By Dr. Jennifer Greer

It only takes a second.

Dog bites can happen to anyone… We were on a long weekend at home, and I was brainstorming ideas from Pinterest to keep my toddlers busy, as the dreary weather kept us cooped up indoors. The kids were completely wound up, and repeatedly tearing their way through the indoor obstacle course we had created out of furniture. Our 13-pound MaltiPoo was getting wound up as well, chasing the kids around the room. I turned my back for just a minute… and heard a shriek from my 3-year-old.

Dog bites are very common.

Dogs bite an estimated 4.5 million people every year. And dog bites to the face are one of the more common reasons my Plastic surgery skills are need in the middle of the night. Preschool age children are more likely to be bitten in the face or neck because they are low to the ground. And as I know from watching my own toddlers, they love to get right up and personal with dogs for hugs and kisses. Older children and teens are bitten in the arms and legs as well as the face. Again, this makes sense. Older kids are taller, and don’t have that same tendency to lead with the face.

I’m usually on the other end of this story.

As a mom I’ve always been very sympathetic for the parents involved whenever I’m called to the ER in the middle of the night. The ER is an unsettling place, especially if you aren’t in the medical field. You’re worried about your child, and you have the added stress of keeping him occupied for several hours in a strange environment. And bites to the face are especially scary: they bleed, sometimes a lot, and of course you worry about how it’s going to heal. Now I understand firsthand the questions that run through your head: “Is my kid going to look okay? Will the scar be bad? Did I fail as a mom?”

As I mentioned, my dog is a MaltiPoo- a Maltese poodle mix that’s the exact opposite of threatening. Given her small size, I’ve always thought she’d be less likely to do significant damage. But it turns out small dogs (Shih-Tzus were specifically named in one study) are the most common culprits when it comes to biting young kids. There wasn’t any explanation of why this might be. But I would suspect it’s because little dogs are cute and approachable to young children.

Older kids, in contrast, are more likely to be bitten by larger dogs; pitbulls and pitbull mixes accounted for 50% of the bites to older kids in one. One other fact you may not be aware of: the dog is known to the victim 68% of the time.  I know I personally have a tendency to get complacent around dogs I know, thinking “he would never bite.”

But biting is natural behavior in dog; older dogs will give younger dogs a quick nip to let them know they need to back off. And it’s not uncommon for a dog to use this same method of communication on an over-exuberant toddler. The toddler, unfortunately, does not have a protective layer of fur. So even a small nip can result in a deep cut.

Wyatt’s bite was little more than a scratch.

We lucked out at my house. I don’t think my dog really meant to hurt my son. He’s a typical three-year-old: loud, boisterous, and low to the ground. And Maggie has a bit of a nervous disposition. This was probably her way of telling my son to back off and get out of her face. Although the bite broke the skin, it could have been much worse.  I’ve seen bites to the face that split the nostril completely or went all the way through the lip. Even these weren’t even true attacks – just a quick nip on the dog’s part. (If you’re wondering what an actual dog attack looks like, imagine multiple bites over multiple areas of the body. Absolutely gruesome, in other words).

Yes, Wyatt’s cut could have used a stitch or two.  If I had seen him as a patient in the ER, I absolutely would have sutured it closed to make the scar better. But when I mentally debated the benefit of a narrower scar vs. the trauma of going to the ER and needing sedation I chose to tape the wound shut with some steri-strips.

The wound healed well.

No infection developed, thankfully. And when the steri-strips fell off a week later the cut was completely healed. The scar is starting to fade, and from my experience as a Plastic surgeon I know it’s going to be a fine white line eventually. But when I recently saw a photo of Wyatt without the scar I was sad: I felt like I failed as a mom.

What if your child is bitten? If your child is bitten by a dog, have a low threshold for going to the ER. Anything more than a very superficial scratch should be seen by a doctor within the first 24 hours. Dog bites can become infected fairly easily, so having the wound evaluated right after the injury is important. You’ll likely be asked the following questions by the ER staff:

When was your child’s last tetanus shot? If it’s been more than five years, or if you can’t remember, then your child will need a tetanus booster shot.

Does your child have any allergies? The data aren’t clear-cut whether giving prophylactic antibiotics (i.e. to prevent infection) actually decreases the risk of infection. So don’t be alarmed if you get sent home without an antibiotic. (And this is why I felt comfortable not starting my own son on antibiotics, knowing I had the experience to recognize the early signs of an infection). But most doctors do error on the side of caution and routinely give antibiotics to anyone with a dog bite.  This is especially important if your child has diabetes, if the bite occurred in the hand, or if it’s been more than 12 hours since the bite occurred: both of these factors increase the risk for infection.

