A 4 YEAR RETROSPECTIVE STUDY OF FACIAL DOG BITE INJURIES IN PATIENTS REPORTED TO PEDIATRIC EMERGENCY, BPKIHS, NEPAL.

facial dog bite injuries and to assess the outcome as well as presenta�on of facial injuries among the children reported to the pediatric emergency, BPKIHS, Nepal.


Introduc on
Dog bites facial injuries are a significant health care problem and their sequelae ranges from minor to fatal injuries.

Objec ves
To determine the incidence of facial dog bite injuries and to assess the outcome as well as presenta on of facial injuries among the children reported to the pediatric emergency, BPKIHS, Nepal.

Methodology
A study was conducted where the clinical records of children with facial dog bite injuries reported from 2015 to 2018, were assessed and analyzed. A proforma was designed to extract relevant clinical data from the case records. Informa on such as age, gender of the vic ms, anatomical site of the injury, interval between injury and presenta on to the hospital, nature of injuries, profile (stray or pet)and immuniza on status the of dog, outcome and complica ons were extracted.

Result
The incidence of facial dog bite injuries has significantly increased poin ng male school going children injured predominantly (70%). Seventeen (81%) vic ms had presented within 24 hrs of injury whereas two(9.5%) pa ents had reported a er 24 hours and 72 hours of the injury. Nineteen pa ents were treated on the same day under local anesthesia, one under general anesthesia where thorough wound lavage with me culous reapproxima on followed by suturing was done. Full recovery was evident in eighteen (86%) cases with primary wound closure whereas two (14%) pa ents had undergone healing with secondary inten on.

Conclusion
There is an increase in incidence of dog bite facial injuries among children in our ter ary health care centre. Sa sfactory healing outcomes were achieved with a thorough wound lavage and primary closure of non-infected wounds under appropriate rabies prophylaxis and proper an bio c regimen.

INTRODUCTION
Dog bites present a major public health threat worldwide. The close rela onship between humans and dogs is some mes deteriorated by bites. Bite wounds have a special posi on in traumatology because of their high complica on rate compared to similar so ssue wounds 1 caused by other reasons. Reports have shown that 92% of the pa ents with bite wounds treated for plas c surgery were between one and 2 seven years of age. Being the most exposed part of the body, the head, neck and cheek region are par cularly more vulnerable to bite injuries in children, while only 10% of adults suffer from similar injuries. This significant difference is a ributed to the short stature of children and their 3 willingness to bring their faces close to the animal. Facial bone fractures may occur with each of the three so -ssue 4 injury types and occur most o en with lacera ons. The types of wounds encountered may range from mild scratches to life-threatening facial injuries where the defects may be superficial, but the extent of injuries can results in amputa ons with severe vascular and nerve or 5 bony destruc on. A typical dog bite usually present a puncture type wounds with tearing of adjacent ssue (Hole and Tear effect) leading to a narrow point of entry and deeper inocula on of microorganisms which ul mately creates an ideal environment for the prolifera on of 6 anaerobic bacteria. Management of such injuries poses a great challenge to the pediatric den sts. The possibility of rabies is another important aspect in dog th bite wounds and is considered as the 10 biggest cause of death worldwide. While rabies is a 100% preventable 3 disease, the lack of prophylaxis makes it 100% fatal. Over the years, repor ng the cases of facial dog bite injuries in pediatric emergency are significantly increasing which necessitates the desire to evaluate the status of the problem. Therefore, the aim of this study was to determine the incidence of facial dog bite injuries in children and to assess the outcome as well as the presenta on of facial dog bite injuries reported to the pediatric emergency, BPKIHS, Nepal.

METHODOLOGY
This was an observa onal retrospec ve study where the clinical records of all the children with facial dog bite injuries reported to the pediatric emergency unit, BPKIHS, from January 2015 to December 2018, were assessed and analyzed. Ethical approval was obtained from the Ins tu onal Review Commi ee IRC/1445/018. A proforma was designed to extract relevant informa on (such as age, gender of the vic ms, anatomical site of the injury, interval between injury and presenta on to the hospital, nature of the facial injuries, profile of dog (stray/pet), immuniza on status (from dog owners) of the dog, clinical profile and outcome from the pa ent case notes. All the collected data were entered into Sta s cal Package for Social Sciences (SPSS, version 12). The results were expressed as frequency distribu on and computed in percentages.

RESULTS
A total number of 21 children with age ranging from six months to 14 years had reported and treated for facial dog bite injuries. The incidence of dog bite has significantly increased from the year 2015 to 2018.  The demographic characteris cs of pa ents revealed that toddlers 9 (42.8%) and school going 5(23.8%) children were main vic ms for facial injuries as shown in Table 2.
Majority of the vic ms 17(81%) had presented within 24 hours of injury, whereas two (9.5%) pa ents had reported a er 24 hours and 72 hours of the injury.   On assessment of vaccina on status of the dogs for rabies, 3 pet dogs (14%)were vaccinated, 17(81%) were unvaccinated and the status of one (5%) dog was unknown. However, none of the owner of pet dogs had any proof of vaccina on of their dogs.  The site of facial injuries was varied in all cases, with lips, cheeks and chin the most commonest areas to be affected. The children were categorized into various types based on the classifica on of facial injuries given by Lackmannet al. Table 6: Severity of injury based on Lackmann et al All the reported pa ents had been treated immediately on the same day. Out of 21 pa ents, 19 were operated under local anesthesia, one pa ent under general anesthesia and one pa ent did not require any surgical interven on. Wounds were cleaned, debrided and irrigated with saline in all cases followed by suturing. Majority of the cases, 18(86%) recovered fully with primary closure whereas 2(14%) pa ents reported with wound infec on on whom healing was achieved with secondary closure.
All the vic ms had received an bio c coverage for five to seven days with tetanus prophylaxis and an -rabies immunoglobulin into and around the wound along with five th dosages (0, 3, 7, 14 and 28 day) of rabies vaccine. Dosage of immunoglobulins administered was based on the weight of the pa ent (20 i.u per kg body weight).

