V Vol. 22, No.
3 March 2000
CE Refereed Peer Review
FOCAL POINT
★ Many aspects of laboratory and
radiographic data in very young
animals differ from those of
adults; to address these
differences, a treatment plan
specifically suited to the
veterinary pediatric patient
must be developed.
KEY FACTS
■ Hematocrit decreases by more
than one third during the first
month of life.
■ Fluid requirements are greater in
neonates (60 to 180 ml/kg/day)
because of higher body surface
area, immature kidneys, and
higher respiratory rate leading
to greater fluid losses.
■ Several factors, including greater
surface area:body weight ratio
and lower amounts of body fat,
contribute to differences in
pharmacologic effectiveness.
■ Predicting a neonate’s response
to cardiovascular drugs is nearly
impossible.
Pediatric Critical Care
Medicine: Physiologic
Considerations
Tufts University
Maureen McMichael, DVM
Angell Memorial Animal Hospital, Boston, Massachusetts
Nishi Dhupa, BVM
ABSTRACT: Data on critical care of pediatric and neonatal veterinary patients are sparse. Physi-
cal examination differs from that of adult animals, and recognizing abnormal physiologic values
is crucial for accurate assessment. In addition, laboratory and radiographic data and fluid and
drug therapy can differ substantially between neonates and adults. Variations in hemodynamic
parameters in neonatal and pediatric patients make assessing and monitoring illness challeng-
ing. An awareness of their unique homeostasis aids in diagnosis and successful treatment.
I
n human medicine, neonates and infants have long been recognized to re-
quire monitoring and treatment that are specific to their unique biochemical
and physiologic systems. Although some data on critical care of neonates in
veterinary medicine are available,1 data for pediatric patients are still lacking.
In veterinary medicine, the term pediatric refers to animals younger than 6
months of age. The information presented here is limited to dogs and cats 0 to
12 weeks of age and focuses on the neonatal age range (0 to 2 weeks). The dif-
ferences between adult and pediatric physiology are discussed; and the effects of
these differences on the results of physical examination, interpretation of diag-
nostic tests, treatment principles, and pharmacology are described.
NUTRITION AND ENVIRONMENT
Neonates should have a strong suckle reflex and begin to show rooting behav-
ior (opening and closing the lips and moving the head in search for milk) shortly
after birth; they should nurse and sleep constantly during the first 2 to 3 weeks
of life. If the amount of milk being ingested is questionable, the neonate can be
weighed on a gram scale before and after nursing. In general, neonates that are
ingesting sufficient quantities of milk appear sleepy or nap consistently between
feedings. Constant crying, failure to gain weight, and reluctance to nurse indi-
cate inadequate intake. A healthy, vaccinated adult foster dog or cat is ideal for a
neonate that cannot ingest milk from the dam. Other alternatives include bottle-
Compendium March 2000 Small Animal/Exotics

and tube-feeding. A bottle nipple Normal Physiologic INTERPRETATION OF

for infants works best for puppies. DIAGNOSTIC TESTS
Tube-feeding can be done by
Parameters in Neonates
Accurate reference ranges for
experienced personnel (or trained ■ Heart rate: approximately 200 beats/min blood values in young animals of
owners) with a small (5-Fr for ■ Respiratory rate: approximately 15 to 35 different ages, especially kittens,
neonates weighing less than 300 breaths/min are generally lacking. In puppies,
g or 8- to 10-Fr for those weigh- ■ Temperature: approximately 96˚F to 97˚F the hematocrit decreases by more
ing more than 300 g) red rubber than one third (47.5% to 29.9%)
(100˚F by 1 to 2 weeks)
catheter.2 Young kittens should in the first 28 days of life6 (see
gain approximately 7 to 10 g/day, ■ Mean arterial blood pressure: 49 mm Hg Blood Reference Ranges). This de-
and young puppies should gain at 1 month (dogs) crease seems to be a response to
approximately 1 g/lb of anticipat- ■ Central venous pressure: 8 cm H2O at 1 the change from a relatively hy-
ed adult weight per day.3 Puppies month (dogs) poxic environment to one rich in
and kittens should be kept warm ■ Eyes open: 12 to 14 days oxygen. It may also partially result
(86˚F to 90˚F for the first week from lack of iron consumption
■ Normal vision: 21 to 28 days
of life) and dry on soft, clean (the nadir occurs at weaning).
