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Medical Conditions



Bites (Human and Animal)

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Human Bites

Biting is very common among young children but usually does not lead to serious infectious disease issues. If the skin is broken, bacteria introduced into the wound can cause a tissue infection that needs to be treated by a health care provider. Blood-borne diseases could be a concern if the biter breaks the skin and blood is drawn into the mouth or if the biter has bleeding gums or mouth sores, which transfers germs to the bitten person. Hepatitis B virus, HIV, and hepatitis C virus are examples of blood-borne disease-causing germs. However, the risk of transmission of these viruses is very low in child care and school settings. For HIV, there have not been any episodes of transmission in a child care setting or school.

What are the roles of the teacher/caregiver and the family?

  • Provide first aid to the child who was bitten by washing any broken skin and applying a cold compress to any bruise.

  • Notify the parent/guardian of the biter and of the bitten child.

  • Recommend a pediatric health care provider visit if the skin is broken because, in some cases, preventive antibiotics may be indicated.

  • Initially focus on the injured child, rather than on the child who did the biting. Later, try to determine why the biting happened. See if the situation could be prevented next time before biting occurs. Giving the child attention before the child bites helps. Avoid giving the biter attention when biting happens. Before biting happens, suggest an alternative acceptable behavior to the child who is biting. Suggest the child use words to express frustration or anger. Offer a harmless, vigorous physical activity the child can do when frustrated or angry. If the biting behavior of a child is repetitive despite several weeks of using these suggested measures, consider seeking additional professional help to develop an effective management plan. Consult the program’s mental health consultant and your health consultant (if your program has one) or the child’s health care provider. Use the following resources:

    • American Academy of Pediatrics (AAP) Healthy Child Care America Health and Safety E-News for Caregivers and Teachers, “Knowing What to Do if Children Act Out or Hurt Others” (www.healthychildcare.org/ENewsOct06.html#actOut).

    • Play Nicely, a free video for parents and early childhood educators about how to handle aggressive behavior in young children (http://playnicely.vueinnovations.com).

    • Early Childhood Education Linkage System (ECELS) of the Pennsylvania Chapter of the AAP (www.ecels-healthychildcarepa.org). Search for “challenging behavior” to locate resources, including a 2016-recorded webinar, a self-learning module, and model policies and procedures. The ECELS materials may be used at no cost. Pennsylvania early educators may pay a fee to have ECELS staff review their responses to assessment questions and obtain state-authorized training credits.

Exclude from group setting?

No, unless the child who was bitten or the child who bit the other child is unable to participate and staff members determine they cannot care for the child without compromising their ability to care for the health and safety of the other children in the group.

Readmit to group setting?

Yes, when all the following criteria are met:

When the child is able to participate and staff members determine they can care for the child without compromising their ability to care for the health and safety of the other children in the group.

Animal Bites/Rabies

Animal bites are common. Dog bites account for 90% of bite wounds, perhaps because dogs are very common pets and have a great deal of contact with humans. Many adults allow interactions between children and dogs. Children can behave unpredictably and dogs have normal protective instincts. The combination can result in provoked injuries for children. The rate of infection after dog bites is 5%. After cat bites, the rate of infection is as high as 80%.

An animal bite that breaks or punctures the skin needs immediate wound care to reduce the risk of infection. The wound should be washed out with water and then promptly evaluated by a health care provider for 2 reasons.

  • First, there is a chance of developing a bacterial infection. The longer the animal’s mouth germs stay in the wound, the greater the potential of infection that will need antibiotics. Some wounds require preventive antibiotics. The health care provider needs to decide whether the wound should be left open or closed with materials such as special tape or stitches. All animal bites need to be watched closely for signs of infection until they are fully healed.

  • Second, the situation in which the animal bite occurred should be evaluated for the possibility of transmission of rabies. Bites of some wild animals (eg, bats, raccoons, skunks, foxes, coyotes, bobcats) and some stray and unvaccinated pet dogs and cats may transmit rabies virus. Wild animals should not be kept or allowed to visit child care facilities or schools. Children should not have direct contact with wild animals in any setting. Rodents (mice, squirrels, and gerbils), bats, and rabbits rarely carry rabies (woodchucks are an exception). Rabies has occurred in animals in a petting zoo, pet store, animal shelter, and county fair.

    Rabies is a very serious viral infection that infects the nervous system. The virus spreads from a rabies-infected animal’s saliva into the bite site. Rabies is usually transmitted by the bite of wild animals. However, the virus can be spread by unimmunized pets and, in rare cases, immunized pets that have been infected with the rabies virus. The possibility that an animal is infected with rabies is greatest when the animal is unimmunized and the bite was unprovoked. If a pet or wild animal bites and breaks the skin, the situation requires urgent medical attention. Because the rabies virus spreads from the animal’s saliva and enters the bite site, the bite wound should be immediately and thoroughly cleaned as soon as possible. The bitten person should be referred for immediate evaluation by a health care provider. If possible, the animal should be observed by a veterinarian for signs of rabies.

