What is the appropriate treatment for a 3-year-old child bitten by a dog?

Dog Bite Management in a 3-Year-Old Child

Immediately irrigate the wound thoroughly with soap and water for 15 minutes, assess for deep tissue involvement, administer amoxicillin-clavulanate 875/125 mg (dosed appropriately for the child's weight) for 3-5 days if the wound is moderate-to-severe or involves the hand/face, update tetanus if needed, and confine the dog for 10-day observation without initiating rabies prophylaxis unless the dog is unavailable or shows signs of illness. 1, 2, 3

Immediate Wound Management

Wound irrigation is the single most effective measure for preventing infection and rabies transmission:

• Wash the wound with soap and water for approximately 15 minutes as soon as possible 2, 3
• Use copious irrigation with sterile normal saline via a 20-mL or larger syringe or 20-gauge catheter to generate adequate pressure 3
• Apply an iodine-containing or similarly viricidal topical preparation to the wound if available 2
• Carefully explore the wound for tendon involvement, bone penetration, joint capsule violation, or foreign bodies—these complications are particularly common in children and require prolonged therapy 1, 3

Wound Closure Decision

Facial wounds in children require special consideration for optimal cosmetic outcomes:

• Primary closure is recommended for facial wounds after copious irrigation, cautious debridement of devitalized tissue, and initiation of preemptive antibiotics 1
• Non-facial wounds should be approximated rather than fully closed, or left open if heavily contaminated 1, 4
• Close wounds only if they can be treated within 8 hours of injury and are well-irrigated and sharply debrided 5
• Never close infected wounds 6

Antibiotic Prophylaxis

Amoxicillin-clavulanate is the first-line antibiotic for pediatric dog bites:

• Administer preemptive antimicrobial therapy for 3-5 days if the child has moderate-to-severe injuries, hand/face wounds, wounds that may have penetrated periosteum or joint capsule, or if the child is immunocompromised 1, 3
• Dose amoxicillin-clavulanate appropriately for the child's weight (standard pediatric dosing is 45 mg/kg/day divided twice daily, up to adult dose of 875/125 mg twice daily) 7, 1
• This provides optimal coverage against Pasteurella species (50% of dog bites), staphylococci, streptococci (40% of dog bites), and anaerobes 7, 1
• Avoid first-generation cephalosporins (e.g., cephalexin) as they have poor activity against Pasteurella multocida 6

Alternative regimens if amoxicillin-clavulanate cannot be used:

• Doxycycline 100 mg twice daily (if age-appropriate, generally >8 years) has excellent activity against Pasteurella 1
• For penicillin allergy: fluoroquinolones with anaerobic coverage (though use in children requires careful consideration) 1
• IV options for severe infections: ampicillin-sulbactam, piperacillin-tazobactam, second-generation cephalosporins, or carbapenems 1, 6

Tetanus Prophylaxis

• Administer tetanus toxoid if the child has not received vaccination within the past 10 years 1
• Use Tdap (tetanus, diphtheria, pertussis) if not previously given; otherwise use Td 1

Rabies Risk Assessment and Management

The dog's availability for observation determines the rabies prophylaxis approach:

If the dog is healthy and available for observation:

• Confine and observe the dog for 10 days without administering rabies vaccine during the observation period 7, 1
• A healthy dog that remains alive and healthy for 10 days would not have been shedding rabies virus at the time of the bite 1
• The dog should be evaluated by a veterinarian at the first sign of illness during confinement 7
• Begin rabies post-exposure prophylaxis (PEP) only if the dog develops signs suggestive of rabies (behavioral changes, paralysis, excessive salivation, aggression, neurological signs) during the 10-day observation 7, 1
• If signs develop, the animal should be euthanized immediately and its head submitted for laboratory testing while simultaneously initiating PEP 7, 1

If the dog is stray, unwanted, or cannot be observed:

• The dog may be euthanized immediately and the head submitted for rabies examination 7
• Initiate rabies PEP immediately without waiting for test results 1, 2

Complete rabies PEP regimen (if indicated):

• For previously unvaccinated children: administer both human rabies immune globulin (HRIG) at 20 IU/kg body weight on day 0 AND a 4-dose vaccine series on days 0,3,7, and 14 1, 2
• Infiltrate the full calculated dose of HRIG around and into the wound(s) if anatomically feasible, with any remaining volume injected intramuscularly at a site distant from vaccine administration 1, 2
• Never administer HRIG in the same syringe or at the same anatomical site as the vaccine 1, 2
• Consult local health officials to determine regional rabies epidemiology and confirm need for PEP 1, 2, 3

Follow-Up Evaluation

All pediatric dog bite patients require close follow-up:

• See the child in follow-up within 24-48 hours to assess for signs of infection and evaluate wound healing progress 1, 6
• Elevate the injured body part to accelerate healing 6
• Consider hospitalization if infection progresses despite appropriate antimicrobial therapy, if there is systemic infection, rapidly progressing infection, or deep tissue involvement 1, 6

Special Considerations for Children

Hand wounds carry the highest infection risk:

• Hand wounds require special attention due to higher risk of infection (up to 25% infection rate overall for dog bites) and functional complications including septic arthritis, osteomyelitis, and tendonitis 1, 6, 5
• Deep wounds near joints or bones must be carefully evaluated for potential penetration of periosteum or joint capsule 1

Facial injuries are most common in children:

• Children are at highest risk for dog bites, with facial injuries being particularly prevalent due to their height relative to dogs 4
• Facial wounds can pose difficult reconstructive problems and require aggressive management for optimal cosmetic outcomes 4

Critical Pitfalls to Avoid

• Do not withhold rabies PEP while waiting for the 10-day observation period to complete if the dog is unavailable for observation or shows any signs of illness 1
• Do not use first-generation cephalosporins, penicillinase-resistant penicillins alone, or clindamycin monotherapy—these have poor or absent activity against Pasteurella multocida 6
• Do not rely solely on topical antibiotics without systemic coverage for moderate-to-severe wounds 6
• Do not delay treatment, as this can lead to complications such as septic arthritis, osteomyelitis, or tendonitis 6
• Do not close heavily contaminated wounds or hand wounds 1, 4