 5–10 Y :
40%, 11–17 Y : 26%
11Dwyer JP et al.
2007/ South Africa
15 Y (4
th
March 1991
to October 2004)
Child Accident Prevention
Foundation of South Africa
(CAPFSA) trauma registry
RS 1871 2.5 Mo to 18.5
Y Mean 6.84
±3.30
1265:606
(2.09:1)
<6 Y: 797, ≥6Y:
1065, Unknown : 9
12Eppley BL et al.
2013/ USA
10 Y (1995–2005) Riley Hospital for Children PS 107 6 Wk to 11.5 Y
Mean 5.7±2.9 Y
56:51
(1.1:1)
Children (<12 years
of age) with dog
bites above the
clavicles
13Fien J et al.2018/
California/ USA
8 Y (2007–2014) Research data sets of
NTDB
RS 7912 <18 Y Mean
5.4 Y
43:57 (0.75:1) 17 years or younger
with the ICD 9
CM E906.0 code, dog
bite.
0–2Y : 30%, 3–5Y:
27%, 6–12 Y : 34%,
13–17 Y : 6%
14Garvey EM et al.
2014/ USA
7 Y 2 mo Phoenix Children’s Hospital
Level I Trauma Centers
RS 282 2 mo to 17 Y
Median 5 Y
54.6:45.4
(1.20:1)
Dog bite patients are
included in the
trauma database if
they are evaluated by
the trauma team or
arrive to the ED
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Table I. (continued).
Author/Country Duration of study Source Design Number of
patients
Age Gender Case definition Age
Classification
15Greenhalgh C et al.
1991 Australia
18 Mo (January 1986
to June 1987)
Emergency Department
(ED) at the
Adelaide Children’s
Hospital
RS 159 100:59 (1.69:1)
16Kasbekar AV et al.
2013/ UK
10 Y (September
2001–August 2011)
Alder Hey Children’s
Hospital Liverpool/ UK
RS 436 1 Mo 16 Y
Median 6 Y
1.2:1 Injury to the head
and neck region by a
dog in children of 16
years of age or under
17Kaye AE et al. 2009/
USA
4 Y (April 2001–
December 2005)
Children’s Hospital
of Philadelphia Emergency
Department
RS 551 5 Mo 18 Y
Mean 8.41 Y for
Males
Mean 8.666 Y
for females
346:205
(1.7:1)
Children presenting
to the Hospital with
ICD 9
th
revision
diagnosis code
E906.0 (dog bite
injury)
Infant 0–1 Y : 4.5%,
Preschooler 2–5Y:
24%, Grade School
6–12 Y : 51%,
Teenager 13–18 Y :
20.5%
18Kahn A et al. 2003 /
Belgium
9 Mo (April 15 to
December 31, 2001)
Questionnaire
based survey
100 <16 Y,
3Mo15 Y
Median 7 Y
1.38:1 The children younger
than 16 years old,
had been bitten by a
dog less than 72 h
earlier, and agreed to
answer a
questionnaire or an
adult care giver
agreed to answer on
their behalf.
19Lang, ME et al. 2005
/Canada
4 Y (1998–2002) 2 tertiary EDs in
Edmonton,Alta.
RS 287 4 Mo to 16.9 Y
Mean 7.4±4.2
145:142
(1.02:1)
Children <16 years
of age presenting
with
a dog bite
20McGuire C et al.
2018/ Canada
2.5 Y (January 2015–
June 2017)
Izaak Walton
Killam Health Centre ED
RS 158 <16 Y 53.8:46.2
(1.16:1)
ICD 10 CA(Tenth
edition) Code W54,
Corresponding to
bitten by Dog
21McHeik, JN et al.
2000/ France
10 Y (1985–1995) RS 100 59:41 (1.44:1)
22Mitchell RB et al.
2003/USA
6 Y (January 1995–
December 2000)
University of New
Mexico Health Sciences
Center
RS 44 1 12.1 Y,
Mean 5.2±2.9 Y
61.3:38.7
(1.58:1)
Children with bites of
the scalp, face, or
neck
E906.0 of ICD/9/CM
23Monroy A et al. 2009
/USA
9 Y (1999–2007) Tertiary care children’s
Hospital
RS 84 0 19 Y
Mean 6.19±4.01
Y Median 4.07
46:38
(1.2:1)
Dog bite injuries
sustained to head
and neck.
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Table I. (continued).
Author/Country Duration of study Source Design Number of
patients
Age Gender Case definition Age
Classification
24Reisner IR et al.
2011/USA
2Y3Mo
(December 2006–
Feburary 2009)
ED of the Level 1 trauma
centre at the Children’s
Hospital of Philadelphia
CS
Questionnaire
based survey
203 3 Mo 17 Y,
Mean 7.2 Y,
Median 6.5 Y
55.2:44.8
(1.23:1)
<17 years presenting
for dog bite injuries
25Schalamon J et al.
2005/ Austria
5 Y (1994–2003) Department of Pediatric
Surgery at the Medical
University
of Graz (Level 1 trauma
center)
RS 341 8 D 16 Y
Mean 5.9 Y
174:167
(1.04:1)
Individuals younger
than 17 years and
sought medical
attention after a dog
bite
26Speirs J et al. 2015/
Texas/ USA
6 Y (2005–2011) Level one trauma centre RS 116 <19 Y <19 yrs old with a
dog bite injuries
27Sribnick EA et al.
2016/ USA
106 Mo (February
2000–December2009)
State mandated trauma
database (Georgia Central
Trauma Registry)
RS 236 Mean 5.83 Y 132:104
(1.27:1)
Patients less than 18
years of age who
were seen in the
Emergency
Department for a
documented acute
injury due to a dog
bite.
28Van As AB et al.
2010/ South Africa
13. 5 Y (March 1991–
November 2004)
The Child Accident
Prevention Foundation of
South Africa (CAPFSA)
trauma registry.
RS 596 2.5 Mo to 13.4
Y
5.1±2.9 Y
404:192
(2.1:1)
29Wu PS et al./ USA 5 Y (January 2003–
December 2008)
Urban tertiary care
hospital
RS 87 9 Mo 17 Y
Mean 6.82 Y
41:46(0.89:1) Patient 18 years or
younger who
sustained a facial
dog bite injury and
was treated by a
single pediatric
surgery practice at
an urban, tertiary
care hospital. Dog
bites to the face of
all severities
*
Y= Year, Mo= Month, Wk= Week, D= Days, ED= Emergency department RS = Retrospective, PS= Prospective, CS= Cross-sectional.
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Table II. Characteristics of animals included in studies.
Author Most common breed
identified (* 3 Most
common in descending
order)
Familiarity of Dog Provocation by child Most common time of year
1 Abraham JT et al. 2019/
USA
Pit bulls, Labrador Pet 41.4%
Non pet 58.6%
Recorded in 74 out of 102
cases
P63.2%
Spring (March to May
31.4%) and Winter
(December to February
29.4%)December 14.7%
2 Akhtar N et al. 2006/ UK Alsatian, Japanese Akita,
Rottweiler
F66%
Pet 75%
P3 cases Summer 36%
3 Alizadeh K et al. 2017/
USA
56 cases that had an
identified dog breed, Pit
bulls, German Shepherd,
Husky, Small terriers
–
4 Avner RJ et al. 1991/ USA Mixed breeds, German
shepherd, Pit bull
K77% P 46% 65% in spring and summer
months (April to
September)
5 Bernardo LM et al. 1998/
USA
Recorded in 17% cases 
German Shepherd,
Rottweiler, Great Dane
Documented in 27(15%)
cases only. P 10, NP 
17
August (15%)
June (13%)
6 Bernardo LM et al. 2000/
USA
Pit bull, German shepherd,
Rottweiler
Parent n= 55 (27%)or a
neighbor n= 57(28%)
unrecorded in 49(24%)
P86+10
NP 17+14
Summer (June August)
40%
7 Bernardo LM et al. 2002/
USA
Pitbull, German shepherd,
Mixed breed/ mutt
Dog’s owner parent n
134 (34.7%) or neighbor n
94 (24.4%).
P191 (49.5%)
NP 66 (17%)
May to Aug 182
(47.2%)
8 Chen HH et al. 2013/ USA Mixed breed, Labrador
retriever, Rottweiler
K90% (family pet
(51.2%) or through a
neighbor (14.7%),friend
(12.7%), or relative
(9.5%)Un 5%
P164 (31%)
NP 144 (27%)
Not documented/
witnessed 229 (43%)
9 Chiam SC et al. 2014/
Australia
Bull Terrier group, Jack
Russell Terriers
F78%
NF 11.6%
Undocumented 10.5%
P67.5%
NP 32.5%
NM
10Daniels DM et al. 2009/
USA
Pit Bulls, German
Shepherd, Great Dane
Child’s caregiver (Family or
baby sitter) 45(37%)
Friend/ Neighbor 19
Stray dog 4
Undocumented 75%
NP 5+3+2
P13+5
Summer & spring (63%)
Peak July(12.6%)
11Dwyer JP et al. 2007/
South Africa
Recorded in 1% of cases
Pit Bull Terrier, German
Shepherd
546(29%) occurred in
summer months of
November and January
12Eppley BL et al. 2013/
USA
Chow, Pit Bull, German
Shepherd
Family 49.4%
Relative 25.3%
Neighbour 19.5%
Un 5.7%
P59.7%
NP 19.5 %
Observed 16 %
Not observed 4.6%

