Bites in children from birth to age 4 occur most frequently in the neck and head area (65%), followed by the arm and leg (27%). In children ages 5 to 9, those rates are 42% and 30%, respectively.⁷ As children get older, bites in the head and neck areas decrease precipitously, while injuries to the arms and legs increase.

Which dogs bite?

Any dog has the potential to bite. That's true whether it's a large dog or a small dog, a stranger's dog or a neighbor's dog—or your own. Indeed, two facts about dog bites run contrary to popular belief, and knowing them may help parents understand the seriousness of this problem:

• Most dog attacks happen at home or in a familiar place
• The vast majority of dogs that bite belong to the victim's family or to a friend.²

Statistics are not readily available on the biting habits of specific breeds in nonfatal cases, but studies have been done on fatalities. Sacks and colleagues found that pit bull-type dogs and Rottweilers accounted for 60% of dog-bite related fatalities in the US between 1997 and 1998.⁸ Noting the unlikelihood that these breeds accounted for anywhere near that percentage of dogs in the US during that time, the authors concluded that "there appears to be a breed-specific problem with fatalities." But the authors also noted limitations in the data on breeds and dog bites, including the inability to factor in owner-related issues, such as whether some owners who want to foster aggression are drawn to certain breeds.

Of the 31 breeds linked to deaths between 1979 and 1998, mixed breeds (not otherwise specified) and German Shepherds followed pit-bulls and Rottweilers on the list of dog-bite related fatalities.⁸ But also on the list were dogs perceived as "family" pets, including boxers, a West Highland terrier, and a Cocker Spaniel.

What makes a dog bite?

If breed alone doesn't determine which dogs become aggressive, what else does? Gershman and colleagues found that male dogs are more likely to bite than female dogs, non-neutered dogs more often than neutered ones, and chained dogs more frequently than unchained ones.⁹ Sacks suggests that additional factors include heredity, early experiences of the animal, socialization and training, mental and behavioral health, reproductive status, victim behavior, and quality of ownership and supervision.⁸

Safe Kids/Safe Dogs,¹⁰ a private project formed to decrease the number of dog-related accidents to children, identifies similar factors: A dog is more apt to be aggressive when it is poorly trained, socialized, and maintained; if it has a low tolerance for human things (e.g., noises); or if it is scared, ill, or hurt. A dog is also more apt to bite when it is overly excited, has puppies, or is disturbed while sleeping.

A child's behavior may, unknowingly, provoke a dog (see the Guide for Parents). For example, wrestling or otherwise playing rough with a dog, or disturbing a dog while it is sleeping or taking care of puppies, may cause it to bite.

The role of the physician

Keep three facts in mind when it comes to dogs:

• Most dogs do not bite
• Any dog may bite at any time
• The victim is most often a child.

As with all health matters, you will want to stand ready to alert parents and children to the problem, provide literature, answer questions, and consult and advise. In other words, include dog bite information in your anticipatory guidance.

Probably the biggest challenge you face is sensitizing parents to the problem of dog bites without unduly alarming them or turning off their love and affection for dogs or other animals. The same difficulty faces parents who want to educate their children about dogs, and is similar to the task they face when teaching children about strangers or inappropriate touching by others: Caution without fright.

Literature. A number of printed references are available to educate parents and children. Among them are the two Guides for Parents that accompany this article—"Rules to teach your children that can prevent dog bites," and "Owning a dog when you have children."

One of the best brochures, in my opinion, is "Don't worry, they won't bite," produced by the American Veterinary Medical Association (AVMA) in association with State Farm Insurance. It is available from any State Farm agency or can be downloaded at www.avma.org/pubhlth/dogbite/dogbitebroc.asp. AVMA also produces a coloring book for children with the same message—"Fido! Friend or Foe?"—which is obtainable from State Farm, as well. These materials are excellent to hand out to parents face to face or to keep in the waiting room. Other reference material is listed in the resource box.

