More than 4.5 million dog bites are reported each year, with approximately 800,000 of these incidents requiring medical attention.1 Dog bites are one of the most common injuries that affect children.1,2 Younger children often experience injuries to the head and neck and need suturing for cosmetic repair; older children typically sustain injuries to their extremities.1 Regardless of where a dog bite occurs on the body, it can result in infection, fractures, psychological trauma, and death.1,2 Bite severity can range from mild to severe, with injuries such as lacerations; skin, muscle, and fascia tearing; and crush injuries.3 While many dog bites are treated on an outpatient basis in urgent care centers and EDs, more than 10,500 hospitalizations have been reported within the past decade for dog bite complications, resulting in significant medical cost for a preventable situation.1
Several risk factors increase the likelihood of dog bite injuries, such as the age, gender, and breed of the dog; the age and gender of the victim; the location of the incident; the dog's ownership; and the relationship between the animal and the victim.3 While most dog bite injuries occur in urban areas, these are typically not influenced by race, socioeconomic status, or ethnicity.1 Gender has been found to influence the occurrence of dog bites, with the highest rates seen in children with masculine gender expression between the ages of 5 and 9 years.2 Most reported dog bites in children occur due to lack of supervision and recognition of the dangers related to leaving children unattended with the family dog, allowing children to participate in rough play with the family dog, or of dogs that are unknown to the family.4,5 Certain breeds, including Pitbull terriers, mixed-breeds, and German shepherds, influence how likely a dog will bite.2,6 These bite injuries can result in varying degrees of severity, including death in rare cases.2
Often, the incidents that lead up to a dog bite can be prevented by recognizing canine behavior cues. Dogs demonstrate specific body language when protecting their environment, food source, or people and other animals.7 These cues may include an aggressive stance with teeth bared, eyes narrowed, raised fur hackles, growling or barking, and a stiffening of the tail.8
Benefits of anticipatory guidance
To prevent dog bites in young children and to educate parents about appropriate supervision over child-dog interactions, the American Pediatric Surgical Nurses Association (APSNA) recommends that pediatric healthcare professionals provide parents with anticipatory guidance during well-child visits.4 Such guidance should include ways to improve the safety of the child's environment when a dog is a member of the household, including the use of baby gates to ensure the separation of the child and the family dog. Parental education should stress that a sleeping infant or child should never be left unsupervised in a room with a dog. Adult caregivers must supervise all toddler-dog interactions. Children should be frequently reminded to avoid approaching a dog while it is eating or sleeping and to avoid putting their faces near a dog's. Furthermore, parents and children should be reminded of the dangers of approaching an unknown dog as aggressive behaviors may not be readily apparent.
Anticipatory guidance is paramount to pediatric nursing and encompasses health promotion and injury prevention. Educational opportunities are proven to decrease the incidence of dog bites in children.4 Those provided education about the precipitating factors of dog bites were shown to better identify aggressive behavior cues in dogs.9 In contrast, children who did not receive or participate in educational opportunities were found to have acted inappropriately around dogs, further increasing their chance to sustain a bite.9
Other preventive measures
Although dog bites are a significant and dangerous concern, no universal prevention program is being used.4 According to the American Veterinary Medical Association, some effective strategies to prevent dog bites include owners familiarizing dogs with the presence of strangers and controlling dogs with a leash.10 Pet owners should also ensure that the dog and family are a good fit for each other and that the dog is appropriately trained and spayed or neutered. Understanding a dog's behavior can be useful in interpreting how it may be feeling.10
Video testimonials and case studies can also be used as effective tools to educate parents and children in preventing dog bites. Evidence suggests that children and their parents who watched and heard testimonials had an increased safety knowledge, higher perceived vulnerability, and decreased risky behavior with dogs.11 Cognitive-behavioral interventions such as classroom lessons, interactive teaching modalities, and computer-based self-guided educational programs have shown to have a moderate effect on safety education and risk reduction for school-age children.12 Those who received training and education had an improved ability to interpret a dog's emotional state and were able to apply the knowledge gained by interacting appropriately with dogs.9
APSNA also highlights the importance of having state-based centralized reporting systems for dog bites to aid in determining the true prevalence of these injuries and identifying areas for further research and prevention.4 They also recommend strengthening collaboration between medical and veterinary professionals for the development of successful dog bite prevention programs.
Using L.O.V.E. in patient education
Anticipatory guidance to prevent dog bites can be addressed through the acronym L.O.V.E. (see Preventing dog bites through L.O.V.E.).4 As most reported dog bites happened when children were left unsupervised with a dog, an important teaching focus should include ensuring children (L) leave dogs alone when the dog is eating, drinking, sleeping, or caring for their young.4,5 Healthcare workers must discuss the importance of (O) observing for threatening behaviors such as barking, growling, or changes in canine body language in both family and unfamiliar dogs. Parents should be encouraged to be (V) vigilant about identifying unknown dogs in their community and reporting them to local animal control. Finally, parents and children must be informed that (E) even if a dog is behind a fence or some other barrier, it can still exhibit aggression. Additional teaching strategies should include never leaving small children alone with dogs even if the dog is described as well-behaved, never allowing aggressive play with dogs, and giving an approaching dog ample time to sniff and become comfortable.5
Dog bite education can be implemented in schools and during well-child visits. In schools, slide presentations, videos, and handouts can be used to educate students about identifying aggressive behavior in dogs and taking the proper steps when encountering an aggressive dog, such as avoiding eye contact with an aggressive dog, remaining quiet and still with arms close to the body, and slowly moving away from the dog to find an adult for help.13 Dog bite education can be presented by the school nurse or an invited speaker each year starting in prekindergarten.14
During well-child visits, dog bite education can be provided by nurses as anticipatory guidance when conducting developmental milestones and home assessment screenings. Information obtained during the screening can help identify parents and children who have regular encounters with dogs at home, and thereby can guide the dog bite prevention education. L.O.V.E. may also be promoted in printed handouts and include pictures. Education provided at well-child visits should be documented and incorporated into routine teaching.
Providing anticipatory guidance, such as L.O.V.E., at well-child visits and appropriate educational materials in school settings can promote effective strategies to prevent dog bites among young children. However, further research is needed to evaluate the effectiveness of L.O.V.E. and other educational programs as well as to develop additional strategies to address these common yet preventable injuries.
Preventing dog bites through L.O.V.E.
L: Leave dogs alone when the dog is eating, drinking, sleeping, or caring for their young.
O: Observe for threatening behaviors, such as barking, growling, baring teeth, changes in ear position, or other body language.
V: Vigilance of unknown dogs in community and report to local animal control.
E: Even if a dog is behind a fence or other barrier, aggression can result from environmental protective responses.
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