Dog Bite Prevention in Children

Cinnamon Dixon, D.O. MPH Capstone Project June 4th, 2010

“4-year-old daughter of Jesse Browning -- the stars of The History Channel's "Ax Men" -- died tragically yesterday in Oregon after being mauled by one of the family's ”

A Minnesota family's newborn boy “was killed by the family's Siberian husky, which jumped onto a bed where the 11-day-old was in a car seat and bit his head.”

“Cincinnati, OH—A 9-year-old boy is in intensive care in a medically induced coma after two viciously attacked the boy, shredding his leg and face.”

http://www.huffingtonpost.com/ http://www.startribune.com/local/84785607.html http://www.justicenewsflash.com Background Dogs of our Lives

77.5 million owned dogs

46.5% households

The majority of bites occur by a known dog

American Pet Products Manufacturers Assoc 2009-2010 survey The Problem

2001-2003: 4.5 million people

(TBI  1.4 million annually  3x)

- Ages 5-9 years: 18.7/1000

Dog bites: still a problem? Inj Prev 2008. Medical Care

885,000 need medical attention – Majority children

>368,000 non-fatal ED visits

– 42% <14 years of age

Dog bites: still a problem? Inj Prev 2008. Incidence of dog bite treated in emergency departments. JAMA 1998. Nonfatal Dog Bite–Related Injuries Treated in Hospital Emergency Departments — United States, 2001. MMWR 2003. Outcomes

Disfigurement: 30,484

Infection: 3-18%

Posttraumatic stress disorder: >50%

Fatalities: 12-13  33 (2009) – 70% Children

Dog-Bite-Related Fatalities -- United States, 1995-1996, MMWR 1997. Bacteriologic analysis of infected dog and cat bites. N Engl J Med 1999 Posttraumatic stress disorder after dog bites in children. J Pediatr 2004. American Society of Plastic Surgeons. 2009 Reconstructive Surgery Procedures. Breeds of dogs involved in fatal human attacks in the United States between 1979 and 1998. J Am Vet Med Assoc 2000. $$ The Costs $$

$102.4 million emergency services – >50% children and adolescents – 26% billed governmental payors + Hospitalization: $62.5 million ------Direct medical care: $164.9 million $235.6 million-$253.7 million

Incidence of dog bite injuries treated in emergency departments. JAMA.1998. Hospitalizations for dog bite injuries. JAMA. 1999. Decreasing dog bites and their impact

Center for disease control and prevention. Healthy people 2010: and violence prevention. World health organization. World report on child injury prevention, 2008. Dog Bite Prevention in Children Literature Review

Dog bites: still a problem? Random household survey ~ 10,000 homes Data extrapolation to population Comparison to 1994 2001-2003 1994 Limitations: • 48% response rate – 4.5 million 4.7 million • Overrepresentation – 885,000 800,000 • 15-17 year old data – Child: 13/1000 24.5/1000

Dog bites: how big a problem? Inj Prev 1996. Dog bites: still a problem? Inj Prev 2008. Literature Review

Analysis of dog bites in children who are younger than 17 years Children presenting to trauma center Austria Chart review, survey, veterinary – 10 years – N=341 Limitations: – More bites in summer • Incidence – 73% from known dog • “Interference” 75% child “interfered with the dog” • Poor generalizability – Risk 5x > German shepherds & Dobermans

Pediatrics, 2006. Literature Review

Which Dogs Bite?

Case control of v non-biting dogs - one year – German shepherds or Chow – Male Limitations: – Unneutered • 50% response • Self-report – Residing with 1+ children • Non-household bites – Chained in a yard • Non-blinding • Breed identification

Archives of . (Jarrett, 1991) Literature Review

Preventing dog bites in children: randomized controlled trial of an educational intervention

RCT 8 primary schools: 346 children, ages 7-8 No education v. 30 min dog handler Videotaped with leashed dog – Intervention: most with distant observation – Control: 79% (118/149) pet and tried to excite it Limitations: • Education description • Scoring • Short term behavior West J Med. (Chapman et al., 2000) Objectives

Domain One: To determine the level of dog bite prevention knowledge in children and parents