    Report all suspected exposure to rabies promptly to public health authorities and be sure health professionals are involved in deciding about appropriate treatment right away. Signs or symptoms of rabies in humans include anxiety, difficulty swallowing, seizures, and paralysis. Once signs or symptoms develop, rabies is nearly always a fatal disease.

How do you control rabies?

  • By immunizing dogs and cats with rabies vaccination

  • By avoiding contact with wild or stray animals, particularly those acting peculiarly or aggressively

  • By not allowing children to touch dead animals

What are the roles of the teacher/caregiver and the family?

  • Provide first aid by washing any broken skin and applying a cold compress to any bruise.

  • Teach children to avoid contact with stray, wild, or dead animals.

  • Make sure any animal in a child’s environment is healthy and a suitable pet for children, fully immunized, and on a flea-, tick-, and worm-control program (when appropriate). If a pet in on-site at the child care center, a time-specified certificate from a veterinarian indicating the pet meets these conditions should be on file.

  • All contact between animals and children should be supervised by a teacher/caregiver.

  • Contact a health professional if

    • A child or an adult is bitten by a pet or an unknown or wild animal.

    • There is redness, swelling, drainage, or pain at the site of the bite.

    • The skin is broken.

    • A bat is found in a room with sleeping children or if children have touched a bat. Bat bites are not easily detected.

  • If you can do so safely, capture or confine the animal for an evaluation. If you cannot make the animal available for evaluation, note the size, appearance, and any distinguishing characteristics of the animal (eg, if it was wearing a collar; if so, if it had tags).

  • If there is a chance a person has been exposed to rabies, arrange for urgent medical attention.

Exclude from group setting?

No, unless the child is unable to participate and staff members determine they cannot care for the child without compromising their ability to care for the health and safety of the other children in the group.

Readmit to group setting?

Yes, when all the following criteria are met:

When the child is able to participate and staff members determine they can care for the child without compromising their ability to care for the health and safety of the other children in the group.

Pets and Interactions of Children With Animals

Pets in child care facilities and contact with animals brought to the facility or during visits to farms, petting zoos, and breeding facilities offer rich opportunities for learning. However, they pose risks that must be addressed. Many pet owners and teachers/caregivers are unaware of the potential risks posed by exposure to animals. Most people are unaware that animals that appear healthy may carry disease-causing germs. Infectious diseases, injuries, and other health problems can occur after contact with animals.

Cats and kittens can carry disease-causing germs without showing signs of illness themselves. Some human diseases associated with cats are Campylobacter infection, a cause of diarrhea; cat-scratch disease, a cause of a generalized illness from a scratch or bite that transmits bacteria (Bartonella henselae), carried by about 40% of cats (especially kittens) without symptoms; mites, a cause of itching and raised bumps on human skin from mites feeding on the skin; and intestinal parasites. For more information about diseases spread by cats, go to www.cdc.gov/healthypets/pets/cats.html.

Planning Interactions of Children With Animals

Pediatric health care providers, veterinarians, and other health professionals should be consulted about proper animal selection and care, as well as how to minimize risks to infants and children. Pet size and temperament should be matched to the age and behavior of a child. Acquisition and ownership of nontraditional pets should be discouraged in any setting with young children or other high-risk individuals. Information, in multiple languages, about guidelines for safe pet selection and appropriate handling are available (www.cdc.gov/zoonotic/gi; www.cdc.gov/healthypets; www.cdc.gov/Features/HealthyPets).

Infections From Animal Contact

Individual cases and outbreaks associated with Salmonella species, Escherichia coli O157:H7, and Cryptosporidium species are among the most commonly reported infections after animal exposure. Many recent outbreaks of diarrhea or vomiting diseases have been linked to contact with ruminant livestock (cattle, sheep, and goats); poultry, including chicks, chickens, and ducks; reptiles, especially small turtles; amphibians; and rodents. Other domestic and wild animals are potential sources of illness. Infected animals often are asymptomatic carriers of germs that can cause disease in humans. Direct contact with animals (especially young animals), contamination of the environment or food or water sources, and inadequate hand hygiene facilities at animal exhibits have been responsible for infection of people who visit these settings.

