Introduction: It is estimated that nearly one million ...



Pediatric Dog Bite Injuries – A 5 Year Review of the Experience at the Children’s Hospital of Philadelphia

Jessica M. Belz, MD, Alison E. Slemp, MD, and Richard E. Kirschner, MD

INTRODUCTION: There are more than 63 million dogs in the United States living with and accompanying Americans as pets [1]. Dog bite injuries in children represent an under-recognized and under-reported public health problem with significant morbidity and mortality. The primary objective of this study is to identify the nature of dog bite injuries treated over a five-year period at a large tertiary pediatric hospital and to identify critical parameters for public education and injury prevention.

METHOD: We performed a retrospective review of emergency room records of all pediatric patients who were evaluated for dog bite injuries sustained between April 2001 and December 2005. Our survey included all children aged 0-18 years, evaluated in the Children’s Hospital of Philadelphia Emergency Department for a dog bite injury to any part of the body. Subjects were identified by querying CHOP emergency department and trauma database records for patients presenting with a complaint of dog bite injury or assigned an ICD-9 diagnosis code of E906.0 (dog bite injury). Once identified, individual medical records pertaining to the dog bite injury were reviewed for all demographic data and dog bite injury details. Demographic information, including the victim’s age, breed of dog, anatomical location of injury, number of wounds, and the relationship of patient to dog were recorded. These findings were then abstracted into the cohort database for statistical analysis.

Medical data and demographic characteristics were summarized using standard descriptive statistics, including means and standard deviations for continuous variables such as age, and percentages for categorical variables such as gender.

RESULTS: 551 patients aged 5 months to 18 years were treated in the emergency department between April 2001 and December 2005 after suffering a dog bite injury. The majority of injuries (62.8%) were sustained by male children. The highest incidence of injury was found in school-aged children (6-12 years; 51.0%). The incidence of injury in preschoolers (2-5 years; 24.0%), teenagers (13-18 years; 20.5%) and infants (birth – 1 year; 4.5%) was lower.

The majority of patients designated a race on admission (98.6%). Of those children with a race documented in their medical record, 72.1% were African-American, followed by Caucasian (20.7%), other (2.9%), Asian (1.8%), and Hispanic (1.1%).

Extremity injuries were documented in 53.9% of the cases. Upper extremity injuries (54.6%) were more prevalent than lower extremity injuries (45.5%). Dog bites to the face occurred in 29.8% of patients, whereas injuries to the trunk (3.1%) and flank (1.6%) were less common. The majority of dog bite injuries among infants and preschoolers affected the face (53.5%), whereas older children mostly sustained injuries to the extremities (60.7%). 62.8% of patients were bitten in more than one body region.

The greatest numbers of dog bite injuries were found to occur during the summer months of June and July, with 24.1% of patients injured during these months over the total five-year period.

More than thirty different offending breeds were documented in the medical records. Of the cases for which a breed was indicated (269 cases), the majority of injuries were caused by pit bull terriers (50.9%), Rottweilers (8.9%), and mixed breeds involving at least one of the two aforementioned breeds (6.0%). Most patients were familiar with the dog involved in the attack (68.8%).

Thirty-five patients (6.4%) required hospitalization due to the overall severity of the dog bite injury sustained or due to a secondary complication, such as cellulitis or abscess formation. 110 consultations were requested by the emergency department for subspecialty services. These included Plastic Surgery, Orthopedic Surgery, Ophthalmology, Psychiatry, General Surgery, Urology, Otorhinolaryngology, and Social Work. Plastic surgical consultation was requested for 62.7% of these patients. 190 patients (34.5%) required a surgical repair of their injuries, whereas 302 patients were treated with local wound care alone. 86 patients (15.6%) received rabies prophylaxis.

CONCLUSION: Pediatric dog bite injuries are preventable, yet they persist as a prevalent public health problem. Children continue to be at a much greater risk of sustaining a serious dog bite injury than adults; 70% of dog bite-associated fatalities and the majority of dog bite injuries that necessitate medical care are in this young population [2, 3]. The physical and psychosocial consequences of being attacked by a dog as a child can be devastating. Whereas some dog bite awareness efforts are already in existence, much more attention is needed to prevent such injuries [4].

Dog bite prevention can be achieved by age-appropriate educational measures. The public, especially dog owners and their children, should be familiar with the rules for relating to dogs. Thompson et al. and others have recommended that families delay introducing a dog into a household until children are of school-age [5, 6]. Dogs often have a sense of dominance, especially if an infant is born into the family while the dog is already a member.

The American Veterinary Medical Association task force argues that singling out only a few specific aggressive dog breeds more prone to biting is futile and overlooks the problem as a whole. Given that any dog of any breed can bite a person, breed specific laws are not inclusive, and it can be argued that they violate an individual’s rights. The complexity associated with proper identification of a dog’s breed also hinders the enforcement aspect of such laws [3].

Understanding proper etiquette around dogs, providing appropriate care, including food, shelter, and supervision of the animals, is paramount in averting dog bite injuries. Further evaluation of pediatric dog bite injuries via the analysis of data from high-volume tertiary pediatric health care institutions will better elucidate patterns of injury with respect to patient age, gender, animal breed, and seasonality. This will allow for the development of more effective prevention strategies, including programs for community outreach, dog bite prevention education, and possibly changes to future legislation.

REFERENCES

1. “Pet Food & Pet Care Products in the US.” 2005. The Pet Food Institute. March 2007. hppt://

2. Sacks JJ, Kresnow M, Houston B. Dog bites: how big a problem? Injury Prevention 2:52-4, 1996.

3. 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. JAVMA 217(6):838-840, 2000.

4. “Teaching Your Child to Avoid Dog Bites.” The Humane Society of the United States. March 2007.

5. Thompson PG. The public health impact of dog attacks in a major Australian city. Med J Aust 167:129-132, 1997.

6. Schalamon J, Ainoedhofer H, Singer G, et al. Analysis of Dog Bites in Children Who Are Younger Than 17 Years. Pediatrics 117(3):e374-e379, 2006.

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