DISCUSSION
Dog bite facial injuries inflicts considerable physical, emo onal and psychological damage on children and now has become a serious concern for parents as well as the clinicians. Facial trauma due to bites in children represents a significant 8 medical health issue. This study revealed that toddlers and school going children were more vulnerable candidates to dog bite injuries. This could probably be due to the fact that children at this age group are more likely to play the dogs and even provoke them, making them less likely to defend when a acked. This is in agreement with a study which showed that the risk factors for dog a acks include school-9 aged children. According to Zerfowski and Bremerich, facial trauma in children are seen mainly on below five years of 10 age which is o en under reported. Mendez Gallart et al in his 10 years retrospec ve study had reported that 654 pa ents under the age of 14 years, being treated for the dog 11 bite injuries. In the present report, male (70%) children were more injured as compared to the females (30%). This is in concurrence with our society and cultural scenarios where boys are more commonly involved in outdoor games/ ac vi es as compared to the girls. A high frequency of dog bites in children, 12 especially boys, had also been reported by Wright et al. For complicated bite wounds presen ng beyond the ''golden 24-hour period'' primary closure remains controversial. The major propor on of pa ent safflicted with bite injury presented within the first 24 hrs to the pediatric emergency unit which is quite appreciable and coincides to the findings reported by Abubakar and Bakari in 13 Northern Nigeria. Majority of the bite injuries were by stray dogs (72%), as there is neither animal control law nor any agencies to control these wandering stray dogs in our part of the country. Lower vaccina on status of the dogs in this study coincides 13 with the observa on reported by Abu bakar et al. The high percentage of the unvaccinated dogs (81%) in this study indicates that rabies s ll remains a significant threat to the popula on and calls for a policy response to ensure higher coverage of an -rabies vaccina on of dogs. Public educa on such as good dog ownership and confinement of dogs by relevant authority along with other preven ve measures are cri cal tominimize risk of dog bite incidences. According to Ozanne-Smith et al the highest rate of serious injury from dog bite occurred in children below five years with the various body region affected in different pa erns 14 for children and adults. The facial region mainly affec ng cheeks, lips, nose and the scalp represent 51% of bites to children, while 50% of the bites in adults were limited to the upper extremity with facial region being uncommon.In the present study it was observed that all injuries mainly involved eyes, cheeks, lips and chin. This addi onally also supports the findings of Palmer and Rees who termed this 15 region as the "central target area (CTA)". Dog bites associated with facial injury are designated into three categories: lacera ons, punctures, and avulsions ( ssue loss). Lacera ons were the most frequently associated so -ssue injury in this study. Based on Lackmann's et al classifica on of facial injuries, 14.2% of injuries falls under type I, type IIA 7 (33.3%), type IIB (28.5%), type IIIA (14.2%) and, type IV with 19%. The surgical approach to bite injuries includes primary closure of the wound whenever possible. Tissue defects in which primary closure is unobtainable can be managed by local flaps, regional flaps, skin gra s or microvascular reconstruc on. A er several years of debate, there seems to be some consensus on the guidelines for the management of facial 16 bite wounds. The principle steps in this management are as follows: · Proper surgical toilet of the wound by copious irriga on · Me culous debridement of devitalized ssue · Primary closure of the wound except in high-risk cases · Appropriate an bio c therapy · Tetanus and rabies prophylaxis where required. The regimen used in this present study with primary closure of wound a er careful debridement of necro c ssue and me culous reapproxima on has been the favored [17][18][19] procedure in almost all recent publica ons. Majority of the children (85%) had undergone healing with primary closure whereas postopera ve complica ons with wound infec ons were seen on two cases (10%) which had undergone healing by secondary inten on and one case (5%) had undergone healing with debridement and an bio c therapy. An bio c therapy is almost mandatory in facial polymicrobial dog bite wounds either from a prophylac c or a therapeu c point of view.A combina on of amoxicillin and clavulanic acid with metronidazole and other combina ons of extended-spectrum penicillin with beta-lactamase inhibitors were prescribed to ensure wide coverage for the pathogenic flora. Tetanus (if the history of immuniza on was unclear), an -rabiesimmunoglobulins prophylaxis and five doses of an -rabies vaccines were given in all the cases as per the WHO protocols. This supports the findings of the study by Kountakis et al where all the pa ents were given prophylac c an bio cs without regard to the 20 severity of their injuries. None of the pa ents had presented with symptoms of rabies during our follow up periods.

CONCLUSION
The present study had shown that increase in incidence of facial dog bite injuries among children were becoming a common presenta on in our ter ary health care centre with higher percentage involving toddlers (42.8%) and school going children(23.8%). Sa sfactory healing outcomes were achieved with a thorough wound lavage and primary closure of non-infected wounds under appropriate rabies prophylaxis and proper an bio c regimen.

RECOMMENDATIONS
· An cipatory guidance by pediatric health care providers should a end to dog bite preven on.
· Wound infec on is the most common complica on following dog bite injuries. Pediatric den sts should provide immediate primary wound care and surgical repair to avoid post-opera ve infec onsin orderto obtain the be er cosme c results.
· A high number of unvaccinated dogs alarmed the possibility of rabies not been eradicated ll date which calls for the preven ve strategies and a policy response to ensure coverage of an rabies vaccina on.

LIMITATION OF THIS STUDY
· This study being a hospital centered one where the data obtained may not be a representa on of the en re popula on. · Retrospec ve design.

CONFLICTS OF INTEREST
There are no conflicts of interest