**6. Conclusion**

An estimated 4.5 million dog bites occur each year with approximately 800,000 requiring medical attention [1–3]. As the number of households with pet dogs continues to rise, the incidence of dog bite injuries will grow. Physicians must be prepared to care for children with dog bite injuries. A number of retrospective studies of dog bite injuries in children have found that the most common age to sustain a bite is 5–9 years old [4, 5]. The majority of bite wounds are inflicted by the pit bull breed and occur in the home setting [1–3]. Fortunately, mortality is rare and there were only 46 cases of death secondary to dog bite injury in the year 2020 [2]. Location of the injury has been found to correlate with age; younger children sustain bites to the head and neck while older children tend to be bitten on the hands and upper extremities [5, 6]. The most extreme injuries requiring surgical intervention tend to occur in children less than 3 years of age [5, 6].

When acutely managing a dog bite, the first step is to follow the Advanced Trauma Life Saving (ATLS) guidelines. Begin with a primary survey of the airway, breathing, and circulation [7, 8]. Additionally, determine the neurologic status of the patient and determine any required immediate interventions. After stabilization, complete a secondary survey to gather specific details of the event and the medical history of the patient. In order to address the wounds, decide whether primary vs. secondary closure is warranted. As stated previously, there continues to be controversy over primary vs. delayed closure but recent studies have found that there is no significant difference in infection rate between the two methods [3]. Cosmetic and functional results can help to drive the decision, as well as any professional input from plastic surgery, otolaryngology, or dermatology. No matter which method of closure is decided upon, begin by irrigating the wound with normal saline using 250 mL–500 mL with a 20 mL syringe to ensure adequate pressure. Debride any necrotic tissue. Contact surgery for large, complex wounds.

Antibiotic prophylaxis is warranted for any high-risk bites, such as presentation 8+ hours after the bite, moderate to severe wounds, patients who are immunocompromised or diabetic, deep puncture wounds, or bites involving the hand or face [3]. Wound infections are usually polymicrobial, with the most common bacteria being *Pasteurella* spp. [9–11]. The first-line therapy for both prophylaxis and treatment of an infected dog bite is oral amoxicillin-clavulanate or parenteral ampicillin-sulbactam, depending on the severity [3, 4, 9]. If the patient has a penicillin allergy, oral extended-spectrum cephalosporins (ceftriaxone, cefotaxime) or trimethoprim-sulfamethoxazole plus clindamycin is recommended [3, 4, 9]. The prophylactic treatment course is 3–5 days; soft tissue infections should be treated for 7–10 days [3, 4, 9]. A 10–14 day course of therapy may be necessary for more severe infections, and up to 6 weeks for osteomyelitis [3, 4, 9].

In addition to localized infection, physicians should think about other possible sequelae of dog bites: tetanus and rabies. The management of tetanus prophylaxis and the decision to provide post-exposure rabies prophylaxis can be determined using the CDC guidelines or as stated above [9, 24, 25]. If the rabies vaccination status of the dog is unknown, contact a veterinarian or department of health agency for further guidance.

In conclusion, dog bite injuries to children are a common and potentially fatal issue. Physicians must know how to stabilize and treat these injuries, as well as methods of preventing dog bites. Each family, with or without a pet dog, should have a brief discussion regarding dog bite prevention in the primary care setting. If a bite has occurred, both family members and physicians should be aware of the potential psychological sequelae of dog bites and how to treat them.