bedding. They maintain their ■ Menace reflex: present at 2 to 3 months Puppies studied from 1 day
warmth by snuggling close to ■ Withdrawal reflex: present at 7 to 19 days through 56 days of age were
their mother and littermates. ■ Testes descended: 4 to 6 weeks (dogs) shown to have a mean leukocyte
■ Pain reflex: present at birth count of 12,000 cells/mm3 at 1
PHYSICAL EXAMINATION day of age, with no significant
Physical examination of neonates can be particularly changes in the total leukocyte count during this time.6
challenging because physiologic values differ from those The mean lymphocyte count peaked at 5000 cells/mm3
of adults (see Normal Physiologic Parameters in Neo- (45%) on day 21 and then began to decrease. The
nates). Recognizing abnormal values is crucial for an eosinophil count peaked at 800 cells/mm3 (5.5%) at
accurate assessment. The higher heart and respiratory day 7 and normalized by day 28. No significant
rates and the smaller thorax limit information gained changes were noted in the number of platelets during
from thoracic auscultation. In addition, a heart mur- this time. The increase in lymphocytes is believed to be
mur may be present for the first 3 months of life in related to increased antibody formation. Whether the
healthy animals. increased eosinophilia results from generalized bone
Normal body temperature in puppies is 96˚F to 97˚F marrow stimulation or a parasite-invoked response is
for the first 1 to 2 weeks of life and increases to 100˚F unclear.6
4
by 4 weeks of age. Normal body temperature in kittens A similar study in kittens showed a hematocrit nadir
is 98˚F at birth and increases to 100˚F after 1 week.2 of 27% at 4 to 6 weeks (weaning), which gradually in-
Systematic physical examination of a neonate should creased to 35% at 16 weeks. The leukocyte count in-
include checking for the presence of cleft palate, umbil- creased from 9600 cells/mm3 at birth to 23,000 cells/
ical hernia, umbilical infection, open fontanel, and mm 3 at 8 to 9 weeks of age and then decreased to
patent urogenital openings. Abdominal palpation usu- 19,700 cells/mm3 at 16 weeks.7
ally reveals fluid-filled bowel loops. To our knowledge, the accuracy of platelet function
Neurologic examination is limited because many tests in puppies and kittens has not been evaluated. On
neurologic parameters are immature at this age. Flexor day 1 of life, the prothrombin time is approximately
tone predominates in the first 4 days of life and can be 1.3 times the adult value in puppies and normalizes at
assessed by gently supporting the neonate upright and 0.9 times the adult value by day 7 (see Blood Reference
watching it fold into a comma shape. Extensor tone Ranges). The partial thromboplastin time on day 1 is
takes over 5 to 8 days later and manifests as stretching 1.8 times the adult value and decreases to 1.6 times the
or extension when the neonate is supported upright. A adult value by day 7. Levels of all clotting factors as
normal neonate vocalizes if it is removed from the dam well as antithrombin III are decreased at birth but in-
or manipulated. Pain sensation is present at birth, with- crease to normal levels by day 7.8
drawal reflexes develop by 1 week, and ambulation oc- The most significant abnormalities in the biochem-
curs in about 16 days. The eyes open between days 12 istry profile (see Biochemistry Profiles) of newborns are
and 14, but vision does not normalize for 3 to 4 weeks. increases in bilirubin and liver enzymes. Bilirubin was
The menace reflex may not be present for 2 to 3 only slightly increased at 0.5 mg/dl in newborn puppies
