| Topic | Dog Bites in Children |
| Author | Rehana Dyson and Lizzie Binham |
| Expert Reviewer | Vicki Currie |
| Facilitator Level | ST3 + in ED Setting |
| Learner Level | Any health care professional involved in initial assessment of children with injuries (emergency departments) |
- Introduction: 10 minutes plus review of your hospitals local guidelines
- Cases: 3x 15 minutes case discussions
- Simulation
- Quiz: 5 minutes
- Take Home Messages: 5 minutes
PRE-READING FOR LEARNERS
The list of link should be sent out in advance to allow time for people to access the
resources at a convenient time:
- NICE Guideline: Bites – human and animal | Health topics A to Z | CKS | NICE
- BMJ Article: Pet dog bites in children: management and prevention | BMJ
Paediatrics Open - Audio Discussion of Management (44mins): Animal Bites in Children | Pediatric
Emergency Playbook - The psychological impact: Review of psychological effects of dog bites in
children – PMC
In the UK 25% of households own a dog, with UK favourite breeds are Labrador,
French bulldog and Cocker spaniel [1](note mixed breeds like cockapoos are not
included) in Australia their favorite are the Cavapoo, Dachshund and Golden
Retriever [2]. There has been an increasing trend of dog bites/attacks that has
increased 3-fold over the last 20 years, with only 1/3 of dog bites thought to
present to the ED, so the true number is unknown [4]. The majority of which are
from family dogs or dogs known to their victim. There were 32 dog fatalities in the
UK from 2019-2020 between 2019-2023 [3].
Children, especially those under 5 years are at increased risk of dog bites as they
are unable to recognise dog behaviours (fear/anger), where their instinct is to
cuddle contrasts with a dogs need for space when emotions are high resulting in
biting and injury. In adults’ injuries tend to focus on the legs and groin, whereas
in children, due to the proportional size of the dog to the child, upwards of 85% of
injuries are to the head, face and neck.[4,7]
The reasons for the increasing number of dangerous dog incidents are multifactorial
including economic, due to increasing vet bills and cost of food, many dogs
seized by South Yorkshire Police require veterinary attention from untreated
conditions or being underfed. It is worth noting that neglect of a dog is often
found to be linked to the neglect of any children in the household.
This is reflected in the NICE statement “A dog bite in the context of inadequate
supervision should raise suspicion of wider neglect”. During the pandemic the
UK saw an increase in demand for dog ownership resulting in many “lockdown
dogs” for which their world was quieter, calmer and more isolated during their
key developmental stages (up to 16 weeks). These dogs were not exposed to
experiences during this crucial time increasing how often dogs are feeling fear
and anxiety – resulting in space avoidance, which children cannot interpret.
Some dogs may display no learned behaviour, making them unpredictable.[4]
Banned Breeds in the UK:
In 2024 Bully XL’s were added to the banned dog list, which already contained
Japanese Tosa, Pit Bull Terrier, Dogo Argentino and Fila Braziliero. Though
people can still currently own these breeds if they obtain an exception
certificate stating they have been spayed/neutered, wear a muzzle and remain
on lead in public in addition to being microchipped, but be mindful there
is a number of unregistered dogs.[5]
Another consequence of the ban has been a trend towards larger more
powerful breeds like the Cane Korso. These dogs have a higher bite strength and
have more potential to cause serious or fatal injuries or similar crossbreeds.[4]
Police Involvement/Powers in the UK:
All presentations to the ED involving dog bites should be considered if it needs
reporting to the police on 101/online interface. For those that are, a police officer
will undergo an in-person visit to assess the animals, their living conditions and
make a safeguarding assessment. The aim is to educate and reduce the risk of
recurrence, the owner may be given rules to follow such as training or muzzle
wearing. In serious cases the dangerous dog act [6] can result in unlimited fines,
banned from owning future dogs and even imprisonment with the dogs being
seized and destroyed by the police.
The Police are involved in a whole range of preventative and proactive measures,
to reduce the number of serious attack incidents such as media campaigns,
recording and attending all incidents reported, education in schools and directing
owners to further support such as: Blue Cross Responsible Dog Ownership Course.
There are a lot of useful resources out there that we can share with our patients
and their families which give tips and information on how to keep children safe
around dogs. Some examples of these are below:
https://www.bluecross.org.uk/advice/dog/keeping-your-toddler-safe-arounddogs
https://www.rspca.org.uk/adviceandwelfare/pets/dogs/company/children
Sammy is a 2 year-old-girl who was playing with her family dog when she was
bitten on the arm. Sammy is usually fit and well, has no allergies and is fully immunised. On examination her arm show’s a red mark but no skin has been broken,
she has full range of movement of the elbow and wrist and indicates no pain.
Q1 – What information is important to obtain during history?
- Incident: Was it witnessed? By Who? Where did it happen? What was the child
doing just before? What was the dog doing just before? Where did the dog bite
(no. of times, location, length of bite). What happened afterwards? Was it an
unprovoked attack? - Dog: Breed of Dog, Dog Owner. Where does the dog usually live?
Where is the dog now? Have they bitten before?