13Fien J et al.
2018/ California/ USA

14Garvey EM et al. 2014/
USA
Pit Bull, Labrador, German
shepherd
Families or extended
families 53%
Neighbor 21%
Family friend 12%
Stray 8%
Un 6%
July and November
15Greenhalgh C et al. 1991
Australia
German shepherd, Kelpie,
Doberman
Ownership established in
110(69%)
K65(59%)
P39%
NP 61%
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8

neck region, the area frequently involved was cheek region and
lip/mouth. The type of wounds afflicted range from minor soft
tissue scratches to life threatening injuries including severe
nerve and vascular or bony destruction. Laceration wound was
the most frequent soft tissue injury.
Risk of bias and methodological quality appraisal
The articles included in this review were observational
studies, which may have led to publication bias. There may be
geography-based bias, with most of the studies in the literature
presenting data from western countries; thus not providing an
accurate representation of global pediatric injuries inflicted
by animals. In addition, bias may be caused by the articles
that were excluded based on unavailability or non-English
language.
The methodological quality appraisal of included studies
using an adapted version of the NIH Scale for case series [50]
and JBI prevalence critical appraisal tool revealed that most of
the studies were of moderate quality (Tab. IV)[51].
Table II. (continued).
Author Most common breed
identified (* 3 Most
common in descending
order)
Familiarity of Dog Provocation by child Most common time of year
Family dog 30(27%),
Relative, friend or
neighbour 78(71%)
16Kasbekar AV et al. 2013/
UK
Terrier group, Husky,
Rottweiler
K98% of which 55%
were family pet
17Kaye AE et al. 2009/ USA Pit bull terriers,
Rottweilers, Mixed breeds
F68.8% June and July 24.1%
18Kahn A et al. 2003 /
Belgium
German Shepherds,
Rottweilers, Labradors
F71 P 86% July and August
19Lang, ME et al. 2005
/Canada
Rottweiler, German
Shepherd, Husky
K73.9%
Stray/ Stranger 10.1%
Not documented 16%
June
20McGuire C et al. 2018/
Canada
Pit bulls, Labrador
retrievers, German
shepherds
Family pet 53.2%
K29.7%
Un 14.6%
Missing 2.5%
NP 46.8%
P26.6%
Not documented 26.6%
June 13.3% and July 
16.5%
21McHeik, JN et al. 2000/
France

22Mitchell RB et al. 2003/
USA
Rottweiler 13.6%, Chow
11.4%, Pitbull 9.0%
K79.4%
Un 20.6%
23Monroy A et al. 2009 /
USA
Pitbulls F 27% Summer 38%
24Reisner IR et al. 2011/USA Mixed breed, Pit bull,
Rottweiler
K72%
Relative, Neighbour, Friend
54%
Family 35%
Stranger 9%
Not clearly mentioned
25Schalamon J et al. 2005/
Austria
Crossbreed, German
Shepherd, Labrador
retriever
F73%
NF 15%
Un 12%
P75% Summer (August)
26Speirs J et al. 2015/
Texas/ USA

