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EQUINE VETERINARY EDUCATION
Equine vet. Educ. (2013) 25 (11) 585-589
doi: 10.1111/eve.12064
Review Article
Assessment of the equine neonate in ambulatory practice
S. M. Austin
Department of Veterinary Clinical Medicine, Equine Primary Care, University of Illinois at Urbana-Champaign,
Illinois, USA.
Corresponding author email: smaustin@illinois.edu
Keywords: horse; neonatal; foal; assessment
Summary
The ambulatory practitioner is usually the first to evaluate the
equine neonate and must assess the foal and determine its
health status. If there is suspicion of one or more abnormalities,
then the ambulatory veterinarian must initiate appropriate
treatment and determine if the foal can be successfully treated
in the field or should be referred to a specialty hospital. This
article will describe the examination procedure including
an accurate history, a comprehensive physical examination,
laboratory evaluation and application of point-of-care
diagnostics. The initial examination is the basis for the correct
determination of health or illness and informing the owner of
the correct course of action for the neonatal foal.
Introduction
Research and literature on neonatal foal care have made
considerable advances over the past 30 years and have led
to a decrease in mortality and an increase in the level of
care available at referral centres around the world. However,
equine practitioners in the field remain the first line of
treatment and are critical to the early recognition and proper
treatment of sick neonates. If abnormalities are detected,
then the field practitioner must decide if the foal can be
managed on the farm or should be referred to a specialty
hospital for further care. The primary care clinician is in a
unique position to evaluate historical, environmental and
management considerations that may impact the ability to
successfully manage the foal on the farm and to begin early
intervention which will improve patient outcome. The value
and insurance status of the foal, availability of referral centres
and prognosis of any identified abnormalities all factor into the
decision to refer. An additional challenge during the current
period of economic recession is the expectation of owners
and managers for the practitioner to do more care in the field.
Assessing the newborn foal
Timing of examination
Successful management of a potentially ill foal is contingent
upon the early recognition and institution of appropriate
therapy. The timing of the initial foal examination is dependent
upon multiple factors, but includes an assessment of the
disease risk during the perinatal period. Maternal factors that
increase the likelihood of an abnormal foal include previous or
concurrent disease, prolonged transport during pregnancy,
malnutrition, poor perineal conformation, placentitis,
premature lactation, twinning and a history of delivering a
previous sick foal (LeBlanc 1997). High risk pregnancies should
be carefully monitored and foaling attended by a veterinarian
if possible. Also, foals that are premature (<320 days
585
gestational age), arrive during adverse environmental
conditions, are the result of dystocia or experience a ‘red-bag’
delivery should be examined immediately by a veterinarian.
If risk factors for an abnormal foal are absent, then the
timing of the first examination is dependent upon the foal
achieving certain predictable milestones for extrauterine
transition: the foal should become sternal by 5 min after
delivery, develop a suckle response within 10 min, successfully
stand by 1 h and nurse by 2 h after delivery. Larger breed foals
may take slightly longer to achieve these milestones. Any
delay in this progression should prompt the owner or manager
to seek veterinary advice and will likely necessitate a
veterinary visit. If the foal successfully achieves these
developmental milestones, then the first examination should
occur between 12 and 24 h of age (Stoneham 2006). The
placenta should be kept for examination and protected from
predation, damage or freezing.
Examination of the neonate
A complete history is imperative, especially if the veterinarian
is not familiar with the mare or client. Items of importance
include history of previous foals produced by the mare, length
of gestation and presence of abnormalities during the
pregnancy. It is especially important to ascertain whether the
mare has leaked colostrum prior to parturition. The caretaker
should be questioned about the foal’s behaviour since birth
and if nursing, urination and defaecation have been
observed. Examination of the foal should begin at a distance
and include assessment of nursing behaviour, musculoskeletal
abnormalities and resting respiratory rate. It is also important to
observe the foal’s interactions with its dam, the environment
and handler. Changes in behaviour are an early predictor of
sepsis or neurological dysfunction. A foal will usually nurse in
short bouts of about 90 s, 7–10 times per h. Milk staining on the
muzzle and forehead are suggestive of potential problems. As
the foal stands and moves around the stall, a base-wide
stance, mildly hypermetric gait and flexed head posture are
typical when compared to adults. Signs of prematurity should
be noted and include a short, soft hair coat, pliant lips and
ears, laxity of the distal limbs and a domed forehead. Lower
birthweight or poor body condition may indicate prematurity
or intrauterine growth restriction (Stoneham 2006).
The ‘hands on’ portion of the physical examination
usually begins with obtaining a rectal temperature. Normal
body temperature of a foal is 37–39°C (99–101.5°F) (Table 1).