How long have they had the dog? Where is the dog from? Is it a family pet? - First Aid: What first aid has been given so far? Have they had analgesia?
- Child’s Medical Hx: Medical History, Medications + Allergies, Immunisation
History - Child Social Hx: Is the family known to social services/family support?
Who lives in the house with the dog? Are there other vulnerable people
(i.e. Children) still with the dog? - Police: Have they been informed (case number)?
Q2 – Does this need to be reported to the police?
- Each case is unique and should be considered on its own merits. There is no set/standardised guideance. Elements to consider include the extent of the injury. Has the dog bitten before? Did the incident take place in public? Was it an unprovoked attack? Is the dog a banned breed?
In this case if the child was younger playing with the family dog by themselves
-the level of supervision could be discussed and information shared with the
child’s health visitor. However, always consider safeguarding/neglect with any
child who presents with a dog bite.
Q3 – Does this child require any clinical management?
- The child has a full range of movement of the arm with no indication of a fracture, the skin has not been broken. They can have analgesia as required.
Muhammed is a 6 year-old-boy who was playing at the park with his family, when
a stranger’s dog came running towards him, jumped up and bit him on the face.
The police have been informed, and you have the incident number. Muhammed
has no past medical history, has no allergies and is fully immunised.
On examination you see the wound of his face which looks clean and not infected:
Cavalcanti et al, Facial Dog Bite Injuries in Children: A Case Report, International
Journal of Surgery Case Reports, 2017, Volume 41; Pages 57-60
Q1 – What examination and documentation is needed?
- Detailed History as documents above (in case 1)
- All wounds/marks should be clearly documented on a body map, clinical photography may also be beneficial as these may need to be used in court.
- Following a full examination of the child’s body documenting size/depth/ extent of injuries, type of wound, any devitalised tissue or underlying structural damage (tendon, vessels). Assess neurovascular status and range of movement distal to the wound. Document if any foreign body is removed (e.g. teeth), presence of lymphadenopathy, level of contamination and if any indication the wound is infected.
- Further examination of the eyes (range of movement, consider fluorescein) and mouth (looking inside) to assess if any underlying structures have been damaged or if the wound has punctured through to the internal oral cavity (as this would need escalation to specialist teams).
Q2 – How would you manage the wound itself?
- Irrigate the wounds well with normal saline
- From this image, the child’s injury to the lip alone would require escalation to plastics/max fax.
- Some very simple wounds can be closed (present early, thoroughly irrigated involving no underlying structure). However, most bites (that do not require further escalation to e.g. plastics) are advised to heal without any formal closure such as [8]:
- Bites >24hrs old
- Bites limbs/hands/face
- Deep puncture wounds
- Crush injuries
- Contamination
- Uncertain adequacy of debridement.
Q3 -How else would you manage this clinically?
- Analgesia
- Prophylactic Antibiotics should be prescribed (Co-Amoxiclav, 3 days)[8]
Prophylactic Antibiotics should be prescribed if [8]:
- Wound is visibly contaminated
- Deep puncture or crush wound
- Penetrated to bone/tendon/nerve/ligaments
Prophylactic Antibiotics could be considered if wound has broken skin + bled [8]:
- Head/Face, Feet, Hands, Genitals, Areas skin with poor circulation, over
cartilaginous structure or near prosthetic joints - The patient has an increased risk of serious infection, immunocompromised,
extremes of ages or prosthetic heart valve.
Choice of Oral Antibiotic [8]:
- 1st Line (>1 month – Adults): Co-Amoxiclav for 3 days for prophylaxis and 5 days for infected dog bite [12]. *Always check with your local microbiology guidance.
- Penicillin Allergies
◦ <12yrs Co-Trimoxazole
◦ 12-17 yrs Metronidazole plus Doxycycline
Kyran is an 11 y.o who was visiting the local farm, he had climbed over a fence
when a large dog working on the farm bit his arm and wouldn’t let go. Eventually
the dog released with help of the farmer, the police are aware and have attended
the Emergency Department due to the extent of Kyran’s injuries
History notes that Kyran has no medical history of note, has no allergies and is
un-immunised. On examination there is a deep laceration across his distal forearm
that is contaminated with mud, he is unable to move his wrist and tendons are
visible, there is minimal evidence of bleeding and no evidence of vascular injury.
His capillary refill distal to the wound is < 2 seconds and his hand is warm, he is
reluctant at present to make any movements with his hands.
Q1 – How would you manage this child?
- Initial assessment of A → E approach/ Primary Survey,
- Adequate Analgesia
- Irrigation of any visible contamination
- IV access – antibiotics (co-amoxiclav), bloods (including clotting/ group +save), fluids (if NBM for surgery)
- Tetanus Immunoglobulin and Tetanus Vaccine
- Escalation to specialist teams for surgery, irrigation, debridement, re-construction of structural damages following admission to hospital.
Dog Bite + Tetanus:
Tetanus is the disease caused by the tetanus toxin, there spores are common in
the environment including soil. The disease results in rigidity, muscular spasms
with case fatality 10-90% and is higher at extremes of age.