months.5 and 0.3 mg/dl in 2-week-old kittens. In one study,9

THORACIC AUSCULTATION ■ NORMAL BODY TEMPERATURE ■ HEMATOCRIT ■ LEUKOCYTE COUNT

Small Animal/Exotics
Blood Reference Ranges
Complete Blood Count for Dogs6
■ Hematocrit: 47% at birth; 29% at 28 days
■ Leukocyte count: 12,000 (×103/mm3)
■ Band count: 500 (×103/mm3); peaks on day 7
■ Lymphocyte count: 5000 (×103/mm3); peaks on
day 7
■ Eosinophil count: 800 (×103/mm3); peaks on day 7
Complete Blood Count for Cats7
■ Hematocrit: 35% at birth; 27% at 28 days
■ Leukocyte count: 9600 (×103/mm3) at birth;
23,680 (×103/mm3 ) at 8 weeks
■ Lymphocyte count: 10,170 (×103/mm3) at 8 weeks;
8700 (×103/mm3) at 16 weeks
■ Eosinophil count: 2280 (×103/mm3) at 8 weeks;
1000 (×103/mm3) at 16 weeks
Coagulation Parameters8
■ Prothrombin time: 1.3 times the adult value on
day 1
■ Partial thromboplastin time: 1.8 times the adult
value on day 1
■ Normal levels of clotting factors: day 7
serum alkaline phosphatase (ALP) and γ-glutamyltrans-
ferase (GGT) levels in puppies were 20 to 25 times
greater than those for adult dogs. In 2-week-old kittens,
the ALP was 2.5 times the adult value whereas GGT
was within the reference range for adults. The cause of
elevated liver enzymes is not fully understood, although
colostrum is a rich source of both ALP and GGT. In
fact, serum GGT levels are used as an indicator of suc-
cessful colostrum ingestion in many species. Albumin
levels do not reach adult values until 8 weeks of age.
Globulin values increase almost linearly with age,
which may be related to increases in antigen stimula-
tion.9 It is common for serum total protein, albumin,
blood urea nitrogen (BUN), and creatinine levels to be
lower than those of adults. The decreased BUN and
slightly increased bilirubin levels are believed to be
caused by immature hepatic function, and the de-
creased creatinine levels are believed to be caused by de-
creased muscle mass. Calcium and phosphorus are ele-
vated (as a result of bone growth), and cholesterol levels
are slightly decreased in puppies at birth (because of de-
creased hepatic synthesis).9 Bile acid levels are normal
BLOOD UREA NITROGEN ■ CREATININE ■ BLOOD PRESSURE ■ RADIOGRAPHIC INTERPRETATION
Compendium March 2000
Biochemistry Profiles
9
Dogs
■ Bilirubin: 0.5 mg/dl (range, 0.2–1.0; normal adult
range, 0–0.4)
■ Alkaline phosphatase: 3845 IU/L (range, 618–8760;
normal adult range, 4–107)
■ γ-Glutamyltransferase: 1111 IU/L (range,
163–3558; normal adult range, 0–7)
■ Total protein: 4.1 g/dl (range, 3.4–5.2; normal
adult range, 5.4–7.4)
■ Albumin: 1.8 g/dl at 2 to 4 weeks (range, 1.7–2.0;
normal adult range, 2.1–2.3)
■ Glucose: 88 mg/dl (range, 52–127; normal adult
range, 65–110)
Cats9
■ Bilirubin: 0.3 mg/dl (range, 0.1–1.0; normal adult
range, 0–0.2)
■ Alkaline phosphatase: 123 IU/L (range, 68–269;
normal adult range, 9–42)
■ γ-Glutamyltransferase: 1 IU/L (range, 0–3; normal
adult range, 0–4)
■ Total protein: 4.4 g/dl (range, 4.0–5.2; normal
adult range, 5.8–8.0)
■ Albumin: 2.1 g/dl (range, 2.0–2.4; normal adult
range, 2.3–3.0)
■ Glucose: 117 mg/dl (range, 76–129; normal adult
range, 63–144)
in puppies (below 15 µmol/L) at birth and kittens (be-
low 10 µmol/L) at 2 weeks of age.9 Because lactate lev-
els increase with decreased perfusion, measuring these
levels should be a helpful indicator of hypovolemia in
neonates. Unfortunately, normal lactate values for neo-
natal puppies and kittens are unavailable. Decreasing
serial lactate values can be used, however, as an assess-
ment of adequate perfusion.