In addition to direct contact, indirect contact with animals can be a source of illness (eg, contact with water in a reptile tank, contaminated barriers or fencing used to contain animals). Salmonella infections are an example of an infection associated with direct contact with certain animals and indirect contact via animal products. The US Food and Drug Administration ban on commercial distribution of turtles with shells less than 4 inches long in 1975 resulted in a sustained reduction of human Salmonella infections. Salmonella infections have also been described as a result of contact with aquatic frogs, iguanas, hedgehogs, hamsters, mice, and other rodents and with poultry or backyard flocks, including chicks, chickens, ducks, ducklings, geese, goslings, and turkeys.

Some pet products and contact with environments that have been occupied by animals are sources of Salmonella infections, especially among young children. Raw and dry dog and cat food and pet treats, such as pig ears and feeder rodents (live and frozen) used to feed reptiles and amphibians, have been associated with Salmonella infections. Pet food should not be handled where human food is prepared. Food bowls should be carefully cleaned and disinfected after contact with pet foods. Be sure to practice careful hand hygiene after handling animal foods or treats or touching anything in the animal’s environment. For more details, go to www.cdc.gov/zoonotic/gi.

Nontraditional pets pose a special risk of infection and injury. Most imported, nonnative animal species are caught in the wild rather than bred in captivity. These animals are held and transported in close contact with multiple other species. This increases the risk of spreading germs that can cause disease for humans and domestic animals. Some nonnative animals are brought into the United States illegally, bypassing rules established to reduce introduction of disease and potentially dangerous animals. Some species of nonnative animals may also be bred in captivity in North America.

The behavior of captive wildlife and wildlife hybrids cannot be predicted. From early life to fully grown, the physical and behavioral characteristics of animals can result in an increased risk of injuries to children. These potential risks are enhanced when these animals are cared for by people who do not fully understand how the animals spread disease and how to prevent it, animal behavior, and how to maintain appropriate facilities, environment, and nutrition for captive animals.

Among nontraditional pets, reptiles, amphibians, and poultry pose a particular risk because of high asymptomatic carriage rates of Salmonella species, the intermittent shedding of Salmonella organisms in their feces, and persistence of Salmonella organisms in the environment. In recent years, multiple large outbreaks of salmonellosis have been spread by contact with these animals.

Reptiles should not be kept as pets for children and should not be allowed in any child care program or school. Salmonella inhabits the gastrointestinal tract and, thus, the environment of reptiles. Therefore, any contact with reptiles or their habitat may cause Salmonella infection in children. Additionally, bites from reptiles may result in Salmonella or other bacterial infection.

Preventive Measures

Young children should always be supervised closely when in contact with animals at home or in public settings, including child care centers or schools. Children should be educated about appropriate human–animal interactions. Parents should be made aware of recommendations for prevention of human diseases and injuries from exposure to pets, including nontraditional pets and animals in the home, animals in public settings, and pet products, including food and pet treats. Pets and other animals should receive appropriate veterinary care from a licensed veterinarian who can provide preventive care, including vaccinations and parasite control, appropriate for the species.

Guidelines for Prevention of Human Diseases From Exposure to Pets, Nontraditional Pets, and Animals in Public Settings a,b

General

  • Always supervise children, especially children younger than 5 years, during interaction with animals

  • Wash hands immediately after contact with animals, animal products, feed or treats, or animal environments and after taking off dirty clothes or shoes; hands should be washed even when direct contact with an animal did not occur

  • Supervise hand washing for children younger than 5 years

  • Do not allow children to kiss animals or to eat, drink, or put objects or hands into their mouths after handling animals or while in animal areas

  • Do not permit nontraditional pets to roam or fly freely in the house or allow nontraditional or domestic pets to have contact with wild animals

  • Do not permit animals in areas where food or drink are stored, prepared, served, or consumed

  • Never bring wild animals home, and never adopt wild animals as pets

  • Teach children never to handle unfamiliar, wild, or domestic animals, even if animals appear friendly

  • Avoid rough play with animals to prevent scratches or bites

  • Pets and other animals should receive appropriate veterinary care from a licensed veterinarian who can provide preventive care, including vaccination and parasite control, appropriate for the species

  • Administer rabies vaccine to all dogs, cats, horses, and ferrets; livestock animals and horses with frequent human contact also should be up to date with all immunizations

  • Keep animals clean and free of intestinal parasites, fleas, ticks, mites, and lice

  • People at increased risk of infection or serious complications of salmonellosis and other enteric infections (eg, children younger than 5 years, people older than 65 years, and immunocompromised people) should avoid contact with high-risk animals (turtles and other reptiles; poultry, including chicks, chickens, ducklings, and ducks in backyard flocks; aquatic frogs and other amphibians; and farm animals) and animal-derived pet treats and pet foods

  • People at increased risk of infection or serious complications of lymphocytic choriomeningitis virus infections (eg, pregnant women and immunocompromised people) should avoid contact with rodents and rodent housing and bedding.

