Management of Pediatric Dog Bite to the Nose
Facial dog bite wounds in children, including the nose, should be primarily closed after meticulous wound care, copious irrigation, and administration of prophylactic antibiotics, ideally by a plastic surgeon or experienced provider. 1
Immediate Wound Management
Irrigate the wound immediately and thoroughly with soap and water for approximately 15 minutes, followed by copious irrigation with sterile normal saline to reduce infection risk and potential rabies transmission. 2, 3
Consider adding povidone-iodine solution to the irrigation as a virucidal agent to further reduce infection risk. 2, 3
Perform superficial debridement only - remove superficial debris but avoid deep debridement that could enlarge the wound and impair skin closure. 1
Carefully examine for deeper structure involvement including cartilage damage, through-and-through injuries, or involvement of nasal structures. 2
Primary Closure Guidelines
Facial wounds are an exception to the general rule against primary closure of bite wounds. 1 The nose, being a facial structure with excellent blood supply and significant cosmetic importance, warrants primary closure under specific conditions:
Close primarily if the wound is seen within 8 hours of injury after meticulous wound care and irrigation. 1
Primary closure can be performed even in wounds presenting later than 8 hours if there is thorough wound preparation, copious irrigation, and prophylactic antibiotics are administered. 1, 4
Plastic surgery consultation is recommended for optimal cosmetic outcomes, particularly for complex nasal injuries. 1, 4
Antibiotic Prophylaxis (MANDATORY)
All pediatric facial dog bites require prophylactic antibiotics. 1, 3
First-line: Amoxicillin-clavulanate at 25 mg/kg/day (of the amoxicillin component) divided into 2 doses orally for 3-5 days. 1, 2, 3
For penicillin-allergic patients: Doxycycline (if age ≥8 years) or a fluoroquinolone plus metronidazole or clindamycin. 1, 2
AVOID first-generation cephalosporins (cephalexin), dicloxacillin alone, macrolides (erythromycin), or clindamycin alone - these have poor activity against Pasteurella multocida, which is present in 50% of dog bite wounds. 1, 2, 3
Tetanus Prophylaxis
- Administer tetanus toxoid (0.5 mL intramuscularly) if the child's immunization status is outdated or unknown. 1, 2, 3
Rabies Risk Assessment
If the dog is healthy and domestic, confine and observe for 10 days without initiating rabies prophylaxis. 1, 3
If the dog is stray, unwanted, or cannot be observed: Euthanize immediately, submit the head for rabies examination, and initiate rabies post-exposure prophylaxis immediately with rabies immunoglobulin and vaccine series (days 0,3,7, and 14). 1, 3
Consult local health department for guidance on rabies risk in your geographic area. 1, 3
Follow-up Care
Schedule follow-up within 24-48 hours to assess for signs of infection (increased pain, erythema, purulent drainage, fever). 1, 3
Monitor for complications including cellulitis, abscess formation, wound dehiscence, or cartilage infection. 3, 5
Common Pitfalls to Avoid
Do NOT delay closure of facial wounds due to infection concerns - the face has excellent blood supply and primary closure with antibiotics is the standard of care. 1, 4
Do NOT use inadequate irrigation - copious irrigation is the single most important intervention to prevent infection. 2, 3
Do NOT prescribe antibiotics with poor Pasteurella coverage - this is the most common pathogen in dog bites. 1, 2, 3
Do NOT forget to document the dog's vaccination status and observability for rabies risk assessment. 1, 3
Special Considerations for Pediatric Patients
Children under 5 years are at highest risk for facial injuries due to their height and proximity to dogs' mouths. 6, 7
The nose is particularly vulnerable in young children and may require specialized reconstruction if there is significant tissue loss or cartilage involvement. 4, 6
Provide psychosocial support for both the child and caregivers, as dog bite trauma can be psychologically significant. 5