27Sribnick EA et al. 2016/
USA
Pitbull, Rottweiler,
Labrador
F75%
Family 44.5%
Neighbor 27.1%
Friend 4.2%
No correlation found
28Van As AB et al. 2010/
South Africa
Summer of December and
February
29Wu PS et al./USA 
*F=Familiar, NF= Non-familiar, K= Known, Un= Unknown, P=Provoked, NP=Non-Provoked.
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
9

Table III. Injury pattern and characteristics.
Author Area Type of injury
1 Abraham JT et al. 2019/ USA Head and neck region 92.1%,
Extremities 15.7 %, Trunk 4.9 %,
Multi region 12 patients
Major in 74 children
Minor in 28 children
2 Akhtar N et al. 2006/ UK Face 59% (Middle third was most
commonly affected), UL 20%, LL 
6%, Scalp 7%
Laceration 75%, Puncture 20%,
Avulsion 2.8%, Fracture 1.4%, Tendon
injury 0.7%
3 Alizadeh K et al. 2017/ USA Head/neck region 59.2%, Upper &
lower extremities 30.5%
4 Avner RJ et al. 1991/ USA Face & scalp 44, Trunk 11,
Extremity 113 Lacerations 38%, Abrasions 33%,
Puncture wounds 29%
5 Bernardo LM et al. 1998/ USA Skull/ head 41, Face 176, Neck 
13, Chest 7, Back 14, Shoulder/
Upper arm/ upper limb 25, Elbow/
forearm/wrist/hand fingers 32, Hip/
thigh 13, Knee 26, Leg 12, Spine
1,Buttocks/genitals 3, Multiple
sites/ unspecified 77
Fractures 26, Dislocations 11, Cerebral
lacerations/ contusions/ intracranial injury
3, Pneumothorax/hemothorax 3, Open
wounds 330, Vessel injury 6.
Amputation of fingers and arm 3,
Superficial injury 25, Contusion 13,
Nerve injury 8, Lacerations of eye 12
Open wounds were most common type of
injury
6 Bernardo LM et al. 2000/ USA Total injuries 511, Facial 221,
(cheek 69 and lip/mouth 66)
Laceration 57%, Puncture 18%
Abrasion/ scrapes 16%
7 Bernardo LM et al. 2002/ USA Total injuries 886
Face 61%
UL 19%
LL 9%
Laceration 55%
Puncture 24%
Abrasion 13%
8 Chen HH et al. 2013/ USA 
9 Chiam SC et al. 2014/ Australia Head& Neck 70.8%, UL 18.4%, LL
9.4%, others 1.4%

10 Daniels DM et al. 2009/ USA Head or neck (642), Trunk (90), Upper
limb (342), lower limb (245)

11 Dwyer JP et al. 2007/ South Africa Head, Neck or Face 633(31%), Trunk 132
(7%), Shoulder, arm or hand 344(17%),
Perineum or buttock 133(7%), Leg or
foot 779(39%)
Minor (Lacerations, Abrasions) 1718 (85%)
Significant 303(15%)
12 Eppley BL et al. 2013/ USA Head & Neck Puncture 15%, Avulsion 25%,
Combination 90%
13 Fien J et al.
2018/ California/ USA Head 852, Face 3594 (54%), Neck 216,
Thorax 207, Abdomen 226, Spine 23,
Upper extremity 1031, Lower extremity
512, Unspecified 1251
AIS classification: Minor(1) 6287
(79.6%), Moderate(2) 1122, Serious(3)
383, Severe(4) 99, Critical(5) 10,
Maximum(6) 1, Not assigned 10
14 Garvey EM et al. 2014/ USA External (skin) 231 (81.9)Face 16 (5.65)
Extremities/Pelvis 16 (5.65)Head/neck
13 (4.6)Abdomen 5 (1.8)Chest 1 (0.4)
AIS classification: Minor(1) 198 (70.2)
Moderate(2) 73 (25.9)Serious (3) 6
(2.1)Severe (4) 4 (1.4)Critical (5) 1
(0.4)Unsurvivable (6) 0 (0)
15 Greenhalgh C et al. 1991 Australia Face 91 bites (57%), Lower leg 11,
Upper leg 9, Forearm 7, Hand 6, Back 5,
Finger 5, Wrist 4, Abdomen 4, Elbow 2,
Knee 2, Chest 2, Foot 2, Ankle 2
16 Kasbekar AV et al. 2013/ UK Lip 46%, Ear 23%, Cheek 15%, Eye/
undereye 5%, Nose 5%
17 Kaye AE et al. 2009/ USA Face 29.8%, UL+LL 53.9%, trunk 4.7% NM
18 Kahn A et al. 2003 / Belgium Face and head (46)
Arms & hands (28) Severe (Puncture & Lacerations) 80
Minor (Scratches & Bruises) 20
19 Lang, ME et al. 2005 /Canada Face 58.5%, Extremity 35.5%, Head
1.4%, Buttock 1.4%, neck 0.7% Mild 46%, Moderate 28.9%, Severe 25.1%
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
10