Children receive a total of 5 tetanus vaccination providing lifelong immunity (2,3,4
months, preschool + secondary school). It is important to determine if a wound
“tetanus prone” or “high risk” as this will determine alongside the child’s
immunisation status if tetanus vaccine is needed or tetanus immunoglobulin is
required [9]:
| Tetanus Prone Wounds | High Risk Tetanus Prone Wounds |
| Puncture injury (i.e. dog bite) from contaminated environment (soil/agricultural setting) Wound containing foreign bodies (i.e. teeth) Open Fractures | Heavily contaminated likely containing tetanus spore (soil, manure) Wounds that have extensive devitalised tissue. Wound needing surgical intervention but there is a delay of >6hours, even if the wound was minimally contaminated. |
Table 30.1 Immunisation recommendations for clean and tetanus-prone wounds
- Clean wound is defined as wounds less than 6 hours old, non-penetrating with negligible tissue damage.
- At least 3 doses of tetanus vaccine. This definition of “adequate course” is for the risk assessment of tetanus-prone wounds only. The full UK schedule is five doses of tetanus containing vaccine at appropriate intervals.
- If TIG is not available, Human Normal Immunoglobulin (HNIG) may be used as an alternative.
Dog Bites & Rabies:
The UK is considered a “no risk” country including dogs from the UK there is no
indication for a vaccine. If the child was bitten abroad or from a dog who has
come from abroad each case should be consider separately:
Guidelines on managing rabies post-exposure (January 2023)
Q2 – What imaging may you consider?
- Consider an Xray to look for fractures and presence of any undetected foreign body.
Question 1
Do all dog bites need to be reported to the police?
Answer 1
As previously stated each situation is unique and needs to be
assessed, each case should be carefully considered if neglect of the child has
occurred. Of the three cases discussed in this module, the authors of this module would report cases 2 and 3, the first case would depend on if any concerns were raised on history taking or examination of the child as a whole.
Question 2
Which dog bites require antibiotic treatment?
Answer 2
Wounds that are contaminated, deep or have damaged underlying
structure (e.g. tendons). Antibiotics should be considered if the wound is to the
head/face, feet/hands or areas of skin with poor circulation, over cartilaginous
structure or near prosthetic joints. Patients have increased risk of serious infection, immunocompromised, extremes of ages or prosthetic heart valves.
Question 3
Which dog bites require tetanus vaccinations?
Answer 3
Depends on the combination of the child’s immunisation status and
degree of the wound. Tetanus prone includes contamination (soil/agriculture),
open fractures or presence of foreign bodies. If the wound is heavily contaminated, has extensive tissue damage or there will be a delay to surgery they need immunoglobulin also.
Question 4
How can dog bites be prevented?
Answer 4
Education is the key to reducing the risk of dog bites. Outside the
home children should be taught not to approach strangers’ dogs, not all dogs
are like their dog at home. Children should not approach dogs when they are
eating or sleeping. Encourage gentle interaction – no pulling, grabbing or sitting on a dog. Children and dogs should not be left alone in a room with a dog.[10,11]
- 1.Most popular dog breeds UK according to KC registration | Horse & Hound
- 4.Sheffield Education Teaching – Speech Paul Jameson from South Yorkshire
- Police Dangerous Dog Team (November 2024)
- 23 Most Popular Dog Breeds in Australia in 2025 – Dogster
- Controlling your dog in public: Banned dogs – GOV.UK
8.Bites – human and animal | Health topics A to Z | CKS | NICE
3.Deaths by dog attack in the UK 2019 to 2023 including all context of death –
Office for National Statistics - Controlling your dog in public: Overview – GOV.UK
9.The Green Book on immunisation – chapter 30 tetanus - Pet dog bites in children: management and prevention | BMJ Paediatrics Open
10.6-Dogs-and-Children-guide-to-staying-safe.pdf
11.Keeping your toddler safe around dogs | Blue Cross - Co-amoxiclav | Prescribing information | Bites – human and animal | CKS
| NICE
A. Image of Japanese Tosa: A short history of the ‘dangerous dog’ and why certain breeds are banned – BBC News
B.Image of Pit Bull and Fila Brasileiro: 4 Banned Dog Breeds in the UK (With Photos)
C.Image of Dogo Argentino: Why are Dogo Argentinos banned in the UK? | The Sun
D. Image of XL Bully: What is the XL bully ban and how dangerous are the dogs? –
BBC News
E.Image of Case 1: CGI Created Image: https://chatgpt.com/s/m_688e4504246c819184228e005e5d78bd
F.Image of Case 2: Cavalcanti et al, Facial Dog Bite Injuries in Children: A Case
Report, International Journal of Surgery Case Reports, 2017, Volume 41; Pages 57-60 Facial dog bite injuries in children: A case report – ScienceDirect
G.Image of Case 3: Hand drawn diagram of patients injuries. Paediatric Body
Map from Whittington NHS Trust:
https://www.whittington.nhs.uk/default.asp?c=38594&print=1
H.Dog Bite Simulation, Written by colleague Frankie Bevis (West Midlands ED
Trainee)