Animals Visiting Schools and Child-Care Facilities

  • Designate specific areas for animal contact

  • Display animals in enclosed cages or under appropriate restraint

  • Do not allow food in animal-contact areas

  • Always supervise children, especially those younger than 5 years, during interaction with animals

  • Obtain a certificate of veterinary inspection for visiting animals and/or proof of rabies immunization according to local or state requirements

  • Properly clean and disinfect all areas where animals have been present

  • Consult with parents or guardians to determine special considerations needed for children who are immunocom-promised or who have allergies or asthma

  • Animals not recommended in schools, child-care settings, hospitals, or nursing homes include nonhuman primates; inherently dangerous animals (lions, tigers, cougars, bears, wolf/dog hybrids), mammals at high risk of transmitting rabies (bats, raccoons, skunks, foxes, coyotes, and mongooses), aggressive animals or animals with unpredictable behavior; stray animals with unknown health history; venomous or toxin-producing spiders, insects, reptiles, and amphibians; and animals at higher risk for causing serious illness or injury, including reptiles, amphibians, or chicks, ducks, or other live poultry; and ferrets. Additionally, children younger than 5 years should not be allowed to have direct contact with these animals.

  • Farm animals are not appropriate in facilities with children younger than 5 years and should not be displayed to older children in school settings unless meticulous attention to personal hygiene can be ensured.

  • Ensure that people who provide animals for educational purposes are knowledgeable regarding animal handling and zoonotic disease issues

Public Settings

  • Venue operators must know about risks of disease and injury

  • Venue operators and staff must maintain a safe environment

  • Venue operators and staff must educate visitors about the risk of disease and injury and provide appropriate preventive measures

  • Venue operators and staff should be familiar with the recommendations detailed in the Compendium of Measures to Prevent Diseases Associated with Animals in Public Settings b

Animal Specific

  • Know that healthy animals can carry germs that can make people sick. People can become ill when they touch an animal, pick up an animal’s dropping, or enter an animal environment even if they don’t touch the animal

  • Children younger than 5 years, pregnant women, and immunocompromised people should avoid contact with reptiles, amphibians, rodents, ferrets, baby poultry (chicks, ducklings), preweaned calves, and any items that have been in contact with these animals or their environments

  • Reptiles, amphibians, rodents, ferrets, and baby poultry (chicks, ducklings) should be kept out of households that contain children younger than 5 years, pregnant women, immunocompromised people, people older than 65 years, or people with sickle cell disease and should not be allowed in child care centers or other facilities that house high-risk individuals (eg, nursing homes).

  • Reptiles, amphibians, rodents, and baby poultry should not be permitted to roam freely throughout a home or living area and should not be permitted in kitchens or other areas where food and drink is prepared, stored, served, or consumed

  • Animal cages or enclosures should not be cleaned in sinks or other areas used to store, prepare, serve, or consume food and drinks; These items should be cleaned outside the house if possible

  • Mammals at high risk of transmitting rabies (bats, raccoons, skunks, foxes, and coyotes) should not be touched

  • Disposable gloves should be used when cleaning fish aquariums, and aquarium water should not be disposed in sinks used for food preparation or for obtaining drinking water

  • Pregnant women and immunocompromised people should avoid contact with cat feces or soil contaminated with cat feces

Pickering LK, Marano N, Bocchini JA, Angulo FJ; American Academy of Pediatrics, Committee on Infectious Diseases. Exposure to nontraditional pets at home and to animals in public settings: risks to children. Pediatrics. 2008;122(4):876–886 (Reaffirmed June 2013).

For complete recommendations, see: National Association of State Public Health Veterinarians, Animal Contact Compendium Committee 2013. Compendium of measures to prevent disease associated with animals in public settings, 2013. J Am Vet Med Assoc. 2013;243(9):1270-1288.

Reprinted from Kimberlin DW, Brady MT, Jackson MA, Long SS, eds. Red Book: 2015 Report of the Committee on Infectious Diseases. Elk Grove Village, IL: American Academy of Pediatrics; 2015:219–224.

Listing of resources does not imply an endorsement by the American Academy of Pediatrics (AAP). The AAP is not responsible for the content of external resources. Information was current at the time of publication.

The information contained in this publication should not be used as a substitute for the medical care and advice of your pediatrician. There may be variations in treatment that your pediatrician may recommend based on individual facts and circumstances.

Quick Reference Sheet from Managing Infectious Diseases in Child Care and Schools: A Quick Reference Guide.

© 2017 American Academy of Pediatrics. All rights reserved.

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