Discussion
A systematic review is the mainstay of evidence-based
practice, commonly used for formulation of prevention and
treatment guidelines and policies [52–56]. It objectively
evaluates all available scientific evidence to answer a research
query; and identify the sectors where evidence is deficient
[54,57]. The present systematic review evaluated the scientific
literature for risk factors of animal bite injuries in children and
adolescents.
Animal aggression may be a result of interaction of several
factors [58]. The study of individual factors, interrelationship
between victim, animals and their environment is very complex
[59], several confounding factors such as perception, risk
taking and health care seeking behaviorof an individual may be
affected by past experiences, education and culture. A good
quality research requires reliable and reproducible measure-
ment of both the outcome and variables of the study [59].
There are many barriers in measuring outcomes as the number
of reported injuries is low in comparison to actual incidence of
animal bite injuries.
Young children below 5 years and male child seem more
vulnerable to be attacked because of their underdeveloped
motor skills [22,24,27–30,33,40,43,46]. Face especially lips,
nose and cheeks, also referred to as ‘central target area’is more
prone, may be because of comparatively smaller body and larger
head size [3,5,6,9,11,60–71]. Some investigators found higher
prevalence of animal bite injuries in older children
[25,31,32,37]. Evidence shows that risk of biting to both
household and non-household members increases if a dog lives
in a house with children or teenagers [59]. This area requires
further research. Daniels et al. (2009) [31] and Thompson
(1997) [62] found that death in younger children was result of
damage to vital structures and the child’s fragile skull [31,62].
In addition, younger children were more susceptible to sustain
deep wounds rather than superficial scratches or lacerations
Table III. (continued).
Author Area Type of injury
20 McGuire C et al. 2018/ Canada Face (42.9%), hands (12.6%) and scalp
(12%) Arms (11%), Legs(11%) Neck
(3.7%) Trunk (2.6%) Genitals (1.6%),
Feet (1.6%) Buttocks (1.2%)
Lackmann’s Type I (91.1%), Type II (3.2%),
Type III (5.1%), Type IVa 0.6%), Type IV b
no cases
21 McHeik, JN et al. 2000/ France Cheek, 35 wounds (24.3%); Lip, 25
wounds (18.5%); Orbit, 24 wounds
(16.4%); Forehead, 21 wounds (15%);
Chin, 11 wounds (7.8%); Nose, 10
wounds (7.3%); Ear, 9 wounds (6.4%);
and Scalp, 6 wounds (4.3%)
Stage 1 (simple wound without lacerations
or muscular injury) 59%; Stage 2, (multiple
injury with tissue lacerations and muscular
injury) 35%; Stage 3 (substance loss) 6%
22 Mitchell RB et al. 2003/USA Head and neck only Scalp Laceration 57%
23 Monroy A et al. 2009 / USA Cheek 34%, Lips 21%, Nose 8%, Ears 8% Laceration complex 45%, Laceration
Linear 32%, Avulsion 18%, Puncture
4%
24 Reisner IR et al. 2011/USA Face/head 52.5%, Arm/hand 32.3%,
Leg/Foot 20.6%, Other 7.0% Injury Severity score
ISS1 85.4%
ISS2 9.1%
ISS3 2.5%
ISS4 3%
25 Schalamon J et al. 2005/ Austria Face 50%, UL 28% LL 18%, trunk
4% Deep wounds 85%
Scratches/ Minor Lacerations 15%
26 Speirs J et al. 2015/ Texas/ USA Upper extremity 26(22.4%), Lower
extremity 41(35.3%), Face/axial trunk 54
(46.6%)
Data mentioned only for upper extremity
injuries
Excoriation 15.38%, Laceration 57.69%,
Puncture wound 30.77%
27 Sribnick EA et al. 2016/ USA Head 73.7%, Other 26.3% 
28 Van As AB et al. 2010/ South Africa Scalp 72 (11), Skull 13 (2), Brain 
closed injury 2 (0), Eye(s) 42 (7), Nose
19 (3), Facial bones 9 (1), Mouth/
oropharynx 64 (10), Mandible 4 (1), Ear
39 (6), Face (other) 353 (56), Neck 15
(2)
Laceration superficial 64%, Laceration
complicated 15%, Abrasion 13%,
Close tissue 4%, Vascular 0, Muscle
tendon 0, Others 3%
29 Wu PS et al./USA ––
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Table IV. Methodological quality appraisal of included studies.
Abraham Akhtar Alizadeh Avner Bernardo 1998 Bernardo 2000 Bernardo 2002 Chen 2013 Chiam Daniels Dwyer Eppley
1 Was the study question or objective
clearly stated?
YYYYYYYYYYYY
2 Was the sample representative of
the target population?
YYYYYYYYYYYY
3 Was the study population and
setting clearly and fully described,
including a case definition?
YNYYYYYYYYNY
4 Were the risk factors clearly
described?
YYNYYYYYYYNY
5 Were objective criteria used for the
measurement of the injury?
YNNNYYNNNNNN
6 Was there appropriate statistical
analysis?
YNNNNNY NNYYN
7 Are all important confounding
factors/subgroups/differences
identified and accounted for?
NNNNNNNNNNNN
Total Score 6 3 3 4 5 5 5 4 4 5 3 4
Fien Garvey Greenhalgh Kasbekar Kaye Kahn Lang Mcguire Mcheik Mitchell Monroy Reisner Schalamon Speirs Sribnick Van As AB Wu
1 Was the study question or objective
clearly stated?
YY N Y Y Y Y Y Y y Y Y Y Y Y N y
2 Was the sample representative of
the target population?
YY Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y
3 Was the study population and
setting clearly and fully described,
including a case definition?
YN N Y NY Y N N N N Y Y Y Y N y
4 Were the risk factors clearly
described?
NY Y N Y Y Y Y N N Y N Y N Y N N
5 Were objective criteria used for the
measurement of the injury?
YY N N NN Y Y Y N N Y N N N N N
6 Was there appropriate statistical
analysis?
YN Y N Y N Y Y N N N Y Y Y Y Y y
7 Are all important confounding
factors/subgroups/differences
identified and accounted for?
NN N N N N N N N N N N N N N N N
Total 5 4 3 3 4 4 6 5 3 2 3 5 5 4 5 2 4
Quality Rating Criteria: Good: 6–7, Fair: 4–5, Poor: 1–3.
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
12

