Neonatal Nursing Care

Key Terms in Neonatal Nursing Care

• Ectopic: Refers to an abnormal location of an organ or tissue.

• Fading Puppy/Kitten Syndrome: A collection of symptoms often leading to death in neonates, generally attributed to environmental or medical issues.

• Fontanel: Soft spot on a baby's skull where the bones have not yet fused.

• Ileus: A condition characterized by the absence of normal digestive tract movement.

• Isoerythrolysis: A condition where antibodies in the mother’s colostrum destroy the neonate's red blood cells, causing anemia.

• Neonatal Period: Refers to the first few weeks of life for a newborn animal.

• Patent Urachus: A condition where the urachus does not close after birth, leading to urine leakage.

• Pectus excavatum: A congenital deformity characterized by a sunken chest.

• Spina bifida: A birth defect in which the spinal cord does not close properly.

• Strabismus: Misalignment of the eyes, which can affect vision.

• Titers: Tests that measure the presence and amount of antibodies in the blood.

• Whelping: The process of giving birth in dogs and other canines.

Overview of Neonatal Period

• Time Frame: The neonatal period covers the first two weeks of a puppy or kitten’s life, with some animals, such as cattle, defined as neonates from birth to weaning.

• Dependence: At this stage, neonates rely fully on their mothers for nutrition and care.

• Initial Conditions: Neonates are born with closed eyes (blind), closed ears (deaf), and lack teeth. They are neurologically underdeveloped, with underdeveloped kidneys until three weeks old and a liver that is immature until one month old.

• Vulnerability: Neonates are particularly susceptible to drug toxicity and biotransformation of drugs occurs more slowly in this age group.

Neonatal Appointments

• Age Consideration: Neonates are defined as less than four weeks old.

• Record Keeping: It is essential to identify individuals in medical records by distinguishing marks or ribbons.

• History Gathering: An accurate and thorough clinical history should be taken, including:
    - Information on all littermates and their health.
    - The number of ill animals in the litter.
    - The environment where the animals are raised.
    - Behavior observations of individual animals.
    - Body weight curves.
    - Duration and types of clinical signs observed.
    - Any medications previously administered.
    - History of disorders in previous litters or relatives.

• Bitch/Queen Information: Key details to obtain, if applicable:
    - Vaccination dates.
    - Estrous cycle details.
    - Breeding practices.
    - Any medications or supplements taken.
    - Problems experienced during pregnancy or birth.

First Veterinary Visit

• Post Whelping Check: This should occur within 24 hours after birth.

• Sick Animals: If one puppy or kitten is sick, it is advisable to bring in a healthy littermate to assess discrepancies.

• Unvaccinated Animals: Unvaccinated puppies and kittens should be taken through an alternate entry point to minimize disease exposure.

Neonatal Physical Examination

Cardiovascular Assessment

• Equipment: Pediatric stethoscope with a 2-cm bell for accurate readings.

• Heart Rates:
    - Kittens: 220-260 beats per minute (bpm)
    - Puppies: 200-250 bpm

Respiratory Assessment

• Breaths per Minute:
    - Kittens: 10-18 breaths per minute (brpm)
    - Puppies: 10-18 brpm

Temperature Regulation

• Thermometer: Use of a digital thermometer that measures as low as 85°F.

• Examination Conditions: Ensure a warm, clean surface for examination, as neonates cannot regulate body temperature for the first two weeks of life.

• Normal Body Temperatures:
    - Kittens: 97-98°F
    - Puppies: 95-97°F

Nutrition Requirements

• Caloric Needs: Neonates require 20 kcal metabolizable energy (ME) per 100 grams per day.

• Stomach Capacity: Approximately 4-5 mL per 100 grams.

Additional Physical Examination Details

• Hydration Status: Checked through oral mucous membranes rather than skin turgor.

• Body Hair: Should cover most of the body except for the ventral abdomen; sparse or absent hair can indicate genetic abnormalities or prematurity.

• Ventral Abdominal Skin:
    - Normal: Dark pink.
    - Cyanosis: Bluish color indicates poor oxygenation.
    - Dark red: Suggestive of sepsis.

• Body Symmetry: Check for signs of abnormalities.