Healthy full-term foals are able to maintain body temperature
at birth, but are susceptible to hypothermia because of low
levels of subcutaneous fat, minimal energy reserves and
relatively high heat loss because of an increased body surface
to bodyweight ratio. They are dependent upon continuous
ingestion of milk and high activity to maintain body
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TABLE 1: Normal values for newborn foals
Age Heart rate Respiratory rate Temperature
(h) (beats/min) (breaths/min) °C (°F)
0–2 120–150 60–80 37–39 (99–100.5)
>2 90–120 20–40 37–39 (99–101.5)
temperature, so hypothermia may be an early indication
of potential problems (Stoneham 2006). Increased body
temperature is most frequently associated with sepsis or
systemic inflammatory response syndrome (SIRS), although
both conditions may also be seen in foals with normal or low
body temperatures and should prompt laboratory evaluation.
Lung sounds are typically louder in foals than adults due to the
thin body wall. However, there is poor correlation between
audible sounds and the presence of lung pathology, so to
assess pulmonary function, close attention to the effort of
breathing is necessary. Normal respirations are characterised
by a gentle in and out motion. At birth, the respiratory rate may
be 60–80 breaths/min before decreasing to a rate of 20–40
breaths/min within the first 24 h after birth (Table 1). The thorax
should be carefully palpated to detect rib fractures which may
click upon palpation. Subcutaneous swelling and oedema are
often found at the fracture site. Fracture of 3 or more ribs is
associated with an increased risk of fatality (Schambourg et al.
2003). A ‘flail’ chest that moves in as the chest expands
indicates that surgical intervention is necessary. An early sign
of respiratory disease is a persistently elevated respiratory rate.
Signs of increasing respiratory difficulty include exaggerated
intercostal movement with synchronous abdominal effort
and an expiratory grunt. Finally, paradoxical movement of
the chest and abdomen are seen as the foal approaches
respiratory failure (Stoneham 2006).
A grade 1–4 holosystolic murmur can be auscultated over
the left heart base for 24–48 h. Also, irregularities in heart rate
may be transiently present immediately after birth due to high
vagal tone and hypoxia associated with delivery (Yamamoto
et al. 1992). Murmurs grade 4 and louder, holosystolic
or pansystolic, bilateral, continuous, diastolic or right-sided
murmurs are more likely to be associated with a pathological,
rather than physiological, cause (Chope 2006). Persistent
arrhythmias and murmurs detected beyond the first 96 h
should be investigated further. Normal heart rate may be high
(150 beats/min) when the foal first stands and will remain
increased (90–120 beats/min) through the first 2 days of life,
before decreasing to between 60 and 80 beats/min by
2 days of age (Table 1) (Rossdale 1967).
Prolonged capillary refill time (>2 s) with cool ears and
distal extremities is indicative of decreased peripheral
perfusion and must be further evaluated. In addition, the
mucous membranes should be examined for potential
abnormalities. Pale mucous membranes are suggestive of
anaemia or decreased perfusion, while sepsis is associated
with mucous membrane, sclera, ear (pinnae) and coronary
band hyperaemia and/or petechiation. Yellow mucous
membranes may be seen with elevations in bilirubin secondary
to liver disease or haemolysis. Dehydration may be associated
with tacky mucous membranes, sunken eyes, decreased
urination and a prolonged skin tent. Tenting the skin of the
eyelids is more reliable than the skin on the neck for assessing
hydration status. Frequent urination with dilute urine is
associated with normal hydration.
© 2013 EVJ Ltd
Assessment of the equine neonate in ambulatory practice
Neonates should be examined for limb, joint or tendon
abnormalities. The umbilicus should be inspected and the
abdominal wall examined for hernias (umbilical and inguinal).
The umbilicus should be dipped in 0.5% chlorhexidine to
decrease the risk of bacterial contamination. The addition
of surgical alcohol to the navel dip will speed drying and
help seal the umbilicus (Madigan 1990; Kavan et al. 1994). The
eyes should be examined for cataracts, corneal ulcers and
entropion; abnormal injection or colour of the sclera should
be noted. The menace response is a learned behaviour and is
not reliably present between birth and 2 weeks of age
(Enzerink 1998).
Signs of illness are usually quite nonspecific and typically
include decreased activity, loss of suckle, decreased
interactions with the mare, increased sleepiness and a
decreased or increased body temperature. In many instances,
the first thing that is noticed is the mare streaming milk.
In addition to the foal, both the placenta and mare should
be examined. The placenta should be examined to ensure the
entire placenta has been passed and to identify abnormalities
suggestive of placentitis. Increased weight of the placenta has
been associated with foal abnormalities (Whitwell and Jeffcott
1975). Normal umbilical cords measure 36–83 cm in length and
cords measuring outside this range have been associated with
increased foal abnormalities (Cottril 1991a; Cottril et al. 1991b).