[4,13,31]. Extremities; either the hands or lower limbs were
more commonly bitten in older children [72–78]. Single bite
wound was most frequently reported rather than multiple
wounds which occurred in cases of severe mauling [4,79].
The upper age limit for inclusion in the study as pediatric
population was not uniform in all the studies. Some included
patients up to 15 years, whereas in some studies patients with
age 17, 18 and 19 were included. This might have led to bias.
Moreover, the categorization of the victims according to the
age was variable, as some authors have categorizedon the basis
of age range and some have used the terminologies infant, pre-
school, grade school and teenagers.
In order to report the injuries inflicted in different areas of
body, few authors have divided the body parts as head & neck,
upper and lower extremities and trunk/torso/chest whereas
some have further subdivided head & neck into face, scalp, eye
and neck. This led to inconsistencies while drawing conclusions
from the data.
All the included studies in present systematic review
reported dogs as the offending animals. No observational study
reported any epidemiological data related to other animals.
Also, the data pertaining to the unreported bite incidents were
not apprehended. Discrepancies in health care seeking
behavior and access to healthcare facilities are well recognized
and affected by a number of factors, like severity of injury and
risks posed, health beliefs and understanding [80–84].
Ignorance regarding appropriate treatment, its completion,
vaccine was also implicated in the outcome.
No study included in present systematic review could
establish high quality evidence regarding risk factors for animal
aggression and none compared the risk across different groups.
To establish a variable as a risk factor, a control or a comparator
group is needed [59,85]. Comparison must be needed to isolate
animals showing aggression from animals with no aggressive
behaviour [86]. Also, comparison between characteristics of
victims and non-affected population has to be included. None
of the studies reaching the final review, examining the
demographics of the target of aggression had a comparator
group.
Pitbulls, Rottweilers, German shepherds, Bull terriers,
Labradors and Dobermans were ranked as breeds with higher
risk of attack [11,15,39,62,63,69]. Some breeds were
considered to be more aggressive, indeed many breed specific
legislations have been enacted [87–89]. However, the
relationship between dog breed and aggression may be
confounded by several factors [59]. Even the experienced
personnel may misidentify certain breeds, particularly cross
breeds, leading to behavioral and expectational implications
[90]. The breeds bull terrier, American Staffordshire bull terrier
(also known as American pit bull terrier), and Staffordshire bull
terrier are collectively referred to as “Pitbull”[91–93].
Misleading information perpetuated by media regarding dog
breed also creates confusion [63]. Very few hospitalized cases
reported or identified breed of the dog inflicting the injury
[31,94–98]. Cognitive biases regarding a particular breed of
dog causing serious injury may result in those recipients being
more likely to attend for treatment [99].
Various authors have used variable terminologies like
known/ unknown, familiar/ unfamiliar and pet/ non-pet to
establish the relationship between the victim and the biting
animal which created disparities while summarizing the data.
Hence, uniformity in data during compilation of results could
not be obtained. The events preceding the animal bite injuries
which were considered as provoked incidents were not
uniformly explained and demand a universally accepted
definition. After reviewing all the articles, we propose, factors
such as playing, teasing and feeding should be considered
under the term “Provocation”. There is seasonal variation across
different sub-continents with summer being the months of
June, July and August in some parts of world while in others
they occur during November, December and January. This could
lead to bias in the registry database.
A lot of incongruity was observed in documentation of type
and severity of injuries. The authors have used variable
terminologies such as minor/major, mild/moderate/severe,
laceration/abrasion/contusion/avulsion. Certain authors have
used Injury severity score (ISS) and few used Lackmann’s
classification [48,49]. These classifications did not address the
full spectrum of animal attack injuries. There is a need of a
globally accepted classification system that will help to make
consistent decisions regarding their management also. So, we
are hereby proposing a new classification-“Singhal-Sikka
Classification of Animal bite injuries”(Tab. V).
There is a need for development and maintenance of an
online database for reporting animal inflicted injuries in all the
countries of the world. Standardized methods for reporting
animal bite are required. Similarly, standardized methods for
measuring and reporting animals particularly dog populations
are required. The patient registry database should follow a
universally accepted animal bite injury reporting form to
Table V. Proposed Singhal-Sikka Classification of Animal bite injuries.
Grade 1 Licking or touching by the animal without any breech in skin continuity
Grade 2 Superficial skin injuries like scratches, abrasions, lacerations
Grade 3 Wound extending from skin to fascia, muscle or cartilage
Grade 4 Wound with tissue necrosis or tissue loss
Grade 5 Neural or vascular injury/ bone involvement /Organ defect/ Amputation
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
13

ANIMAL BITE INJURIES REPORTING FORM
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
14

J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
15

document an incident of animal attack. An animal bite injury
reporting form for attending physician (Checklist 1) and a
checklist for the authors while writing a paper on animal bite
injuries (Checklist 2) for accurate compilation is hereby
proposed in this article.
Checklist for the authors while writing a paper
on animal bite injuries
Details of victims
Frequency
Age range and Mean age
Sex ratio
Locality: Urban/ Rural
Family characteristics: Joint Family/ Nuclear family/
Single parent
Case definition
Non case definition
Details of biting animal(s)
Species: Dog/ Cat/Monkey/Others
Sex ratio of biting animal: Male/ Female/ Unknown
Breed of the animal
Ownership of animal: Pet/ Stray/ Wild/Unknown
Vaccination status of animal: Yes/No/Not known
Neuter status: Yes/No/Not known
Current Location of the animal: Alive and in Quarantine/
Waiting to be tested/ Euthanized/ UnknownCircumstances of
the injury
Location of incident
Familiarity of the victim with the biting animal:
Familiar/ Nonfamiliar/ Unknown
Owner of the animal: Self/ Parent/ Relative/ Neighbor/
Friend/ No relation/ Not reported/ Other
Behavior of animal leading to the incident: Provoked/
unprovoked/Sick/Unknown/Other
Most common time of year
Most common time of day
Time lag between the injury and presentation to the
emergency services
Characteristics of the injury
Number of wounds: Single/Multiple
Anatomical site(s) involved: Head and Neck,Upper Limb,
Lower Limb, Torso
Type of tissue(s) affected: Skin/ Muscle/ Tendon/ Nerve/
Vascular/ Bone
Severity of animal bite injuries: Grade I/ Grade II/ Grade
III/ Grade IV/ Grade V
Management:
Self- toileting of the wound
Agents used for self-toileting of wound
Wound flushed at the hospital
Agent used for wound flushing
Suturing
Tetanus vaccine
Rabies vaccine
Antibiotic therapy
Dose, Frequency, Duration
Hospitalization
Average stay
Scarring
Permanent disability
Fatalities
Follow up
Psychological counselling
Have the victim or the caregiver ever received education
on prevention of animal bite injuries
Design priorities in future research
Future research regarding animal bite injuries should follow
good methodological standards that will help to provide strong
evidence for development of preventive strategies. Studies
comparing victims with a control or comparator group should be
undertaken. Importance of educational interventions need to be
supported and should be area of future research. Educational
intervention regarding expected behavior of children in presence
ofanimalsand adequatesupervisionbyparents/caregiversshould
be emphasized. These studies can focus on public awareness
about such injuries and importance of timely intervention.
Longitudinal prospective studies to establish relationship
between behavior of animals and their confounders like their
temperament and training may reduce the risk of animal biting
trait. Reliable methods for accurate identification of dog breed
should be established like an atlas, including photographs as well
as size of particular breed need to be developed and validated
internationally. Observational studies shouldfollow multivariable
analysis to control the effect of confounders. Studies should also
identify barriers in implementation of preventive strategies like
neutering, avoiding high risk breeds of pets and supervision in
household with young children. A Standardized Checklist as
proposed in this article for reporting animal inflicted injuries
should be followed and validated internationally.
Why this paper is important?
Children are the most frequent victims of animal bite
injuries. These injuries have a deep impact on social and
psychological development of children.
Pediatric dentists can play an active role in early diagnosis,
initial management and timely referral for proper treatment.
This paper provides an insight how pediatric dentists can
impart anticipatory guidance to the patients and their families
regarding risk factors of animal bite injuries and the behavioral
response in case of an encounter.
Author contributions
R.S. and N.S. conceived the ideas; R.S. and N.S. collected
the data; R.S. and N.S. analysed the data; and R.S., N.S.and R.
N. led the writing.
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
16