• Head Examination: Look for open fontanel, cleft palates, and bulging eyes associated with other conditions.

• Neck Examination: Check for gas in the esophagus, ectopic heart (heart located in an abnormal position), and goiter.

• Thoracic Examination:
    - Pectus Excavatum: A condition where the sternum is deformed, which can lead to respiratory distress and swimmer syndrome.

• Tail Examination: Assess for muscle tone, length, curliness, and kinks, indicative of innervation of distal pelvis.

Abdominal Examination

• Signs of Bloating: Can indicate abnormalities or defects in the abdominal wall.

• Patent Urachus: Check for urine leakage.

• Signs of Cannibalism: Common in cats, associated with various stressors, can be recognized as a source of mortality in neonates.
    - Not real cannibalism; often related to the umbilical cord.

• Genitals and Anus: Ensure patency by stimulating with a moist cotton ball.

• Dorsal Examination: Look for signs of spina bifida, which can cause incontinence and partial paralysis.

Developmental Landmarks

Week 1

• Sleep: Neonates sleep approximately 80% of their time.

• Nursing Frequency: Every 2-4 hours.

• Reflexes: Neuromuscular reflexes are absent.

• Motor Skills: Present, including head lifting by day three.

• Crawling: Achieved by one week.

• Vocalization and Response: Start to vocalize and respond to stimuli including odor, touch, and pain.

• Elimination: Initiated by the dam.

• Thermoregulation: Absent initially;
    - Birth Temperature: 95.4-97.3°F, rising during the first week.
    - Heart Rate at Birth: 160-200 bpm.
    - Respiratory Rate at Birth: 10-20 brpm.

• Umbilical Cord: Dries within the first day and falls off between days 2-4.

• Sex Determination: In kittens, greater anogenital distance in males than in females.

Week 2

• Crawling: Ability to crawl begins.

• Body Temperature: Increases toward adult levels.

• Weight Gain: Neonates should double their birth weight by:
    - Kittens: 7-10 days.
    - Puppies: 10-12 days.

• Eye Development:
    - Eyes begin to open between days 7-12.
    - Corneas increase in water content, with normal vision developing after four weeks.
    - Strabismus noted during this period, with no pupillary light reflex until after four weeks.

• Ear Development: Ear canals open between days 6-17, with functional hearing developing around four to six weeks.

Maternal and Patient Sample Handling

Blood Sample Collection

• Method: Preferably from the jugular vein.

• Sample Volume: Less than 10% of circulating volume/week.
    - For a 250-gram puppy, this translates to:
      -
  $ext{Max blood volume} = 2.5 ext{ mL/week}$
    - A single drop of blood equals 0.1 mL.

• Appropriate Tubes: Sizes will depend on breed-specific newborn weights.
    - Boston Terrier newborn: 220 g; Greyhound newborn: 500-600 g.

Urine Sample Collection

• Techniques:
    - Stimulate to urinate by gently expressing bladder; cystocentesis is discouraged.

• Daily Output: About 25 mL/kg for kittens.

Imaging Techniques

• Ultrasound: Conducted using a 7.5-MHz transducer.

• Radiography: Requires high-detail emulsifying screens and single-emulsion films, ensuring no whole-body imaging is done and reducing kV by half compared to adults.

Routine Neonatal Maintenance

• Initial Care: Generally, healthy neonatal puppies and kittens require minimal direct care during their first weeks, as healthy mothers typically manage their needs.

• Owner Responsibilities: New owners must understand the importance of:
    - Providing proper nutrition.
    - Administering preventative medications and vaccines to prevent fatal diseases and maintain health.
    - Deworming at two weeks with pyrantel pamoate every two weeks for three doses.
    - Scheduling the first wellness exam and vaccinations between 6-8 weeks.
    - Re-checks at intervals of every three to four weeks.
    - Addressing behavioral problems early to prevent potential surrender or euthanasia.

Common Neonatal Diseases Requiring Immediate Attention

• Hypothermia: Abnormally low body temperature.

• Dehydration: Loss of fluids critical for health.

• Low Blood Sugar (Hypoglycemia): Insufficient glucose supply affecting energy levels.

