How should a child be managed after a possible rabies exposure from an animal bite or scratch?

Management of Rabies Exposure in Children

Children with possible rabies exposure from an animal bite or scratch require immediate wound care followed by simultaneous administration of rabies immune globulin (RIG) and rabies vaccine, unless the child was previously fully vaccinated against rabies. 1, 2, 3

Immediate Wound Management (Within Minutes of Presentation)

Thoroughly wash and flush all bite wounds and scratches with soap and copious amounts of water for at least 15 minutes. 1, 2, 4 This is the single most critical intervention to reduce rabies transmission risk. 4

• Irrigate with dilute povidone-iodine solution after soap and water cleansing, as this provides additional virucidal activity. 1, 4
• Explore the wound for tendon or nerve damage and foreign bodies. 4
• Avoid suturing wounds when possible, particularly puncture wounds, hand bites, and cat bites, as closure increases infection risk. 4 Suturing should only be considered for cosmetically important areas like the face, weighing infection risk against cosmetic outcome. 1

Risk Assessment: Determine Need for Rabies Prophylaxis

The decision to initiate prophylaxis depends on the animal species, its availability for observation/testing, and local rabies epidemiology. 1, 3

High-Risk Exposures Requiring Immediate Prophylaxis:

• Wild carnivores (raccoons, skunks, foxes), bats, and primates: Initiate prophylaxis immediately without waiting for testing. 2, 3 Bats are particularly concerning as bites may be minor and unrecognized; any physical contact with a bat where bite/scratch cannot be excluded warrants prophylaxis. 3
• Stray or unwanted dogs, cats, or ferrets: May be euthanized immediately for testing, but begin prophylaxis without delay. 1
• Any animal that cannot be captured or observed: Begin prophylaxis immediately. 1, 3

Lower-Risk Exposures Allowing Observation:

• Healthy-appearing owned dogs, cats, or ferrets: Confine and observe for 10 days while withholding prophylaxis. 1 If the animal develops signs of rabies during observation, euthanize immediately and submit the brain for testing while initiating prophylaxis in the child. 1
• Small rodents (squirrels, rats, mice, hamsters) and lagomorphs (rabbits, hares): Rarely transmit rabies; consult local health department before initiating prophylaxis. 3

Rabies Post-Exposure Prophylaxis Protocol

For Previously Unvaccinated Children:

Administer both RIG and rabies vaccine simultaneously on day 0 at different anatomical sites. 1, 2, 3

Rabies Immune Globulin (RIG):

• Dose: 20 IU/kg body weight (applicable to all ages including infants). 1, 2, 3
• Infiltrate the full dose around and into the wound(s) if anatomically feasible. 1, 2, 3 This local infiltration is critical based on reports of prophylaxis failures when inadequate RIG was infiltrated at exposure sites. 1
• Inject any remaining volume intramuscularly at a site distant from the vaccine injection. 1, 2, 3
• RIG can be administered up to and including day 7 if not given initially, but never after day 7, as it will suppress the active antibody response to the vaccine. 1, 4, 3
• Never exceed the 20 IU/kg dose, as excess RIG partially suppresses active antibody production. 1, 4
• Never administer RIG in the same syringe or same anatomical site as the vaccine. 1

Rabies Vaccine:

• 5-dose series over 28 days: days 0,3,7,14, and 28. 2, 4, 3
• Use cell culture vaccines (HDCV, RVA, or PCEC). 1
• Administer intramuscularly in the deltoid area (or anterolateral thigh in young children). 1

For Previously Vaccinated Children:

Children who have completed a full pre-exposure or post-exposure rabies vaccination series with documented antibody response require vaccine only (no RIG): 2 doses on days 0 and 3. 1, 3

Additional Essential Measures

• Assess tetanus immunization status and administer booster if the child's last dose was >5 years ago (for contaminated wounds) or >10 years ago (for clean wounds). 1, 2, 4
• Consider antibiotic prophylaxis, particularly for high-risk wounds: cat bites, puncture wounds, hand wounds, or presentation >8-12 hours after injury. 2, 4 Amoxicillin-clavulanate is first-line. 5
• Report the incident immediately to the local health department. 1, 2

Critical Timing Considerations

Never delay rabies prophylaxis waiting for animal testing results if the animal is high-risk, unavailable, or confirmed rabid. 2, 4 Rabies has an incubation period typically of 2-6 weeks but can exceed 1 year in humans. 1, 3 Once clinical symptoms develop, rabies is nearly 100% fatal. 6, 7

Prophylaxis should be initiated regardless of time elapsed since exposure, provided clinical rabies is not already present. 1, 4 Even delayed presentation warrants full prophylaxis.

Prophylaxis can only be discontinued if laboratory testing (direct fluorescent antibody test) confirms the animal was not rabid. 4

Common Pitfalls to Avoid

• Never delay prophylaxis in children bitten by wild animals, especially bats, while awaiting capture or testing. 2, 3 The animal is often unavailable, and delay can be fatal.
• Never administer RIG after day 7 of the vaccine series, as it interferes with active immunity development. 2, 4, 3
• Never give more than 20 IU/kg of RIG, even if there are multiple or large wounds, as excess suppresses vaccine response. 1, 4
• Do not assume a bat bite did not occur simply because the child or parent did not witness it. 3 Bat bites can be trivial and unrecognized; prophylaxis is indicated for any bat contact where exposure cannot be excluded.
• Do not withhold prophylaxis based on the animal's vaccination status alone if the species is high-risk or the period of virus shedding is unknown. 1, 3