J Oral Med Oral Surg
Volume 28, Number 3, 2022
|Number of page(s)||19|
|Published online||23 September 2022|
Animal bite injuries in pediatric population: a systematic review
Department of Pedodontics, PGIDS, Rohtak, India
2 Department of Dental Materials, PGIDS, Rohtak, India
* Correspondence: firstname.lastname@example.org
Accepted: 6 July 2022
Objectives: To assess the scientific literature pertaining the risk factors for injuries among victims of animal bite injuries. Data and sources: A systematic review of scientific literature published until May 2020 was carried out in the following databases: PubMed, Cochrane Library, Google Scholar and Journals@ovid. Study selection: A total of 924 records were found, of which 29 articles fulfilled the inclusion criteria and were analyzed. There was a male preponderance in most of the studies with male/female ratio ranging from 0.75:1 to 2.1:1. The age range varies from 0 to 19 years with the mean age varying from 3.6 to 8 years. Pitbulls, Rottweiler's, German shepherds, Bull terriers, Labradors and Dobermans were breeds with higher risk of attack. The animals were familiar to the victim (own, friends, neighbors) in 27–98% instances. Most cases of animal bite injuries were recorded during Summer and Spring months. Head and neck followed by extremities was found to be most inflicted area. Conclusions: The sociodemographic characteristics of victim as well as the biting animal affect the circumstances leading to biting episode. However, the results should be interpreted with caution due to the high heterogeneity among studies and moderate quality evidence.
Key words: Animal bite / injury / child / adolescent / dog
© The authors, 2022
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Animals are an indispensable part of the human ecosystem. The animals might display many kinds of behavioral traits towards humans like loyalty, affection or aggression. Animal bite injuries in children of all ages represent an unsatisfactorily understood but significant medical and public health issue. Unaesthetic soft-tissue and skeletal injuries, scars and disfigurements are outcome of such incidents . It is estimated that 50% of population in the United States experience an animal or human bite wound at least once in their lifetime, and 45% of children had been bitten during their lifetimes [2–4]. These types of injuries are ever-growing burden for public health, especially in developing and third world countries. Amongst bites caused by domestic animals, dog bites account 80–90% [5,6], whereas cat bites account for 5% and 15% [7,8], as second common cause. Children are especially susceptible to dog bite injuries of the head and neck region [4,9–12]. The kind of wounds afflicted span from insignificant scratches to fatal injuries and/or infections . These injuries are considerably preventable by studying the attributes of the children who are traumatized, the characteristics of biting animals and the detailed features of biting incident. Accurate reporting of animal bites to authorities is important for framing appropriate prevention strategies, identifying the traumatic load and development of a more efficacious planning of resource allocation and to provide care [14–16]. Various studies have been conducted in different regions of the world to elucidate and characterize injuries resulting from animal-inflicted bites [17–20]. However, there are significant scientific controversies in literature, and no consensus on risk factors and optimal management. Therefore, this systematic review aims to explore the literature to understand the nature and severity of outcomes of bites from animals, and identify the risk factors for injuries among young victims of animal bite.
The databases PROSPERO, the Cochrane Database of Systematic Reviews, the JBI Database of Systematic Reviews and Implementation Reports and MEDLINE were searched and no systematic reviews (completed or in process) on this topic were identified.
The systematic review was conducted following the PRISMA Statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and the Cochrane's Guidelines. The proposed systematic review was registered in PROSPERO under registration number # CRD42020177845.
The primary review question was, “What is the epidemiology of animal-inflicted injuries in children and associated risk factors?” PECO strategy as proposed by Maia and Antônio was followed instead of PICO . The PECO used was Population (patients ≤ 19 years of age), Exposure (animal bite), Comparison (sociodemographic and bite wound characteristics) and Outcome (injury pattern and characteristics).
Inclusion criteria were observational studies (prospective studies, retrospective, cohort, case-control and cross-sectional) in which risk factors for animal bite in children and adolescents (≤19 years) were reported. There was no restriction of year, or publication status (Epub ahead of print). Exclusion criteria were: (1) review articles, opinion articles and single case reports; (2) studies with no apparent aim of studying risk factors for injuries caused by animals; (3) studies on adults with age >19 years and injuries caused by human bites; and (4) studies addressing other etiologies (e.g., interpersonal violence).