• Neonatal Isoerythrolysis: Destruction of neonate’s red blood cells due to maternal antibodies.

• Malnutrition: Insufficient nutrition and hydration impacting growth and health.

Further Details on Hypothermia

Normal Body Temperature

• Development:
    - Neonates initially shiver and vasoconstrict by 6-8 days and reach similar temperature regulation as adults by six weeks.

• Critical Temperatures:
    - Birth: <94°F,
    - 1-3 days: <96°F,
    - 1 week: <99°F

Symptoms

• Signs:
    - Heart rate drops, GI motility slows leading to ileus.
    - Feeding must be avoided under 94°F to prevent aspiration pneumonia and bloat.
    - Impaired cellular immune function increases infection risks.

• Specific Indicators:
    - 88-94°F: Symptoms include restlessness, continuous crying, and cool integuments.
    - 78-85°F: Animals become lethargic, uncoordinated; heart rate falls below 50 bpm.
    - Below 70°F: Neonates may appear dead but require stimulation.
    - Hypoxia: Contributes to hypothermia due to low oxygen levels.

Treatment

• Oxygen: Provide as needed.

• Heat Support: Increase body temperature by 2°F per hour; more than 4°F/hour elevation is often fatal.

• Medicines: No oral medications until gut sounds are audible and body temperature is normalized.

Neonatal Dehydration

Causes

• Often caused by disease processes or fluid imbalances and reflects the immaturity of the renal system.

Treatment

• Fluid Administration: Warm fluids to 98-99°F, administered at a maintenance rate of 6 mL/kg/hr.

• Deficit Calculation: Add 50% to maintenance for deficits:
  ext{Deficit (mL)} = rac{(BW imes ext{% dehydrated})}{2}

• Bolus Protocol: Administer boluses of 3.3 mL/100 g over 5-10 minutes.

• Administration Routes:
    - IV or IO (by an 18-19g needle in the femur or tibia), IP, or SQ (less effective).

Hypoglycemia

Causes

• Linked to an immature liver, which affects gluconeogenesis and limits glycogen stores.

Symptoms

• Healthy neonates can typically maintain normal blood glucose levels for up to 24 hours post-birth without nursing.

• Adult blood glucose level ranges:
    - Dogs: 60-111 mg/dL (52-127 mg/dL for 1-3 days).
    - Cats: 80-120 mg/dL (75-154 mg/dL for 1-3 days).

• Failure to nurse within the first 24-36 hours can lead to hypoglycemia. A critical threshold for levels is below 30 mg/dL, which presents with symptoms such as tremors, crying, and irritability. Severe cases can lead to lethargy and coma.

Treatment

• Dextrose Solution: Administer 0.5 - 1 g/kg in a 5-10% solution slowly via IV/IO.

• Oral Dextrose: Apply 1-2 mL of 5-15% dextrose solution on the mucous membranes in the mouth, but avoid SQ routes to prevent tissue damage.

• Monitoring: Continuously monitor blood glucose levels as part of treatment.

Neonatal Isoerythrolysis

Causes

• Particularly in cats, neonates with Type A blood have low titers of antibodies against Type B red blood cells, while those with Type B blood possess high titers against Type A.

• The incidence is notable with Type A being most common in the U.S. (94%-99% DSH and long-haired breeds).

• Neonates receive antibodies through colostrum from queens with Type B blood, leading to incompatibility.

Symptoms

• Rarely displays initial symptoms; can rapidly progress to jaundice and death within the first two days.

• Notable signs include tail tip necrosis that may appear between days 10-14.

Treatment

• Testing: Kittens should be tested at birth for compatibility.

• Management: Incompatible kittens should be removed within the first day and either fostered or hand-raised before returning to the mother.

Malnutrition

Management Strategies

• Ensure hydration and adequate nutrition through milk replacement.
    - Mother's milk contains bile salt-activated lipase for optimal digestion.
    - Use bottle replacements with caution due to high lactose content which can cause diarrhea.
    - Regularly stimulate urination and defecation following feedings until 16-21 days old.

Tube Feeding Techniques

Guidelines

• Ensure the formula is at normal body temperature.

• Use a 5 French feeding tube, measuring the distance from the tip of the nose to the last rib to determine length.