Domain Two: To review dog bite prevention education programs comparing key messages and activities To determine current state or federal policies regarding dog bite prevention education

Domain Three: To describe possible public health strategies to decrease the burden of dog bites in children Domain One

To determine the level of dog bite prevention knowledge in children and parents Domain One - METHODS

Cross-sectional study at CCHMC ED

Inclusion Criteria – Children ages 5-15 and parents – Non-urgent complaints &/or stable dog bites

Exclusion Criteria – Non-English speaking – Previously enrolled – Unable to complete the study Data Collection - Questionnaires

Parents: Children: – Sociodemographic – Demographics – Dog experiences – Dog experiences Dog ownership Prior education Prior dog bites Current dog Prior education interactions Dog bite education Previous bite history desires Data Collection – Knowledge Test

Parents: Children:

– 14 simulated scenario questions 7 written 7 picture

– Yes/No answers

– Based off AAP recommendations Sample Test Questions

A mommy dog is nursing her , do you try to pet her or the puppies?

Your cousin’s dog is playing with a toy, do you run up and take the toy?

Walking home from the bus stop, a strange dog comes near you and starts barking, do you run away? Should you pet this dog? Should you pet this dog? Should you pet this dog? Analysis

Categorical variables compared Test scoring: – Summing correct answers – A priori pass rate ≥ 75% (11/14) Logistic regression Continuous linear model Domain One – RESULTS Parent Child Mean age: 35.1 (± 8.2) 8.7 (± 3.1) Female: 90% 50% White: 48% ≤ HS: 43% Income: <$20K 37% $20-40K 32% $40-60K 11% <$60K 20% Domain One – RESULTS

Parent Child Prior dog bite: 21% 23%

No prior education: 72% 46% (63% fam)

Dog ownership: 73% Other items to note

88% parents desired education 73% didn’t know where to go

82% ED 87% Pediatrician

43% children failed 8% parents failed Multivariable – Passing Scores

Regression Linear Model CHILD Odds ratio 95%CI p-value Para. Est. 95%CI p-value

Child age Cont. 1.15 1.06-1.25 <0.01 0.25 0.16-0.33 0.009 Parent Race W v NW 1.88 1.17-3.02 <0.01 0.97 0.34-1.51 0.001

Older children and children with white parents have higher test scores and higher odds of passing the test No associations between test scores & gender, education level, SES, dog ownership, prior dog bite, or prior education Domain Two – Education METHODS

To review dog bite prevention education programs comparing key messages and activities

To determine current state or federal policies regarding dog bite prevention education Domain Two – Education METHODS

Online review of 5 national organizations – American Academy of Pediatrics – Center for Disease Control and Prevention – American Veterinary Medical Association – Humane Society of the United States – American Society for the Protection of

Websites: “dog” AND/OR “bite” AND/OR “prevention”

Key messages across all 5 venues Educational tools & activities Domain Two – Education RESULTS

Responsible dog ownership

Safe dog interactions

What do to if an unknown dog approaches Domain Two – Education RESULTS

Responsible dog ownership: Consider pet selection & consult professional Socialize and train your dog Keep your dog healthy, including regular vaccination Spay or neuter your dog Domain Two – Education RESULTS

Safe dog interactions: Be alert for dangerous situations, ie. dog aggression Infant or children always have adult supervision Teach young children how to be safe around dogs Always ask permission from a dog’s owner before petting Always let the dog sniff your hand first before petting Do not disturb dog caring for puppies, eating or sleeping Do not reach through or over a fence to pet a dog Do not run past a dog Do not approach any unfamiliar dog Domain Two – Education RESULTS

What to do if an unfamiliar dog approaches Do not run from the dog, scream or look the dog directly in the eye Stay still (i.e. "like a tree") If knocked over by a dog, roll into a ball, cover your head/neck with your hands, and be still Domain Two – Education RESULTS

Educational tools/activities All: website information, factsheet or pdf AVMA: “Blue dog” guide & CD; AVMA-TV ASPCA: child and parent pledge HSUS: catalogs, books, coloring books, videos, posters, certificates and stickers; age-specific lesson plans Domain Two – Policy METHODS Online review of 2 national organizations – Michigan State University College of Law: Animal Legal & Historic Web Center – United States Government