Blood pressure is lower in neonates (mean arterial
pressure is only 49 mm Hg at 1 month of age) than in
adults.10 Central venous pressure is higher (average of 8
cm H2O at 1 month of age).10
Radiographic interpretation in pediatric patients poses
a challenge. The thymus appears as a triangular opacity
in the left cranial thorax on the ventrodorsal view (this is
often referred to as the sail sign) and may masquerade as
a mediastinal mass or lung consolidation in the cranio-
ventral thorax on the lateral view. In pediatric patients,
Compendium March 2000
the heart occupies more space
in the thoracic cavity than it
does in adults, causing it to
appear enlarged. The pul-
monary interstitium of new-
borns appears more opaque,
possibly because of the in-
creased water content of the
interstitial lung parenchyma.11
Because of an absence of
costochondral mineralization,
the liver appears to protrude Figure 1—Intraosseous catheterization of a newborn puppy.
further from under the rib
cage than in adults and may
be mistaken for hepatomegaly. The decreased mineraliza-
tion of the skeleton and open physes could mimic trau-
ma or disease.12 Loss of abdominal detail, primarily
caused by lack of fat, makes specific organ abnormalities
difficult to detect. A small amount of abdominal effusion
may be present normally and can hamper interpretation.
A review of pediatric imaging (e.g., ultrasonography) can
be found elsewhere in the literature.11
TREATMENT PRINCIPLES
Fluid requirements are substantially higher in neo-
nates than in adults. The higher percentage of total
body water (caused primarily by extracellular fluid),
greater surface area:body weight ratio, lack of body fat,
higher metabolic rate, and decreased ability of imma-
ture kidneys to concentrate urine are all contributing
factors.13 Maintenance rates ranging from 60 to 180
ml/kg/day have been suggested.14 However, overhydra-
tion is also serious because immature renal dilution
mechanisms can lead to respiratory distress secondary
to pulmonary edema. An accurate pediatric gram scale
is essential for monitoring fluid loads, and weighing the
patient at least every 12 hours is recommended. Base-
line chest radiographs are recommended to allow fol-
low-up comparison if overhydration is suspected. Be-
cause neonates have increased interstitial water and
their heart takes up more space in the thoracic cavity,
fluid overload is difficult to detect without a baseline
radiograph.
Hematocrit and total protein values can also be moni-
tored, bearing in mind that the hematocrit normally de-
creases from birth to 4 weeks of age; total protein is low-
er than that of adults; and blood volume is low, making
repeated phlebotomy a risk for anemia. If a jugular in-
travenous (IV) catheter can be placed, central venous
pressure can be monitored serially to determine intravas-
cular volume. The tip of the catheter should be just at
the right atrium, and such placement can be difficult in
neonates because many central catheters are too long.
FLUID REQUIREMENTS ■ CENTRAL VENOUS PRESSURE ■ INTRAOSSEOUS CATHETERIZATION
Small Animal/Exotics
Magrini 10 reported that the
average central venous pres-
sure in 1-month-old puppies
was 8 cm H 2 O compared
with 2 cm H2O in 9-month-
old pups. Thus central venous
pressure is 75% higher in
neonates than in adults; this
increase is believed to be relat-
ed to low venous compliance
and increased plasma volume.
Suggestions for accurate
volume resuscitation include
monitoring the hematocrit
and total protein; obtaining chest radiographs; carefully
auscultating the heart and lungs; measuring central ve-
nous pressure; and placing a urinary catheter, if possible,
to measure urine output. We measure the urinary
catheter from the point of insertion to just past the en-
trance of the urinary bladder and use a 3.5- to 5-Fr red
rubber catheter in most neonates. We suggest a fluid bo-
lus of 30 to 45 ml/kg as a starting point in moderately
to severely dehydrated animals, followed by continuous-
rate infusion of 80 to 100 ml/kg/day. Warm (37˚C) iso-
tonic crystalloid solution is the fluid of choice. Lactated
Ringer’s solution is recommended because lactate has
been shown to be a preferred metabolic fuel in the
neonatal brain during hypoglycemia.15
Intravenous catheterization is ideal but may not be
possible in dehydrated neonates. Intraosseous (IO)
catheterization of the proximal femur or humerus, with
either an 18- or 22-gauge spinal needle or an 18- to 25-
gauge hypodermic needle, has many advantages and
can be used for fluid administration as well as for blood
transfusion.16 The area is prepared in a sterile manner,
and the needle is inserted into the bone (parallel to the
long axis) and gently aspirated to check engagement
(Figure 1). Once the catheter is patent, it is secured
with a sterile bandage. Access to a rigid vessel during
severe hypovolemia can be lifesaving and is especially
suited to a neonate that still has a large ratio of red
marrow to yellow (fat) marrow. IV access must be es-
tablished as soon as possible to minimize the time that
the IO catheter is in place because complications with
catheterization tend to correlate with duration of use.17
Intraperitoneal infusion can be used when IV or IO ac-
cess is unavailable. Subcutaneous fluid administration is
not recommended because absorption during hypov-
olemia is minimal.