Examination of the mare should include temperature, pulse
and respiration, mucous membrane colour, inspection of the
udder and evaluation of perineum for foaling injuries.
Ancillary diagnostic testing
Evaluation of passive transfer
Although foals are practically immunocompetent at birth,
they are immunologically naïve and must rely upon the
absorption of maternal antibodies from the colostrum for
protection until sufficient time has passed to mount a primary
antibody response against environmental pathogens. Failure
to ingest adequate amounts of colostrum has been
associated with increased risk of sepsis and the incidence of
failure of passive transfer (FPT) has been estimated to
between 3 and 38% of foals. Failure of passive transfer has
been established as serum IgG at less than 4 g/l and levels
between 4 and 8 g/l have been termed partial failure of
passive transfer (McGuire et al. 1977; Perryman and McGuire
1980; Morris et al. 1985; Kohn et al. 1989; Baldwin et al. 1991;
Clabough et al. 1991; Stoneham et al. 1991; Raidal 1996;
McClure et al. 2003).
The most common causes of FPT are poor quality
colostrum, loss of colostrum before suckling, failure to ingest
adequate amounts before 24 h of age and insufficient
absorption of colostral antibodies. Mares produce between
1.8–2.8 l of colostrum late in gestation (Kohn et al. 1989).
Colostrum quality appears to increase in the later parts of the
foaling season as the amount of solar radiation increases;
however, antibody concentration declines in the face of mare
illness during pregnancy, ingestion of endophyte-infected
fescue and mares greater than 10 years of age (Clabough
1990; LeBlanc et al. 1992). Colostral quality can be assessed
by measurement of specific gravity with a ‘colostrometer’
(Equine Colostrometer)1; good quality colostrum should have
a specific gravity of at least 1.060 (LeBlanc et al. 1986).
Absorption of colostrum in the neonatal gut occurs
by nonselective pinocytosis through specialised intestinal
S. M. Austin 587

epithelial cells. Normal foals begin absorbing colostral TABLE 2: Normal reference values for neonatal foals
antibodies at first nursing and capacity declines rapidly to 22%
Parameter 1 day 2–7 days
by 3 h after birth and reaches less than 1% by 20 h (Jeffcott
1971, 1974). A delay in nursing does not appear to delay Red blood cells (¥1012/l) 9.5–11.5 8.46–10.6
closure of the equine neonatal gut (Raidal et al. 2005). Haemoglobin (g/l) 13.3–15.5 12.0–14.4
Therefore, foals slow to nurse will have a decreased ability Packed cell volume (%) 38–46 33–40
to absorb intact immunoglobulin from the gastrointestinal MCV (fl) 36.6–43.8 37.1–41.6
tract and are at risk for the development of FPT. Premature MCHC (%) 31.8–35.8 35.1–37.5
or dysmature foals may actually ingest adequate amounts Total WBC (¥109/l) 6.1–11.2 6.9–11.3
Neutrophils (¥109/l) 4.2–8.6 4.5–8.5
of colostrum but fail to absorb antibodies through the
Lymphocytes (¥109/l) 1.0–2.2 1.6–2.8
gastrointestinal tract. Numerous studies have demonstrated a
Monocytes (¥109/l) 0.05–0.4 0.05–0.5
link between foals with failure of passive transfer and an Eosinophils (¥109/l) 0 0–0.2
increased risk for the development of sepsis (McGuire et al. Neutrophil:lymphocyte ratio 3.2 3.0
1977; Perryman and McGuire 1980; Kohn et al. 1989; Baldwin Platelets (¥109/l) 100–3250 140–315
et al. 1991; Clabough et al. 1991; LeBlanc et al. 1992; Raidal Total plasma protein (g/l) 54–69 58–70
1996; Raidal et al. 2005). Since sepsis is recognised as among Albumin (g/l) 25–34 25–34
the leading causes of foal mortality (Cohen 1994), all foals Fibrinogen (g/l) 1.7–3.1 2.2–4.0
should be evaluated for FPT. Serum amyloid A (mg/l) <30 <50
Maternal antibodies peak in the foal at 18–24 h of age Sodium (mmol/l) 134–146 135–144
Potassium (mmol/l) 3.5–5.3 4.1–4.9
(Sheoran et al. 2000), so foals can be tested as early as 12–18 h
Chloride (mmol/l) 100–107 97–105
of age (LeBlanc 2001). There are numerous commercial
Calcium (mmol/l) 2.7–3.2 2.7–3.1
tests available that have been shown to be suitable as Phosphate (mmol/l) 1.3–1.9 1.8–2.3
screening tests for detection of FPT (Davis and Giguere 2005). Magnesium (mmol/l) 0.8–1.0 1.0–1.2
All commercial tests have a sufficient sensitivity to correctly Bicarbonate (mmol/l) 23 24
identify foals with failure of passive transfer, but at higher Glucose (mmol/l) 5.3–9.8 6.7–10.0
antibody concentrations between 4–8 g/l, the commercial Urea (mmol/l) 3.5–4.0 2.3–4.0
tests kits may underestimate serum IgG levels and result in the Creatinine (mmol/l) 150–256 88–150
unnecessary treatment of a few foals that actually had Total bilirubin (mmol/l) 19–111 16–94
adequate serum immunoglobulin levels. Determination of Congugated bilirubin (mmol/l) 5–12 7–20
Bile acids (mmol/l) 0–8.0
serum total protein, although simple, is not accurate enough
Glutamate dehydrogenase (GLDH) (iu/l) 8–43
to determine if adequate transfer of antibodies has occurred Alkaline phosphatase (iu/l) 1182–3382 849–590
(Davis and Giguere 2005). It is recommended that healthy, Gamma glutamyltransferase (iu/l) 15–45 11–26
vigorous foals with complete failure and high risk foals with Aspartate aminotransferase (iu/l) 99–209 165–285
either partial or complete failure of passive transfer should be Lactate dehydrongenase (iu/l) 387–487 390–590
treated to increase serum immunoglobulin to greater than
8 g/l.