The primary study source, PubMed/MEDLINE, Cochrane Library, Google Scholar and Journals @ Ovid were used. The descriptors were searched in the MeSH database (Medical Subject Headings). With the help of the Boolean operators “AND” and “OR”, the research strategy was developed. The keywords searched were (((((“maxillofacial injuries” OR ”facial injuries”))) AND ((”wounds and injuries” OR bites and stings OR trauma OR soft tissue injuries OR wounds OR lacerat* OR injuries OR wounds))) AND ((animal OR mammal* OR dog OR cat OR domestic OR non domestic OR pet OR stray OR wild))) AND ((infan* OR child* OR adolescen* OR pediatr* OR human)).
The search strategy was modified for each included information source. In addition, reference lists of literature, existing networks and websites, were scrutinized to enhance procurement of documents. Following initial search, all the citations were transferred to EndNote 9 (Clarivate Analytics) and duplicates were removed.
To minimize inter-examiner variability, 2 reviewers applied the eligibility criteria to 20% of retrieved studies as calibration exercise and a good agreement level was achieved (x = 0.841). The studies were assessed in two main phases: (1) two reviewers (RS and NS) systematically analyzed titles and abstracts, and when they fulfilled the inclusion criteria for the review, articles were selected for the next phase and (2) full texts of eligible studies were obtained and evaluated. Reasons for exclusion of full text studies that do not meet the inclusion criteria were documented. Any disagreements between the reviewers during selection process were resolved through discussion, or with a third reviewer. The whole procedure was presented stepwise in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow chart.
Two evaluators (RS and NS) performed data extraction independently using a spreadsheet specially created to extract the necessary information including the following items: article identification (author, location, duration of study, source of information, type of study and case definition); victim characteristics (age and sex); causative animal characteristics (breed, familiarity, provoked/unprovoked) and results (area and types of injuries and months of year when incidence is at peak) and other relevant variables.
After data extraction of all relevant articles, an objective appraisal process was initiated. The process of appraisal aims to assess the quality of the study by evaluating the design and methodology. The quality assessment of included studies were independently rated by two reviewers using an adapted version of the NIH Scale for case series and JBI prevalence critical appraisal tool having 7 questions, assigning Y/N/U (Yes/No/Unclear) for each question. The higher the score, the better was the methodological quality of the study.
The variability among studies was appraised by parameters such as the outcome analyzed, sample attributes, predictor measures, statistical tests and summary variables. This prevented the pooling of data for meta-analysis.
A sum total of 924 potentially relevant articles were recognized. Of the 924 articles, 842 were excluded after the analysis of titles and abstracts. Full-text analysis was done for eighty two articles, out of which twenty nine were included in the systematic review according to the eligibility criteria. Figure 1 shows the stepwise process of searching, evaluation, inclusion and exclusion of articles.
The prime characteristic features of eligible studies are summarized in Tables I–III. The time span assessed in the studies ranged from 1985 to 2017 [4,9,11,22–47]. Majority of the included studies in the review were retrospective studies except 4 studies (2 were prospective studies [11,25] and 2 were cross-sectional questionnaire-based surveys [38,43]). The animals involved in the biting episode were dogs in all the included studies. The male/female ratio ranged from 0.75:1 to 2.1:1. Most of the included studies depict males are more prone to animal bite injuries except only 3 studies which showed female preponderance [22,33,47]. The age range varies from 0 to 19 years with the mean age varying from 3.6 to 8 years [25,26]. The usual age in all studies analyzed corresponded to preschool and grade school children being the most affected group [22,24,25,27–33,37,40,43,46]. The list of breeds commonly causing ABI are given in Table II. Pitbulls, Rottweiler's, German shepherds, Bull terriers, Labradors and Dobermans were breeds with higher risk of attack. The animals were familiar to the victim (own, friends, neighbors) in 27–98% instances. Provocation was seen to be a risk factor for animal bite. Most cases of animal bite injuries were recorded during summer and spring months. Head and neck in younger children followed by extremities in older children was found to be the most inflicted area [22,24,25,27–33,37,46]. Among head and neck region, the area frequently involved was cheek region and lip/mouth. The type of wounds afflicted range from minor soft tissue scratches to life threatening injuries including severe nerve and vascular or bony destruction. Laceration wound was the most frequent soft tissue injury.
Demographic characteristics of patients included in studies.
Characteristics of animals included in studies.
Injury pattern and characteristics.
The articles included in this review were observational studies, which may have led to publication bias. There may be geography-based bias, with most of the studies in the literature presenting data from western countries; thus not providing an accurate representation of global pediatric injuries inflicted by animals. In addition, bias may be caused by the articles that were excluded based on unavailability or non-English language.
The methodological quality appraisal of included studies using an adapted version of the NIH Scale for case series  and JBI prevalence critical appraisal tool revealed that most of the studies were of moderate quality (Tab. IV) .