Feeding Protocol

• Mark the tube at 75% of the determined length and insert gently to this mark.

• Check for negative pressure (should pull back on the plunger) before feeding slowly.

• General volume: approximately 5 mL per feeding for 160 g puppies or kittens.

Fading Puppy/Kitten Syndrome

Causes

• Primarily poor management practices affecting hygiene, temperature, humidity, overcrowded conditions, introduction of new animals, exposure to chemical toxins, or improper medication use.

• Malnutrition due to inadequate care of the mother or neonate.

• Environmental conditions that are inappropriate for healthy development.

• Congenital or genetic defects that predispose to weakness.

• Infections leading to weakness or mortality.

Symptoms

• Signs include anorexia, lethargy, and emaciation.

• Birth defects may be evident, with some neonates exhibiting weakness at birth, leading to stillbirth or subsequent death.

• Necropsy is recommended for cases with undetermined cause.

Orphan Puppy/Kitten Care

Required Materials

• Essentials include warm clean bedding, milk bottles with nipples, feeding tubes, syringes, a gram scale for monitoring weight, cotton balls, heat sources, and hand sanitizing materials.

Care & Treatment Protocols

• Weigh or record daily to monitor growth, and maintain an appropriate ambient temperature, with kittens unable to regulate body temperature until 28 days old.
    - First week: maintain 84°-90°F with 55-60% humidity.
    - Second week: decrease to 73°-84°F.
    - Third week: maintain around 73.4°-79°F.

• Ensure housing is clean and dry to promote health.

• Provide proper nutrition and supplementation.

• Stimulate urination and defecation after each feeding until the age of 16-21 days.

Common Pitfalls in Care

• Mismanagement leading to over- or under-feeding of neonates.

• Avoid homemade diets that aren't proven; rely on balanced commercial diets, as fluid needs must be met.

• Watch for energy density that could require additional SQ fluid supplementation.

• Be cautious of housing overcrowded with sick animals.

Infant and Pediatric Development Periods

Infant Period

• Dogs: Ranges from 2-6 weeks; significant behavioral development occurs, including socializing with mother and siblings, opening of ears and eyes, first steps, eruption of teeth, initiation of weaning, and starting to eat solid food.

• Ducklings: Require supervision while swimming.

Pediatric Period

• Canine Development Timeline:
    - Ideal adoption age: 8-10 weeks.
    - Eruption of adult incisors: 3-5 months.
    - Permanent canines/premolars erupt: 4-6 months.
    - Adult molars erupt: 5-7 months.
    - All 42 permanent teeth expected by 6 months.

• Feline Development Timeline:
    - Weight gain in kittens should be around 1 lb per month until 6 months.
    - 14-16 weeks: administer rabies vaccine.
    - Adult incisors emerge between 3-4 months.
    - Adult canines and premolars erupt between 4-6 months.
    - Total of 30 permanent teeth expected by 6 months.

Pediatric Appointments

At 6-8 Weeks

• Setup: Create individual patient information with signalment and take thorough histories akin to neonatal appointments.

• Examinations: Check for congenital defects and monitor development, and conduct diagnostics including fecal tests and blood tests for FeLV and FIV, ensuring follow-ups every 3-4 weeks for ongoing health management.

Spay/Neuter Considerations

Benefits of Spaying/Neutering

• Eliminates unwanted pregnancies.

• Overall benefits for male cats include reduced aggressive behaviors.

• For female cats, it eliminates/reduces behaviors during heat and reduces risks for ovarian cancer, pyometra, and mammary carcinoma.

Risks of Surgical Procedures

• Risks include postoperative complications and surgical complications, which must be considered due to the sentience of the animals involved.

• Research indicates mixed correlations between spaying/neutering and certain health risks, particularly in dogs.

Timing Considerations

• Kittens become sexually mature as early as 5 months.

• Female Dogs:
    - Spaying before the first heat cycle reduces factors associated with mammary cancers (<1% risk).
    - Post 2+ heats carry increased risks (20% develop neoplasia).

• Male Dogs: Typically neutered at around 6 months but may have better behavior when retained with gonadal hormones longer, correlating with certain health issues later on.