PHARMACOLOGY
Several factors make neonatal and pediatric drug ab-
sorption, distribution, metabolism, and elimination
Small Animal/Exotics
unique. The greater surface area:body weight ratio;
lower amount of body fat, total protein, and albumin
(the protein to which most drugs preferentially bind);
and reduced renal excretion caused by immature renal
tubules all contribute to variations in pharmacologic ef-
fectiveness. Clearance of drugs is decreased, and the
half-life of drugs excreted through the kidneys (primar-
ily water-soluble drugs) is decreased because of low
glomerular filtration rate and renal blood flow in
neonates. Hepatic enzyme systems, both phase I (oxida-
tion) and phase II (glucuronidation), are not fully func-
tional, and adult levels may not be attained until the
animal is 4.5 months of age.13,18,19 This results in higher
plasma levels for most drugs requiring hepatic metab-
olism for excretion.
Drugs that require hepatic metabolism for activation
have lower concentrations in plasma because of the im-
maturity of the hepatic enzyme systems. In addition,
oral drugs that undergo first-pass metabolism may ac-
cumulate at toxic levels in plasma if given at the adult
dose. The greater permeability of the blood–brain bar-
rier (a protective function that allows oxidizable sub-
strates, such as lactate, to be used for energy in emer-
gency situations) in neonates can cause wide variations
in drug distribution.13 Differences in maturity of the
Raise the Standard of Practice at Your Hospital with
STANDARDS of CARE
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EMERGENCY AND CRITICAL CARE MEDICINE®
Feline Hepatic Lipidosis
Sharon A. Center, DVM, DACVIM
Professor, Internal Medicine
College of Veterinary Medicine
Cornell University
H
epatic lipidosis (HL) is the most common cause of jaundice in cats
in North America. It develops primarily in obese cats that have
recently been anorectic. By definition, HL occurs when >50% of
hepatocytes accumulate excessive triglycerides (TGs), resulting in severe cell
vacuolation, cholestasis, and liver dysfunction. Left untreated, HL progresses
to metabolic dysregulation and death. Although HL was initially considered
an idiopathic disorder, it is now known to more commonly occur secondary
to other disease conditions.
DIAGNOSTIC CRITERIA
Historical Information
■ Age/gender/breed
predispositions. None.
■ Other historical considerations.
• Most commonly noted in
indoor, obese cats; most cats
have been anorectic for several
days or longer.
• On presentation, many have
lost at least 25% of pre-illness
body mass.
• Reclusiveness, affection, and
lethargy are typical owner
observations.
• Jaundiced mucous membranes,
nonpigmented skin or sclera, and
hyperbilirubinuria may be noted.
• Ptyalism, vomiting, diarrhea, or
Articles with this symbol provide
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Articles with both symbols cover canine
and feline topics.
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EMERGENCY AND CRITICAL CARE MEDICINE
constipation may occur as part of
primary disease, but these signs are
highly variable among cats.
Physical Examination
Findings
■ Unkempt and in poor condition,
jaundice, and weakness.
■ May have ptyalism without
provocation or on oropharyngeal
examination.
■ Variable dehydration attributed
to anorexia, vomiting, and
diarrhea.
■ Head and neck ventroflexion.
■ Cats show some signs
consistent with severe hepatic
encephalopathy (HE), such as
lethargy, collapse, obtundation,
and seizure activity.
■ Abdominal palpation discloses
nonpainful hepatomegaly.
■ Bleeding tendencies may be
evidenced by bruising around
venipuncture, palpation, or
ultrasound probe sites.