Conflicts of interest
The authors declare that they have no conflicts of interest
in relation to this article.
Informed consent
As it was a systematic review involving data from previously
published scientific literature, informed consent from subjects
was not required.
Ethical committee approval
Since the study involved retrospective collection of data of
patients who had already been managed and their identity shall
not be disclosed at any point of time, the ethical approval was
not obtained.
Source of funding
This research did not receive any specific funding.
References
1. Sikka N, Jayam C, Choudhary RS, et al. Animal bite in a 6-month-
old child and facial injury with associated unusual nasal injury:
management of injuries along with 1-year follow-up. Int J Clin
Pediatr Dent 2019;12:560–565.
2. Beck AM, Jones BA. Unreported dog bites in children. Public
Health Rep 1985;100:315e21.
3. Hoxworth RE. Pediatric dog bite injuries: a 5-year review of the
experience at the Children’s Hospital of Philadelphia. PlastRe-
constr Surg 2009;124:559.
4. Schalamon J, Ainoedhofer H, Singer G, Petnehazy T, Mayr J, Kiss
K, et al. Analysis of dog bites in children who are younger than 17
years. Pediatrics 2006;117:e374–e379.
5. National Institute for Health and Care Excellence (2015) Bites:
Human and Animal. cks.nice.org.uk/biteshuman-and-animal
(Last accessed: 8 March 2017).
6. Murray GE. Examining evidence on dog bite injuries and their
management in children. Nurs Children Young People
2017;29:35–39.
7. Yadav AK, Jaisani MR, Pradhan L, et al. Animal inflicted
maxillofacial injuries: treatment modalities and our experience.
J Maxillofac Oral Surg 2017;16:356–364.
8. Esposito S, Picciolli I, Semino M, Principi N. Dog and cat bite-
associated infections in children. Eur J Clin Microbiol Infect Dis
2013;32:971–976.
9. Mcheik JN, Vergnes P, Bondonny JM. Treatment of facial dog bite
injuries in children: a retrospective study. J Pediatr Surg
2000;35:580–583.
10. Calkins Casey M, et al. Life-threatening dog attacks: a devastating
combination of penetrating and blunt injuries. J Pediatr Surg
2001;36:1115–1117.
11. Eppley BL, Schleich AR. Facial dog bite injuries in children:
treatment and outcome assessment. J Craniofac Surg
2013;24:384–386.
12. Kizer KW. Epidemiologic and clinical aspects of animal bite
injuries. J Am Coll Emerg Phys 1979;8:134–141.
13. Abuabara A. A review of facial injuries due to dog bites. Med Oral
Patol Oral Cir Bucal 2006;11:E348–50.
14. Abedi M, Doosti-Irani A, Jahanbakhsh F, Sahebkar A. Epidemi-
ology of animal bite in Iran during a 20-year period (1993–2013):
a metaanalysis. Trop Med Health 2019;47:55.
15. Essig G, Sheehan C, Rikhi S, Elmaraghy C, Christophel JJ. Dog Bite
injuries to the face: is there risk with breed ownership? a
systematic review with meta-analysis. Int J Pediatric Otorhino-
laryngol 2019;182–188.
16. Yardley AME, Hoskin AK, Hanman K, Hanman SL, Mackey DA.
Animal-inflicted ocular and adnexal injuries in children: a
systematic review. Surv Ophthalmol 2015;60:536–546.
17. Chapman S, Cornwall J, Righetti J, Sung L. Preventingdog bites in
children: randomized controlled trial of an educational inter-
vention. West J Med 2000;173:233e4.
18. Duperrex O, Blackhall K, Burri M, Jeannot E. Education of children
and adolescents for the prevention of dog bite injuries. Cochrane
Database Syst Rev 2009;CD004726.
19. Gilchrist J, Sacks JJ, White D, Kresnow MJ. Dog bites: still a
problem? Inj Prev 2008;14:296e301.
20. Erickson BP, Feng PW, Liao SD, Modi YS, Ko AC, Lee WW. Dog bite
injuries of the eye and ocular adnexa. Orbit 2018;38:43–50.
21. Maia LC, Antonio AG. Systematic reviews in dental research.
A guideline. J Clin Pediatr Dent 2012;37:117–124.
22. Abraham JT, Czerwinski M. Pediatric dog bite injuries in Central
Texas. J Pediatr Surg 2019;54:1416–1420.
23. Akhtar N, Smith MJ, McKirdy S, Page RE. Surgical delay in the
managementofdogbiteinjuriesin children,doesit increasetherisk
of infection? J Plastic Reconstruct Aesthet Surg 2006;59: 80–85.
24. Alizadeh K, Shayesteh A, Xu ML. An algorithmic approach to
operative management of complex pediatric dog bites: 3-year
review of a level I regional referral pediatric trauma hospital. Plast
Reconstr Surg Glob Open 2017;5:e1431.
25. Avner JA, Baker MD. Dog bites in urban children. Pediatrics
1991;88:55–57.
26. Bernardo LM, Gardner MJ, Amon N. Dog bites in children admitted
the Pennsylvania trauma centers. Int J Trauma Nurs 1998;4:121–
127.
27. Bernardo LM, Gardner MJ, O’Connor J, Amon N. Dog bites in
children treated in a pediatric emergency department. J Soc
Pediatric Nurs 2000;5:87–95.
28. Bernardo LM, Gardner MJ, Rosenfield RL, Cohen B, Pitetti R.
A comparison of dog bite injuries in younger and older children
treated in a pediatric emergency department. Pediatr Emerg Care
2002;18:247–249.
29. Chen HH, Neumeier AT, Davies BW, Durairaj VD. Analysis of
pediatric facial dog bites. Craniomaxillofac Trauma Reconstruct
2013;6:225–231.
30. Chiam SC, Solanki NS, Lodge M, Higgins M, Sparnon AL.
Retrospective review of dog bite injuries in children presenting
to a South Australian tertiary children’s hospital emergency
department. J Paediatr Child Health 2014;50:791–794.
31. Daniels DM, Ritzi RBS, O’Neil J, Scherer LRT. Analysis of nonfatal
dog bites in children. J Trauma Injury Infect Crit Care 2009;66:
S17–S22.
32. Dwyer JP, Douglas TS, van As AB. Dog bite injuries in children a
review of data from a South African paediatric trauma unit. S Afr
Med J 2007;97:597–600.
33. Fein J, et al. Pediatric dog bites: a population-based profile. Inj
Prev 2019;24:290–294
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
17