Websites: “dog” AND/OR “bite” AND/OR “prevention”

State or federal policies Other bite-related policies/procedures Domain Two – Policy RESULTS

No state or federal dog bite prevention education policies Multiple states mandate education for pet population – NC: 5¢ of all dog toward general “education and prevention” OR: dog owners receive education to “avoid conflict between dogs and livestock” DE: only state includes decreasing dog bites in injury prevention strategic plan (1) dog bite prevention education to children, parents, dog owners, institutions, and communities (2) supporting legislative proposals mandating dog bite prevention education in Delaware schools (3) a state dog bite prevention day Domain Three

To describe possible public health strategies to decrease the burden of dog bites in children Domain Three – METHODS

Background: children are the most frequent and most severe victims of dog bites, and education is paramount

Domain One: children are lacking this knowledge and parents desire it

Domain Two: consistent educational messages; educational tools or activities; no state or federal policy Domain Three – RESULTS

Mandatory dog bite prevention education within elementary school curriculum

Strength: – access large populations of children – utilize consistent educational messages and tools Limitations: – Home-schooled children – Infants and young children – No live dog Domain Three – METHODS

Background: – Majority of dog bites are by known dogs – Education should address dog owners

Domain Two: consistent educational messages; educational tools or activities; no state or federal policy Domain Three – RESULTS

Mandatory registration of all dogs and dog bite prevention education for all dog owners Strength: – Access the large populations of dog owners – Keep infants and young children safe from dog bites – Fee for registration  fund educational interventions Limitations: – Creation of dog registry system/infrastructure – Dog owner push back – Enforcement challenges Domain Three – METHODS

Background: – Need for overseeing group to advance and promote the agenda – Multidisciplinary nature may help diversify interests and funding possibilities Domain Three – RESULTS

Implementation of a Dog Bite Task Force Strength: – Overseeing body, coordinate – Promoting or advancing the agenda Limitations: – Funding to create and sustain – Intergroup disagreements – Incongruity of ideas and directions Conclusion

Dog bites are a major public health problem affecting children

Prevention knowledge in children is lacking Majority children have never education - parents desire it

Consistent prevention education messages & activity variety No state or federal mandates

Potential public health interventions or policies: 1. Mandatory dog bite prevention education in school 2. Mandatory registration of dogs & education for dog owners 3. Implementation of a dog bite task force Limitations

Domain One: – Captive sample may not reflect the dog bite prevention knowledge level of all – Knowledge test was newly developed and non-validated

Domain Two: – Possible programs offer different messages and opportunities – Local policy and/or individual school-related procedures

Domain Three: – Strategies have not been proven or validated – Other possible interventions exist Children and dogs can coexist with prevention education and training

It is our duty to continue to advance & promote dog bite prevention education to keep children, families, and communities safe Thank You