Anticipatory guidance. Such advice can be given prenatally, at the first newborn visit, or any time during the life of the child—it is appropriate at all ages. Given the extent of the dog bite problem, it is prudent to address the issue at the family's first visit to your office. Find out whether there is a dog in the household and what its relationship is to the patient. Questions about pets can also be used as a part of an allergy history. They should be embedded in every initial visit.

A handout such as those described above is an excellent way to introduce the subject. Supplement it with your own words and advice. Ask the parents whether they have a dog or are considering getting one. If the family is contemplating getting a dog, strongly advise them to first consult a veterinarian or dog trainer. Let them know the importance of children's behavior in preventing injury from dogs and share with them the rules outlined in the Guide for Parents. Do the same with families that already have a dog. If the family has a dog that has a behavior problem, strongly recommend that they see a dog expert—sooner rather than later.

Treating a dog bite wound

Parents may bring up the subject of dogs on their own, perhaps after seeing literature in your waiting room or a report in the news, or if their child has sustained a minor dog scratch. If they have not seen any printed material, give them helpful reprints or tell them where to get such literature. Discuss dog bites with them—at least briefly—and answer their questions.

Let parents know that they can come back to you with further questions. Many questions are best answered by experts on dogs, so you may need to provide a referral to local dog trainers or general organizations, such as the AVMA.

After a bite has occurred

When a child has been bitten, your role may include treating the wound (see the sidebar), referring the patient to a specialist, and hospitalizing the child. After the wound is treated, care includes ongoing observation of the physical healing process—to completion—and addressing concerns about ambulation, school, play, and sports.

The psychic effects of the bite need to be considered, as well. The role you play in this area usually depends on your interests and training and may range from initiating therapy to referring the child to a mental health professional.

Too often, the mental health aspect of bites is ignored. Any bite, minor or major, can be a stress on the child's psyche. Peters and colleagues reported that 12 of 22 children who suffered a bite had symptoms of posttraumatic stress disorder two to nine months after being bitten.¹¹ Here, then, is an important role for the family pediatrician: anticipate the possibility of posttraumatic stress disorder, recognize its symptoms—especially symptoms that the family does not see or misinterprets—and refer the patient to a specialist as needed.

Web resources about dogs and dog bites

Among the symptoms commonly reported in posttraumatic stress disorder are sleeplessness, nightmares, anxieties, fears, irritation, guilt, thoughts of suicide, and unexplained new physical symptoms.¹² Consider any unusual complaints that even vaguely suggest a mental health problem. Such symptoms may develop months after the dog bite—long after the physical wounds have healed and the surgeons have departed the scene.

Control, through education

We have an epidemic (endemic) of dog bites in the US (and in some other countries, such as Canada and Australia): 4.7 million cases a year. A large percentage of those bitten require medical care. Some victims have serious sequelae, physical or psychological. Some die.

The incidence of dog bites is out of proportion to the number of dogs and is increasing. While stricter dog laws have been recommended in some quarters, the only real answer at the moment seems to be education.¹³ Because most victims are children, and pediatricians routinely deliver anticipatory guidance, some dent may be made in this public health problem if you and your peers take it on as a cause.

REFERENCES

1. National Center for Injury Prevention and Control: National Dog Bite Prevention Week. www.cdc.gov/ncipc/duip/biteprevention.htm. Accessed March 3, 2005

2. Philips KM: Dog bite law. www.dogbitelaw.com/PAGES/statistics.html, June 4, 2005. Accessed June 27, 2005

3. Voelker R: Dog bites recognized as a public health problem. JAMA 1997;277:278,280

4. Weiss HB, Friedman DI, Coben JH: Incidence of dog bite injuries treated in emergency departments. JAMA 1998;279:51

5. American Pet Products Manufacturers' Association. 2000/2001. National Pet Owners Survey, Greenwich, Conn., 2001

6. National Center for Infectious Diseases: Health Benefits of Pets. www.cdc.gov/healthypets/health_benefits.htm, September 22, 2004. Accessed June 21, 2005