34. Garvey EM, et al. Morbidity of pediatric dog bites: A case series at
a level one pediatric trauma center. J Pediatr Surg 2015;50.
DOI:10.1016/j.jpedsurg.2014.09.051
35. Greenhalgh C, Cockington RA, Raftos J. An epidemiological survey
of dog bites presenting to the Emergency Department of a
Children’s Hospital. J Paediatr Child Health 1991;27:171–174.
36. Kasbekar AV, Garfit H, Duncan C, Mehta B, Davies K, Narasimhan G,
Donne AJ. Dog bites to the head and neck in children; an
increasing problem in the UK. Clin Otolaryngol 2013;38:248–274.
37. Kaye AE, Belz JM, Kirschner RE. Pediatric dog bite injuries: a
5-year review of the experience at the Children’s Hospital of
Philadelphia. Plast Reconstr Surg 2009;124:551.
38. Kahn A, Bauche P, Lamoureux J. Child victims of dog bites treated
in emergency departments: a prospective survey. Eur J Pediatr
2003;162:254–258.
39. Lang ME, Klassen T. Dog bites in Canadian children: a five-year
review of severity and emergency department management. Can J
Emerg Med 2005;7:309–314.
40. McGuire C, Morzycki A, Simpson A, Williams J, Bezuhly M. Dog
bites in children: a descriptive analysis. Plast Surg 2018;26:256–
262.
41. Mitchell RB, Nañez G, Wagner JD, Kelly J. Dog bites of the scalp,
face, and neck in children. Laryngoscope 2003;113:492–495.
42. Monroy A, Behar P, Nagy M, Poje C, Pizzuto M, Brodsky L. Head and
neck dog bites in children. Otolaryngol Head Neck Surg
2009;140:354–357.
43. Reisner IR, Nance ML, Zeller JS, et al. Behavioural characteristics
associated with dog bites to children presenting to an urban
trauma centre. Injury Prevent 2011;17:348–353.
44. Speirs J, Showery J, Abdou M, Pirela-Cruz MA, Abdelgawad AA.
Dog bites to the upper extremity in children. J Paediatr Child
Health 2015;51:1172–1174.
45. Sribnick EA, Sarda S, Sawvel MS, Reisner A, Chern JJ. Dog bite
injuries in children: clinical implications for head involvement.
Trauma 2016;0:1–6.
46. Van As AB, Dwyer JP, Naidoo S. Dog bites to the head, neck and
face in children. Southern Afr J Epidemiol Infect 2010;25:36–38.
47. Wu PS, Beres A, Tashjian DB, Moriarty KP. Primary repair of facial
dog bite injuries in children. Pediatr Emerg Care 2011;27:801–
803.
48. Gennarelli TA, Woodzin E, editors. The Abbreviated Injury Scale
2005-update 2008 Barrington, IL: Association for the Advance-
ment of Automotive Medicine; 2008.
49. Lackmann GM, Draf W, Isselstein G, Tollner U. Surgical treatment
of facial dog bite injuries in children. J Cranio-maxillo-Facial Surg
1992;20:81–86.
50. NIH scale for case series. https://www.nhlbi.nih.gov/health-
topics/study-quality-assessment-tools
51. JBI prevalence critical appraisal tool. https://jbi.global/critical-
appraisal-tools
52. Scottish Intercollegiate Guidelines Network, http://www.sign.ac.
uk/ Accessed:8 February 2010. -189
53. Oxford Centre for Evidence-based Medicine Levels of Evidence
(March 2009). Centre for Evidence Based Medicine: University of
Oxford, http://www.cebm.net/index.aspx?o=1025 Accessed: 9th
April 2011.
54. Higgins JPT, Green S. Cochrane Handbook for Systematic Reviewsof
Interventions Version 5.1.0 (The Cochrane Collaboration, 2011).
55. Glasziou P, Vandenbroucke J, Chalmers I. Assessing the quality of
research. BMJ 2004;328:39–41.
56. Chalmers I, Altman DG. Systematic reviews BMJ Publishing Group,
1995.
57. Glasziou P, Irwig L, Bain C, Colditz G. Systematic reviews in health
care: a practical guide Cambridge University Press, 2001.
58. Task Force on Canine Aggression and Human-Canine Interactions,
American Veterinary Medicine Association. A Community
Approach to Dog Bite Prevention. J Am Veterin Med Assoc
2001;218:1732–1749.
59. Newman J. Human-directed dog aggression; a systematic review,
Thesis June 2012.
60. 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;10:67–72.
61. Ullah F, Tahir M, Masoodurehman, Aslam M. Mammalian bite
injuries to the head and neck region. J Coll Phys Surg Pak
2005;15:485–488.
62. Thompson PG. The public health impact of dog attacks in a major
Australian city. Med J Austr 1997;167:129–132.
63. Ozanne-Smith J, Ashby K, Stathakis VZ. Dog bite and injury
prevention analysis, critical review, and research agenda. Inj
Prev 2001;7:321–6.
64. Donkor P, Bankas DO. A study of primary closure of human bite
injuries to the face. J Oral Maxillofac Surg 1997;55:479–81.
65. Mendez Gallart R, Gomez Tellado M, Somoza Argibay I, Liras Munoz
J, PaisPineiro E, Vela Nieto D. Dog bite-related injuries treated in
a pediatric surgery department: analysis of 654 cases in 10 years.
An Esp Pediatr 2002;56:425–429.
66. Weiss HB, Friedman DI, Coben JH. Incidence of dog bite injuries
treated in emergency departments. JAMA 1998;279:51–53.
67. Scheithauer MO, Rettinger G. Bite injuries in the head and neck
area. HNO 1997;45:891–897.
68. Borud LJ, Friedman DW. Dog bites in New York City PlastReconstr
Surg 2000;106:987–990.
69. Wei LA, Chen HH, Hink EM, Durairaj VD. Pediatric facial fractures
from dog bites. Ophthal Plast Reconstr Surg 2013;29:179–182.
70. WolffKD. Managementofanimal bite injuriesoftheface:experience
with 94 patients. J Oral Maxillofac Surg 1998;56:838–844.
71. Jaindl M, Grunauer J, Platzer P, et al. The management of bite
wounds in children a retrospective analysis at a level 1 trauma
centre. Injury 2012;43;2117–2121.
72. Knobel DL, Cleaveland S, Coleman PG, Fevre EM, Meltzer MI,
Miranda MEG, et al. Re-evaluating the burden of rabies in Africa
and Asia. Bull World Health Organ 2005;83:360–368.
73. Hon KLE, Fu CCA, Chor CM, Tang PSH, Leung TF, Man CY, et al.
Issues associated with dog bite injuries in children and
adolescents assessed at the emergency department. Pediatr
Emerg Care 2007;23:445–449.
74. Garcia VF. Animal bites and Pasturella infections. Pediatr Rev
1997;18:127–130.
75. Alabi O, Nguku PM, Chukwukere S, Gaddo A, Nsubuga P, Umoh J.
Profile of dog bite victimsin Jos plateau state, Nigeria: a review?
of dog bite records (2006–2008). Pan Afr Med J 2014;18:12–15.
76. Maragliano L, Ciccone G, Fantini C, Petrangeli C, Saporito G, Di
Traglia M, et al. Biting dogs in Rome (Italy). Int J Pest Manag
2007;53:329–334.
77. Sacks JJ, Sinclair L, Gilchrist J, Golab GC, Lockwood R. Breeds of
dogs involved in fatal human attacks in the United States
between 1979 and 1998. J Am Veter Med Assoc 2000;217:836–
840.
78. Stefanopoulos PK, Tarantzopoulou AD. Facial bite wounds:
management update. Int J Oral Maxillofac Surg 2005;34:464–472.
79. Lone KS, Bilquees S, Salimkhan M, Haq IU. Analysis of dog bites in
Kashmir: an unprovoked threat to population. Natl J Commun Med
2014;5:66–68.
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
18