Dr. Elizabeth Bragg & Dr. Melinda Mahabee-Gittens References

Dixon, C, DO; Mahabee-Gittens, M. MD, MS. Parental and Child Dog Bite Education and Awareness in a Pediatric . IRB #08-01-23 American Pet Products Association: Industry Trends and Statistics, 2009-2010. RetrievedMay 15th, 2010 from http://www.americanpetproducts.org/press_industrytrends.asp American Academy of Pediatrics. Dog bite prevention. Retrieved May 10th, 2010 from http://www.aap.org/advocacy/releases/dogbiteprevention.pdf American Society of Plastic Surgeons. 2009 reconstructive surgery procedures. Retrieved May 15th, 2010 from http://www.plasticsurgery.org/Documents/Media/statistics/2009-UScosmeticreconstructiveplasticsurgeryminimally-invasive-statistics.pdf American Society for the Prevention of Cruelty to Animals. Retrieved May 10th, 2010 from http://www.aspca.org American Veterinary Medical Association. Retrieved May 10th, 2010 from http://www.avma.org Center for Disease Control and Prevention. Healthy people 2010: Injury and violence prevention. Retrieved October 15, 2009 from http://www.healthypeople.gov/dOCUMENT/HTML/volume2/15injury.htm Centers for Disease Control and Prevention. (1997). Dog-bite-related fatalities--United States, 1995-1996. MMWR. Morbidity and Mortality Weekly Report, 46(21), 463-467. Centers for Disease Control and Prevention. (2003). Nonfatal dog bite-related injuries treated in hospital emergency departments--United States, 2001. MMWR. Morbidity and Mortality Weekly Report, 52(26), 605-610. Centers for Disease Control and Prevention. Dog bite prevention. Retrieved May 10th, 2010 from http://www.cdc.gov/homeandrecreationalsafety/dog- bites/biteprevention.html Chapman, S., Cornwall, J., Righetti, J., & Sung, L. (2000). Preventing dog bites in children: Randomized controlled trial of an educational intervention. The Western Journal of Medicine, 173(4), 233-234. Gershman, K. A., Sacks, J. J., & Wright, J. C. (1994). Which dogs bite? A case-control study of risk factors. Pediatrics, 93(6 Pt 1), 913-917. Gilchrist, J., Sacks, J. J., White, D., & Kresnow, M. J. (2008). Dog bites: Still a problem? Injury Prevention : Journal of the International Society for Child and Adolescent Injury Prevention, 14(5), 296-301. Humane Society of the United States. Retrieved May 10th, 2010 from http://www.humanesociety.org Jarrett, P. (1991). Which dogs bite? Archives of Emergency Medicine, 8(1), 33-35. Langlois JA, Rutland-Brown W, Thomas KE. (2004). Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta, GA: Dept. of Health and Human Services (US), Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Michigan State University College of Law: Animal Legal & Historical Web Center. Dog bite laws. Retrieved May 15th, 2010 from http://www.animallaw.info/articles/armpusdogbite.htm#Mississippi# Peters, V., Sottiaux, M., Appelboom, J., & Kahn, A. (2004). Posttraumatic stress disorder after dog bites in children. The Journal of Pediatrics, 144(1), 121-122. Quinlan, K. P., & Sacks, J. J. (1999). Hospitalizations for dog bite injuries. JAMA : The Journal of the American Medical Association, 281(3), 232-233. Sacks, J. J., Kresnow, M., & Houston, B. (1996a). Dog bites: How big a problem? Injury Prevention : Journal of the International Society for Child and Adolescent Injury Prevention, 2(1), 52-54. Sacks, J. J., Kresnow, M., & Houston, B. (1996b). Dog bites: How big a problem? Injury Prevention : Journal of the International Society for Child and Adolescent Injury Prevention, 2(1), 52-54. Sacks, J. J., Lockwood, R., Hornreich, J., & Sattin, R. W. (1996). Fatal dog attacks, 1989-1994. Pediatrics, 97(6 Pt 1), 891-895. Sacks, J. J., Sattin, R. W., & Bonzo, S. E. (1989). Dog bite-related fatalities from 1979 through 1988. JAMA : The Journal of the American Medical Association, 262(11), 1489-1492. Sacks, J. J., Sinclair, L., Gilchrist, J., Golab, G. C., & Lockwood, R. (2000). Breeds of dogs involved in fatal human attacks in the United States between 1979 and 1998. Journal of the American Veterinary Medical Association, 217(6), 836-840. Schalamon, J., Ainoedhofer, H., Singer, G., Petnehazy, T., Mayr, J., Kiss, K., et al. (2006). Analysis of dog bites in children who are younger than 17 years. Pediatrics, 117(3), e374-9. State of Delaware: Strategic Plan for Injury Prevention 2005-2010. Retrieved May 20th, 2010 from http://www.dhss.delaware.gov/dhss/dph/ems/files/strategicplanforinjuryprevention.txt United States Government. Retrieved May 20th, 2010 from http://www.usa.gov/index.shtml Weiss, H. B., Friedman, D. I., & Coben, J. H. (1998). Incidence of dog bite injuries treated in emergency departments. JAMA : The Journal of the American Medical Association, 279(1), 51-53. World health organization. World report on child injury prevention, 2008. Retrieved March 2, 2009 from http://whqlibdoc.who.int/publications/2008/9789241563574_eng.pdf Wright, J. C. (1985). Severe attacks by dogs: Characteristics of the dogs, the victims, and the attack settings. Public Health Reports (Washington, D.C.: 1974), 100(1), 55-61.