Methodological quality appraisal of included studies.
A systematic review is the mainstay of evidence-based practice, commonly used for formulation of prevention and treatment guidelines and policies [52–56]. It objectively evaluates all available scientific evidence to answer a research query; and identify the sectors where evidence is deficient [54,57]. The present systematic review evaluated the scientific literature for risk factors of animal bite injuries in children and adolescents.
Animal aggression may be a result of interaction of several factors . The study of individual factors, interrelationship between victim, animals and their environment is very complex , several confounding factors such as perception, risk taking and health care seeking behavior of an individual may be affected by past experiences, education and culture. A good quality research requires reliable and reproducible measurement of both the outcome and variables of the study . There are many barriers in measuring outcomes as the number of reported injuries is low in comparison to actual incidence of animal bite injuries.
Young children below 5 years and male child seem more vulnerable to be attacked because of their underdeveloped motor skills [22,24,27–30,33,40,43,46]. Face especially lips, nose and cheeks, also referred to as ‘central target area’ is more prone, may be because of comparatively smaller body and larger head size [3,5,6,9,11,60–71]. Some investigators found higher prevalence of animal bite injuries in older children [25,31,32,37]. Evidence shows that risk of biting to both household and non-household members increases if a dog lives in a house with children or teenagers . This area requires further research. Daniels et al. (2009)  and Thompson (1997)  found that death in younger children was result of damage to vital structures and the child's fragile skull [31,62]. In addition, younger children were more susceptible to sustain deep wounds rather than superficial scratches or lacerations [4,13,31]. Extremities; either the hands or lower limbs were more commonly bitten in older children [72–78]. Single bite wound was most frequently reported rather than multiple wounds which occurred in cases of severe mauling [4,79].
The upper age limit for inclusion in the study as pediatric population was not uniform in all the studies. Some included patients up to 15 years, whereas in some studies patients with age 17, 18 and 19 were included. This might have led to bias. Moreover, the categorization of the victims according to the age was variable, as some authors have categorized on the basis of age range and some have used the terminologies infant, pre-school, grade school and teenagers.
In order to report the injuries inflicted in different areas of body, few authors have divided the body parts as head & neck, upper and lower extremities and trunk/torso/chest whereas some have further subdivided head & neck into face, scalp, eye and neck. This led to inconsistencies while drawing conclusions from the data.
All the included studies in present systematic review reported dogs as the offending animals. No observational study reported any epidemiological data related to other animals. Also, the data pertaining to the unreported bite incidents were not apprehended. Discrepancies in health care seeking behavior and access to healthcare facilities are well recognized and affected by a number of factors, like severity of injury and risks posed, health beliefs and understanding [80–84]. Ignorance regarding appropriate treatment, its completion, vaccine was also implicated in the outcome.
No study included in present systematic review could establish high quality evidence regarding risk factors for animal aggression and none compared the risk across different groups. To establish a variable as a risk factor, a control or a comparator group is needed [59,85]. Comparison must be needed to isolate animals showing aggression from animals with no aggressive behaviour . Also, comparison between characteristics of victims and non-affected population has to be included. None of the studies reaching the final review, examining the demographics of the target of aggression had a comparator group.
Pitbulls, Rottweilers, German shepherds, Bull terriers, Labradors and Dobermans were ranked as breeds with higher risk of attack [11,15,39,62,63,69]. Some breeds were considered to be more aggressive, indeed many breed specific legislations have been enacted [87–89]. However, the relationship between dog breed and aggression may be confounded by several factors . Even the experienced personnel may misidentify certain breeds, particularly cross breeds, leading to behavioral and expectational implications . The breeds bull terrier, American Staffordshire bull terrier (also known as American pit bull terrier), and Staffordshire bull terrier are collectively referred to as “Pitbull” [91–93]. Misleading information perpetuated by media regarding dog breed also creates confusion . Very few hospitalized cases reported or identified breed of the dog inflicting the injury [31,94–98]. Cognitive biases regarding a particular breed of dog causing serious injury may result in those recipients being more likely to attend for treatment .
Various authors have used variable terminologies like known/ unknown, familiar/ unfamiliar and pet/ non-pet to establish the relationship between the victim and the biting animal which created disparities while summarizing the data. Hence, uniformity in data during compilation of results could not be obtained. The events preceding the animal bite injuries which were considered as provoked incidents were not uniformly explained and demand a universally accepted definition. After reviewing all the articles, we propose, factors such as playing, teasing and feeding should be considered under the term “Provocation”. There is seasonal variation across different sub-continents with summer being the months of June, July and August in some parts of world while in others they occur during November, December and January. This could lead to bias in the registry database.