7. Centers for Disease Control and Prevention: Nonfatal dog bite-related injuries treated in hospital emergency departments—United States, 2001. MMWR 2003;52(26):605

8. Sacks JJ, Sinclair L, Gilchrist J, et al: Breeds of dogs involved in fatal attacks in the United States between 1979 and 1998. JAMA 2000;217:836

9. Gershman KA, Sacks JJ, Wright JC: Which dogs bite? A case-control study of risk factors. Pediatrics 1994;93:913

10. Peck K: www.safekidssafedogs.com (Why Dogs Bite). Accessed July 1, 2005

11. Peters V, Sottiaux M, Appelboom J, et al: Posttraumatic stress disorder after dog bites in children. J Pediatr 2004;144:121

12. Sheslow DV: Posttraumatic Stress Disorder. Nemours Foundation, 2005.

www.kidshealth.org/parent/emotions/feelings/ptsd.html Accessed June 22, 2005

13. Sacks JJ, Kresnow M, Houston B: Dog bite: How big a problem? Inj Prev 1996;2:52

GUIDE for PARENTS

Rules to teach your children that can prevent dog bites

Most dogs do not bite. But ALL dogs—a stranger's dog, your neighbor's dog, even your own dog—have the potential to bite. That's especially true if a dog feels threatened or scared or becomes overly excited. The following rules for children can minimize the risk that they will get bitten. Most of these rules apply to adults, as well.

General rules

• Never play with a dog unless an adult is present.
• Never go near an unfamiliar dog.
• Never pet a dog without first asking the owner's permission.
• Never pet a dog without first letting it smell you.
• Don't pat a dog on the top of its head. Pat it under the chin or on the back.
• Never move if a dog sniffs you. Stand still.
• Never scream around a dog.
• Never run past a dog. Don't run up to a dog—even one that you know.
• Never sneak up on a dog. Approach from the side or front.

Don't "play rough"

• Never tease a dog, hit it, or pull its ears, tail, or feet.
• Never play rough games, such as wrestling, with a dog.

When to "stay away"

• Never disturb a dog that is eating or sleeping.
• Never approach a dog that is taking care of puppies. Never touch the puppies.
• Never go near a dog that is growling or showing teeth.

How to handle threatening situations

• Don't turn and run if a dog threatens you; try to stay calm and do not scream.
• If a dog approaches, stand very still—"like a tree." Do not make eye contact.
• If you fall or are knocked to the ground, curl up into a ball and put your hands over your head and face.
• If you have been bitten or threatened by a dog, or if you see a dog acting strangely, tell an adult!

Owning a dog when you have children

If you are thinking of getting a dog ...

• Consult with a professional (e.g., veterinarian, animal behaviorist, dog trainer, or reputable breeder) to learn about suitable breeds for your household.
• A dog known to have a history of aggression is inappropriate in a household with children.
• Be sensitive to cues that a child is fearful or apprehensive about a dog. If you observe such cues, reconsider (or delay) getting a dog.
• If possible, spend time with a dog before buying or adopting it. Try to find out where the dog originally came from and its background.

If you get a dog ...

• Use caution when bringing a dog into the home of an infant or toddler. Never leave infants or young children alone with any dog.
• Spay or neuter your dog (this often reduces aggressive tendencies).
• Do not wrestle with or play aggressive games with your dog.
• Properly socialize and train the dog. Teach submissive behaviors (e.g., rolling over to expose abdomen, relinquishing food without growling).
• Be consistent with training and daily life—just as you are with children.
• Immediately seek professional advice (e.g., veterinarian, animal behaviorist) if your dog develops aggressive or undesirable behaviors.

If your dog bites someone ...

• Immediately restrain the dog, away from the scene.
• Check on the victim. Seek medical advice.
• Provide needed information to the authorities or the victim (e.g., your name and address, the date your dog was vaccinated against rabies).
• Report the incident to your homeowner's insurance company and comply with all local reporting laws.
• Contact a veterinarian about the behavior of your dog and ask for suggestions.