The Breed Question… Breeds – A Word of Caution

Identification and reporting – Appearance and characteristics Pure breed v. mixed/cross-breed Veterinary specialists v. DNA – Terminology Pitt bull = generic for phenotype : Bull, American Staffordshire, Staffodshire Bull – Owner knowledge 1994-2003 Austria: 89% (305/341) couldn’t determine – Cultural trends Study interpretation/implications – Specific dog bite rate in relation to breed prevalence – Mixed breed prevalence difficult to determine

Will breed-specific legislation reduce dog bites? Can Vet J August 1996 Breed – a Few Statistics

US: 1985 S. Carolina (no data) – American Staffordshire or Staffordshire Bull Terrier – Saint Bernard – Mixed breed – Cocker – Cockapoo US: 1991 Case Control (with data) – , Chow, Collie, Akita US: 1979-1998 CDC Fatality Study (no data) – Pitt Bull or >50% – 25 different breeds or cross breeds represented

Severe Attacks by Dogs: Characteristics of the Dogs, the Victims, and the Attack Settings. Public Health Reports Jan-Feb 1985 Gershman, KA et all. Which Dogs Bite? A Case-Control Study of Risk Factors. Pediatrics June 1994 Breeds of dogs involved in fatal human attacks in the United States between 1979 and 1998. Breed – a Few Statistics

UK: 1989 Line-Up (with data) – German Shepherds greater than relative popularity mix, other mixed breed, Collie Canada: 1993 (with data) – No specified breed most (15.2%) German shepherd, Terrier, Rottweiler, Collie, Doberman, Great Dane, Poodle Canada: 1990-2007 Fatal Attacks (with data) – Mixed-breed, “”, Husky, Rottweiler Austria: 1994-2003 (with data) – German Shepherd or Doberman 5x > than Labrador/ or cross-breed

Which Dogs Bite? Archives of Emergency Medicine, 1991. Raghavan, Malathi. Fatal dog attacks in Canada, 1990-2007 Analysis of Dog Bite in Children Who are Younger than 17 years. Pediatrics March 2006 What We’ve Learned

“Breed alone is not an adequate indicator of a dog’s propensity to bite.” Humane Society of the United States Other considerations

Most dog bites are by 35 single dog ~98% 30 Owned or familiar dog: 25 73%-89% 20 Having dog in house Adult increases incidence 15 Children Incidence increase relative 10 to increasing number of dogs 5 – Adults: 5x more likely 0 0 1 2+ Children: 3x more likely

Dog bites: still a problem? Inj Prev 2008. Other considerations

Previous biting or behavior abnormalities – Aggression/Anxiety Location: – Younger: In victim’s home or yard – Older: Other location (ie. Home/yard visitor) Dog chained in yard Male dogs and sexually intact Obedience training Year round; SUMMER Multivariate Models Risk Factors

Variable All Ages <13 Years Old Predominant Breed German Shepherd 16.4 22.1 Chow Chow 4.0 3.7 Male 6.2 5.3 >1 child in house 3.5 6.9 Not neutered 2.6 2.3 Chained while in yard 2.8 5.4 No obedience school 1.9 1.4 Purebred 1.7 1.8 Weight >50 lbs 1.5 1.3

Gershman, KA et all. Which Dogs Bite? A Case-Control Study of Risk Factors. Pediatrics June 1994 Why Do Dogs Bite? Why Do Dogs Bite?

Aggression to Familiar Children Category Stimulus <6 6-17 Resource Guarding Food/Toys 44 18 Benign (non aversion) Petting/Hugging 15 19 Resting Waking 3 10 Aversion (painful) Stepping 18 0 Aversion (non-painful) Grooming 0 6

Behavioral assessment of child-directed canine aggression. Injury Prevention 2007. Why Do Dogs Bite?

Aggression to Unfamiliar Children

Category Stimulus <6 6-17 Territorial (non-interactive) On property 9 23 Territorial (interactive) On property 6 10 Not Territorial (non-interactive) Not on property 3 5 Not Territorial (interactive) Not on property 0 5 Aggression other 6 9

Behavioral assessment of child-directed canine aggression. Injury Prevention 2007.