Is the dog up-to-date on vaccinations? Rabies is fortunately pretty rare in the United States – there are fewer than 100 cases per year in dogs. But once symptoms develop rabies is always fatal. If the dog isn’t up-to-date on vaccinations, animal control will observe the dog for 10 days. As long as the dog remains healthy, no further treatment is needed. But if the dog develops symptoms of rabies such as seizures, excessive drooling, or difficulty walking, then a series of shots can prevent rabies from developing. If the dog cannot be watched, i.e. in the case of a stray dog that ran away, your local health department can advise whether rabies prophylaxis is needed.

How bad will the scar be? How a scar heals depends on a few factors. First, how traumatic (physically, not emotionally) was the injury? The more trauma to the tissue, the worse the scar may be. Dog bites can range from a fairly clean scratch to torn or missing tissue.

Second, how is the wound closed? Contrary to common belief, closing a dog bite with sutures doesn’t always increase the risk of infection. The face is obviously a cosmetically sensitive area, and I always suture wounds on the face closed so that the scar is the best possible. Puncture wounds or wounds on the hand have a higher risk of infection, so these may be left open. Time from the injury affects the risk of infection as well. If it’s been more than 12 hours since the bite occurred (24 hours if the bite is to the face), then the wound may be left open as well.

The third factor that affects scarring is how quickly the wound heals. The more quickly the healing, the better the scar. While the dog bite is healing I advise my patients to apply Vaseline or bacitracin a couple times a day. This keeps the wound moist, and moist wounds heal more quickly. I do recommend cleansing the wound with mild soap and water once a day. Soaking in a bathtub isn’t recommended, but if your child is old enough to shower, it’s okay to let soapy water run over the wound.

Once the dog bite is fully healed, it can take 6-12 months for the scar to settle. During this period the scar will be pink or red, and may be slightly raised. Applying a silicone-based scar cream like Siligen or Biocorneum will help the scar fade more quickly. These scar creams are clear and dry quickly, so most kids tolerate them pretty well. If your child won’t let you apply the scar cream, try having him apply it himself. My son still likes to put scar cream on the fading scar on his cheek! Many of these scar creams already have SPF. But if yours does not, applying sunscreen daily is critical for the first year if the scar is in a sun-exposed area. This will prevent the scar from becoming permanently darker than the surrounding skin.

Some people do develop widened or thickened scars, despite our best efforts. And kids especially have a tendency to heal a little overenthusiastically, meaning they form excess scar tissue. If the scar does raise up or thicken, steroid injections or laser treatments can improve the appearance, even years down the road.

So what now?

Prevention is always the best treatment for a dog bite. Keep a close eye on children and pets. Even a well-tempered dog can get frustrated, and one good nip is all it takes to do damage.

My husband and I talked at length about the situation in our house. We agree that not keeping a closer eye on the dog with the kids was our failing as parents, so we’ve made a few changes. We’re teaching Wyatt not to get in the dog’s face. We’re also showing him how to give commands to Maggie, so that she respects him as a person, and doesn’t treat him like an unruly puppy. Most importantly. we’ve agreed not to leave the dog and the kids alone, even for the amount of time it takes to run to the bathroom.  Once the kids are 4 and 5, we’ll probably be able to relax a little. For now, if Maggie spends a lot of time in the bedroom during the day, that’s okay.

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Dr. Greer is a Plastic Surgeon who practices in Cleveland, OH. Her passion is helping moms regain self-confidence by getting rid of sagginess, wrinkles, and stubborn fat. Read more at her blog.

 

Sources:

Dog bites in a U.S. county: age, body part and breed in paediatric dog bites. Ramgopal SBrungo LBBykowski MRPitetti RDHickey RW. Acta Paediatr. 2018 May;107(5):893-899. doi: 10.1111/apa.14218. Epub 2018 Feb 5.

Pediatric Dog Bite Injuries: A 5-Year Review of the Experience at The Children’s Hospital of Philadelphia. Kaye, Alison E.; Belz, Jessica M.; Kirschner, Richard E.

Plastic and Reconstructive Surgery. 124(2):551-558, August 2009.

 

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