A bite in the playroom: managing human bites in child care settings

Question 1

What is the approximate incidence of biting in a child care setting with full time enrollment of 60 children younger than 3yo?

Answer 1

1 biting episode per day

1 every 8-10 weeks breaking the skin

Question 2

Administrative recommendations for biting

Answer 2

1. Should have written policies
2. Staff should be trained in the proper care of bite wounds
3. First aid equipment should be available on site
4. All parents and personnel should be given information on blood-borne viruses
5. Parents should be proactively informed that if a serious bite results in significant blood exposure parents of both children will be informed
6. Testing for HBV, HIV, or HCV cannot be a prerequisite for admission to child care
7. Children cannot be excluded from child care because of HBV, HCV, or HIV
8. Care of a child who is a known HBV carrier and exhibits frequent aggressive biting should be assessed on an individual basis by the MD and public health authority

Question 3

What are measures that may help decrease biting incidents?

Answer 3

1. Avoidance of stressful situations, frustrations, and conflicts
2. provision of age-appropriate small group activities
3. Observation of how, when, and why a child bites to help guide management
4. Paying attention first to the victim, not the biter
5. Firm statements to the biter that this is not acceptable behavior and will not be tolerated
6. Directing the biter to appropriate activities
7. Positive reinforcement of appropriate behavior
8. Collaboration with the family

Question 4

What are some measures to prevent continued frequent aggressive biting?

Answer 4

1. Specialist advice in behavior modification and therapy specifically tailored to the needs of the individual child may be indicated
2. Temporary exclusion from the centre or placement in an alternative type of centre may be required

Question 5

What are some recommendations to prevent HBV transmission in child care setting?

Answer 5

1. All child care centre staff should be immunized against HBV
2. Parents of children attending child care should be encouraged to immunize their children against HBV
3. If a child is a known carrier all children and staff should be immunized against HBV without revealing the identity of the infected child

Question 6

What are some recommendations to prevent HIV transmission in child care settings?

Answer 6

1. Decisions about child care for HIV infected children should be made by the parents in consultation with the MD
2. Parents do NOT need to disclose their child’s HIV status
3. If child’s parents choose to inform the child care centre of their child’s HIV status this information should be shared with the minimum number of people, kept in confidence, and other parents should NOT be informed

Question 7

What should you do if a bite occurs and the skin is NOT broken?

Answer 7

Clean with soap and water and apply a cool compress

Soothe the child

Question 8

What should you do if a bite occurs and the skin IS broken?

Answer 8

1. Allow the wound to bleed gently without squeezing.
2. Clean the wound carefully with soap and water and apply a mild antiseptic
3. An official report should be written and filed
4. Both parents (biter and bitten child) should be notified within 2h
5. The bite should be reported to public health
6. Observe the wound and if redness or swelling occurs consult an MD

Question 9

What general medical evaluation should occur for a child referred for a bite that breaks the skin?

Answer 9

Review and update tetanus status

Question 10

When should prophylactic antibiotics be considered in the context of a bite that breaks the skin?

Answer 10

1. moderate or severe tissue damage
2. deep puncture wounds
3. bite to the face that is more than simple superficial abrasions
4. bite to the hand that is more than simple superficial abrasions
5. bite to the foot that is more than simple superficial abrasions
6. bite to the genital area that is more than simple superficial abrasions

Question 11

What medical evaluation should occur for HBV exposure in a child referred for a bite that breaks the skin?

Answer 11

NOTE for below only if the bite breaks the skin

1. HBV carrier bites a non-immune or incompletely immunized child give HBV Ig 0.06mL/kg IM and HBV vaccine to the bitten child
2. If non-immune or incompletely immunized child bites a known HBV carrier give HBV Ig 0.06mL/kg IM and HBV vaccine to the biter
3. If non-immune child is bit by a child with unknown HBV status or if a non-immune child bites a child of unknown HBV status give the non-immune child HBV vaccine. No testing is required
4. If HBV status of both children is unknown do not test and give both children the HBV vaccine unless fully immunized already
5. Arrange f/u to complete the HBV vaccine series prn and for HBV serology @ 6m after known HBV exposures

Question 12

What medical evaluation should occur for HIV exposure in a child referred for a bite that breaks the skin?

Answer 12

1. If a child known to have HIV bites or is bitten by another child, in the absence of blood in the saliva or in the bite wound, PEP with antiretroviral agents is not indicated and there is no obligation to investigate or disclose the child’s HIV status. Confidentiality should be respected.
2. Consult a specialist to determine if PEP is needed (start within a few hours of the exposure, max 72h) if there is a deep bloody wound. Arrange f/u, including HIV serology @ 6wk, 3m, and 6m
3. Do not screen for HIV post biting incident at child care

Question 13

What medical evaluation should occur for HCV exposure in a child referred for a bite that breaks the skin?

Answer 13

1. If blood exposure is significant and one of the children is known to have HCV arrange for serology in 6m for the exposed child