A lot of incongruity was observed in documentation of type and severity of injuries. The authors have used variable terminologies such as minor/major, mild/moderate/severe, laceration/abrasion/contusion/avulsion. Certain authors have used Injury severity score (ISS) and few used Lackmann's classification [48,49]. These classifications did not address the full spectrum of animal attack injuries. There is a need of a globally accepted classification system that will help to make consistent decisions regarding their management also. So, we are hereby proposing a new classification-“Singhal-Sikka Classification of Animal bite injuries” (Tab. V).
There is a need for development and maintenance of an online database for reporting animal inflicted injuries in all the countries of the world. Standardized methods for reporting animal bite are required. Similarly, standardized methods for measuring and reporting animals particularly dog populations are required. The patient registry database should follow a universally accepted animal bite injury reporting form to document an incident of animal attack. An animal bite injury reporting form for attending physician (Checklist 1) and a checklist for the authors while writing a paper on animal bite injuries (Checklist 2) for accurate compilation is hereby proposed in this article.
ANIMAL BITE INJURIES REPORTING FORM
Proposed Singhal-Sikka Classification of Animal bite injuries.
Details of victims
Age range and Mean age
Locality: Urban/ Rural
Family characteristics: Joint Family/ Nuclear family/ Single parent
Non case definition
Details of biting animal(s)
Species: Dog/ Cat/Monkey/Others
Sex ratio of biting animal: Male/ Female/ Unknown
Breed of the animal
Ownership of animal: Pet/ Stray/ Wild/Unknown
Vaccination status of animal: Yes/No/Not known
Neuter status: Yes/No/Not known
Current Location of the animal: Alive and in Quarantine/ Waiting to be tested/ Euthanized/ UnknownCircumstances of the injury
Location of incident
Familiarity of the victim with the biting animal: Familiar/ Nonfamiliar/ Unknown
Owner of the animal: Self/ Parent/ Relative/ Neighbor/ Friend/ No relation/ Not reported/ Other
Behavior of animal leading to the incident: Provoked/unprovoked/Sick/Unknown/Other
Most common time of year
Most common time of day
Time lag between the injury and presentation to the emergency services
Characteristics of the injury
Number of wounds: Single/Multiple
Anatomical site(s) involved: Head and Neck,Upper Limb, Lower Limb, Torso
Type of tissue(s) affected: Skin/ Muscle/ Tendon/ Nerve/ Vascular/ Bone
Severity of animal bite injuries: Grade I/ Grade II/ Grade III/ Grade IV/ Grade V
Self- toileting of the wound
Agents used for self-toileting of wound
Wound flushed at the hospital
Agent used for wound flushing
Dose, Frequency, Duration
Have the victim or the caregiver ever received education on prevention of animal bite injuries
Future research regarding animal bite injuries should follow good methodological standards that will help to provide strong evidence for development of preventive strategies. Studies comparing victims with a control or comparator group should be undertaken. Importance of educational interventions need to be supported and should be area of future research. Educational intervention regarding expected behavior of children in presence of animals and adequate supervision by parents/caregivers should be emphasized. These studies can focus on public awareness about such injuries and importance of timely intervention. Longitudinal prospective studies to establish relationship between behavior of animals and their confounders like their temperament and training may reduce the risk of animal biting trait. Reliable methods for accurate identification of dog breed should be established like an atlas, including photographs as well as size of particular breed need to be developed and validated internationally. Observational studies should follow multivariable analysis to control the effect of confounders. Studies should also identify barriers in implementation of preventive strategies like neutering, avoiding high risk breeds of pets and supervision in household with young children. A Standardized Checklist as proposed in this article for reporting animal inflicted injuries should be followed and validated internationally.
Children are the most frequent victims of animal bite injuries. These injuries have a deep impact on social and psychological development of children.
Pediatric dentists can play an active role in early diagnosis, initial management and timely referral for proper treatment.
This paper provides an insight how pediatric dentists can impart anticipatory guidance to the patients and their families regarding risk factors of animal bite injuries and the behavioral response in case of an encounter.
R.S. and N.S. conceived the ideas; R.S. and N.S. collected the data; R.S. and N.S. analysed the data; and R.S., N.S.and R.N. led the writing.
The authors declare that they have no conflicts of interest in relation to this article.
As it was a systematic review involving data from previously published scientific literature, informed consent from subjects was not required.
Since the study involved retrospective collection of data of patients who had already been managed and their identity shall not be disclosed at any point of time, the ethical approval was not obtained.
This research did not receive any specific funding.
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