1
Compendium March 2000
autonomic nervous system can cause fluctuations in the
effectiveness of autonomic and cardiac drugs.
The route of drug delivery in puppies and kittens
must also be taken into account. In general, intestinal
flora is still developing and is very susceptible to dis-
ruption by oral antimicrobials. Oral drug absorption is
much higher in the first 24 to 72 hours of life because
of greater permeability of the gastrointestinal tract. Par-
enteral routes seem to be the most predictable, with IV
routes preferred over subcutaneous or intramuscular
routes.13
To our knowledge, studies have not been done on the
ideal dose level or interval in neonates for the drugs dis-
cussed. We suggest that when decreasing the dose, it
should be reduced by approximately 30% to 50%;
when widening the interval, it should be increased by 2
to 4 hours (e.g., from every 8 hours to every 12 hours).
Antimicrobials to Avoid in Neonates
The adverse effects of chloramphenicol on the
hematopoietic system include risk for polychromasia,
anisocytosis, target cells, and basophilic granulation of
leukocytes.13,20 Gentocin was initially believed to be safe
for neonates because elevations in BUN or creatinine
levels had not been reported, even when very high doses
(10 mg/kg/day) were administered. However, histologic
analysis of kidneys from neonatal puppies that had re-
ceived gentocin at 5 mg/kg/day for 7 days showed sig-
nificant drug accumulation and pathologic damage to
the renal cortex.21 Neonates have low levels of BUN
and creatinine and are isosthenuric for the first few
months of life; therefore, measurements of these pa-
rameters cannot be used to assess damage. The inability
to monitor toxicity makes gentocin an undesirable
...An exciting new publication
choice.21 Tetracyclines cause fetal skeletal retardation
and discoloration of the deciduous teeth. Quinolones,
from the trusted publishers of
■ Other abnormalities may be
Compendium. such as enrofloxacin, cause destructive lesions in the
cartilage of the long bones; this effect is particularly im-
found depending on the primary
disease.
Laboratory Findings
■ CBC.
• Poikilocytosis (i.e., irregular
RBC shapes) is common.
• A mild nonregenerative anemia
accompanies primary
Expert help fast in a portant in large-breed dogs.13
practical and readable format
underlying chronic
inflammatory disorders.
• Hemolytic anemia may
be severe and related to
hypophosphatemia or Heinz
body formation at presentation
and/or during treatment.
Antimicrobials Requiring Dose Adjustments
• Leukogram reflects underlying
disorders; HL is not a reactive
Each monthly* issue
process (no necrosis,
inflammation, fibrosis).
• Icteric plasma.
■ Biochemistry.
• Hyperbilirubinemia.
• ↑↑↑ALP, ↑↑ALT, ↑↑AST,
normal or mildly ↑γGT.
Discordance between
ALP–γGT is an important
is peer-reviewed Potentiated sulfonamides should be avoided in ane-
diagnostic feature. The ↑γGT
mic animals because of the ability of these drugs to in-
indicates necroinflammatory
VOLUME 2 • NUMBER 10
OCTOBER 2000
In each article you will find:
INSIDE THIS ISSUE:
Peer-Reviewed Articles on
HEPATIC DISORDERS
duce bone marrow suppression. (However, it must be
■ Danger signs
1 Feline Hepatic Lipidosis
6 Congenital Portosystemic Shunts
remembered that the hematocrit is lower in neonatal
10 Correction
■ Guidelines
puppies and kittens and thus anemia is not necessarily
■ Step-by-step tips
present.) The prolonged half-life of these drugs in
Standards of Care: Emergency neonates warrants administering a decreased dose or in-
and Critical Care Medicine. creasing the dosing interval.13 Metronidazole is the drug
Concise. Authoritative. Cur-
rent. No general practice should
of choice for giardiasis and anaerobic infections in
be without it. neonates. It has a decreased clearance and longer half-
life in these animals, and the dose should be decreased
or the dosing interval increased to avoid central ner-
HEPATIC METABOLISM ■ DRUG DELIVERY ROUTES
Compendium March 2000
vous system toxicity.13 β-Lactam antibiotics, such as
first-generation cephalosporins, seem to be safe in
neonates; however, an increased dose interval (i.e., ev-
ery 12 hours instead of every 8 hours) is suggested be-
cause of a prolonged half-life.