80. Marmot MAJ, Goldblatt P, et al. Fair Society, Healthy Lives: A
Strategic Review of Health Inequalities in England Post- 2010.
The Marmot Review (University College London, 2010), p. 88.
http://www.marmotreview.org/
81. Morris S, Sutton M, Gravelle H. Inequity and inequality in the use
of health care in England: an empirical investigation. Soc Sci Med
2005;60:1251–1266.
82. Alberts JF, Sanderman R, Gerstenbluth I, van den Heuvel WJA.
Sociocultural variations in help-seeking behavior for everyday
symptoms and chronic disorders. Health Policy 1998;44:57–72.
83. Butchart A, Kruger J, Lekoba R. Perceptions of injury causes and
solutions in a Johannesburg township: implications for pre-
vention. Soc Sci Med 2000;50:331–344.
84. Simons J. in The Health Transition: Methods and Measures, edited
by J. Cleland, A.G. Hill (Australian National University Press,
1991), pp. 103–114
85. Pfieffer D. Veterinary Epidemiology: An Introduction (Wiley-
Blackwell, 2010).
86. Guy NC, et al. Risk factors for dog bites to owners in a general
veterinary caseload. Appl Animal Behav Sci 2001;74:29–42.
87. United Kingdom. Dangerous Dogs Act 1991. (65/1991). Enacted
12th August 1991–129
88. Republic of Ireland. Control of Dogs Act, 1986. 1986. (32/1986).
Enacted 17th December 1986–165
89. Germany. Dangerous Animals Act of Lower Saxony, Germany
(GefTVO). 2000. Enacted 5th July 2000 182
90. Voith VL. A comparison of visual and DNA identification of breeds
in Annual American Veterinary Medicine Association Convention
July 11-14 2009, Seattle, Washington, USA
91. Lockwood R, Rindy K. Are “pit bulls”diVerent? An analysis of the
pit bull terrier controversy. ANTHROZOÖS 1987;1:2–8.
92. Blackshaw JK. Dog bites and bull terriers. Aust Vet J
1991;68:117–18.
93. Magazanik M. RSPCA seeks tough controls on pit bulls. The Sunday
Age 19 May 1996.
94. Bini JK, Cohn SM, Acosta SM, McFarland MJ, Muir MT, Michalek JE.
Mortality, mauling, and maiming by vicious dogs. Ann Surg
2011;253:791.
95. Brogan TV, Bratton SL, Dowd MD, Hegenbarth MA. Severe dog
bites in children. Pediatrics 1995;96:947–950.
96. Shields LB, Bernstein ML, Hunsaker 3rd JC, Stewart DM. Dog
bite-related fatalities: a 15-year review of Kentuckymedical
examiner cases. Am J Forensic Med Pathol 2009;30:223–230.
97. Castrodale LJ. Hospitalizations resulting from dog bite injuries:
Alaska, 1991–2002. Int J Circum Health 2007;66:320–327.
98. Morales C, Falcon N, Hernandez H, Fernandez C. Dog bite
accidents in a children hospital at Lima, Peru. Retrospective study
from 1995–2009. Rev Peruana de Med Exp SaludP
ublica
2011;28:639–642.
99. Gershman KA, Sacks JJ, Wright JC. Which dogs bite? A case-
control study of risk factors. Pediatrics 1994;93:913–917.
J Oral Med Oral Surg 2022;28:37 N. Sikka and R. Namdev
19