Anticonvulsants, Sedatives, and Analgesics
Neonates are particularly dependent on high respira-
tory rates to prevent hypoxia. High airway resistance
coupled with high oxygen demand results in a respira-
tory rate that is two to three times faster than that of
adults. Because of decreased myocardial contractility,
neonates depend on a relatively fast heart rate to main-
tain cardiac output.22 Drugs that significantly depress
the heart or respiratory rate should be avoided in neo-
nates. If agents that cause respiratory depression are used,
ventilation must be controlled.
Renal excretion of diazepam is decreased, which in-
creases the half-life.13 Thus a dose reduction is recom-
mended. Thiopental can cause an exaggerated response
in young animals because the decreased body fat and
decreased hepatic clearance result in higher blood lev-
els; a dose reduction is recommended for barbiturates.3
Opioids (e.g., fentanyl, butorphanol) are a good choice
because they are reversible; however, they can depress
heart and respiratory rates and thus should be moni-
tored carefully and titrated to effect.
Cardiovascular Drugs
Cardiovascular drugs pose a unique problem in the
pediatric population. Because of individual variations
in maturation of α- and β-receptors, predicting re-
sponse to these drugs is almost impossible. In critically
ill neonates, exogenous catecholamines are used to in-
crease contractility, heart rate, and blood pressure. Re-
sponse to treatment and monitoring of hemodynamic
variables are essential when using these drugs in
neonates. In general, elevations in the heart rate after
administration of dopamine, dobutamine, or isopro-
terenol are unpredictable until 9 to 10 weeks of age in
puppies.23 Response to atropine and lidocaine24,25 and
renal excretion of digoxin are diminished.13
CONCLUSION
Neonates pose significant challenges because of their
unique anatomic and physiologic characteristics. Adult
physical examination parameters, drug doses, and mon-
itoring parameters may not be suitable for this age
group. Veterinary medicine lacks published physiologic
values for neonates and pediatric patients. Kittens and
puppies are not simply little cats and dogs and should
not be treated as such. An awareness of their unique
homeostasis and response to disease can aid in the diag-
β-LACTAMS ■ OPIOIDS ■ CATECHOLAMINES
Small Animal/Exotics
nosis and successful treatment of disease syndromes.
Meticulous attention to detail is the only hope for mak-
ing advances in this area.
REFERENCES
1. Hoskins JD: Veterinary Pediatrics: Dogs and Cats from Birth
to Six Months. Philadelphia, WB Saunders Co, 1990.
2. Hoskins JD: Pediatric health care and management. Vet Clin
North Am Small Anim Pract 29:837–852, 1999.
3. Murtaugh RJ, Kaplan PM: Veterinary Emergency and Criti-
cal Care Medicine. St Louis, Mosby, 1992, p 464.
4. Johnson CA, Grace JA: Care of newborn puppies and kit-
tens. Kal Kan Forum 6:9, 1987.
5. Averill DR: The neurologic examination. Vet Clin North Am
Small Anim Pract 11:511, 1981.
6. Earl FL, Melveger BE, Wilson RL: The hemogram and bone
marrow profile of normal neonatal and weanling beagle
dogs. Lab Anim Sci 23:690–695, 1973.
7. Meyers-Wallen VN, Haskins ME, Patterson DF: Hemato-
logic values in healthy neonatal, weanling, and juvenile kit-
tens. Am J Vet Res 45:1322, 1984.
8. Massicotte P, Mitchell L, Andrew M: A comparative study
of coagulation systems in newborn animals. Pediatr Res
20:961–965, 1986.
9. Center SA, Hornbuckle WE, Hoskins JD: The liver and
pancreas, in Hoskins JD (ed): Veterinary Pediatrics: Dogs and
Cats from Birth to Six Months. Philadelphia, WB Saunders
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Compendium March 2000
About the Authors
When this article was submitted for publication, Drs.
McMichael and Dhupa were affiliated with the Depart-
ment of Clinical Sciences, School of Veterinary Medicine,
Tufts University, North Grafton, Massachusetts. Dr. Dhu-
pa is now affiliated with Angell Memorial Animal Hospital,
Boston, Massachusetts.