Laboratory tests marker, serum amyloid A (SAA), increases significantly within

A complete blood count (CBC) is recommended for any
foal suspected of being abnormal and is required by some
insurance companies before issuance of foal insurance.
Packed cell volume (PCV) and red blood cell (RBC) count
are influenced by the transfer of placental blood flow,
catecholamine secretion and fluid balance. A low PCV and
RBC count may be associated with premature rupture of
the cord or neonatal isoerythrolysis (Table 2).
In a newborn foal, it is normal for the neutrophil:lymphocyte
ratio to be greater than 2:1 and this finding is indicative
of normal adrenocortical function. Neutropenia with the
presence of band or degenerative neutrophils, toxic
neutrophils and neutrophilia are suggestive of a systemic
inflammatory response and should prompt intervention
(Koterba et al. 1984). Lymphopenia is associated with infection
with equine herpesvirus (EHV) or equine arteritis virus (EAV)
and may be seen in Arabian foals with severe combined
immunodeficiency.
Platelet numbers should be similar to adult values and
decreased levels may be associated with immune-mediated
disease. Fibrinogen levels increase over the first few months of
age from 2–4 g/l (Harvey et al. 1984). A minimum of 48 h is
necessary before fibrinogen levels increase in response to an
inflammatory insult, so elevations present at birth indicate an
intrauterine insult. An additional acute phase inflammatory
24–48 h after bacterial infection to >100 mg/l (normal range
0–27 mg/l). Levels between 27 and 100 mg/l may occur with
inflammation or changing SAA status and should prompt serial
testing. Levels of SAA also decrease rapidly in response to
appropriate therapy and serve as a useful monitor of
therapeutic response (Stoneham et al. 2001).
Creatine kinase (CK), an enzyme marker of muscle
damage, is generally within the normal adult range at
birth, but may be increased with prolonged recumbency,
dystocia, convulsions or white muscle disease. Serum alkaline
phosphatase originates from bone, gastrointestinal tract
and liver and is elevated in foals at birth to several weeks
of age due to an increase in the isoenzymes associated
with bone metabolism. Bile acids are increased, when
compared to adult levels, in foals aged 1–7 days. Bilirubin
elevations are not uncommon at birth. Levels normally
decrease rapidly and should be monitored in conjunction
with PCV to rule out concurrent neonatal isoerythrolysis.
Serum creatinine levels in foals are typically at the upper
level of the adult range. Elevations in serum creatinine
found in the first few days of life usually reflect placental
pathology, rather than renal disease in the foal, and should
decline rapidly in otherwise normal foals (Table 2). Failure to
decline should prompt further investigation of kidney function
(Stoneham 2006).

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588
Point-of-care testing
The availability of stall side testing allows ambulatory
practitioners to obtain additional information at the
point-of-care that can establish and monitor the health status
of a foal. In addition, these tests can provide invaluable
information regarding response to treatment which can be
used to determine prognosis or establish the need for referral
to a hospital.
Elevations of lactate are not diagnostic of a specific
condition but do indicate that a severe disease process is
present and signals the need for prompt intervention. The
highest values of lactate are seen in foals with septic shock,
haemorrhagic shock, prematurity and complicated neonatal
asphyxia syndrome (Henderson et al. 2008; Castagnetti et al.
2010). The handheld scout analyser (Lactate Scout)2 measures
lactate concentration in whole blood and has been shown
to be reliable for use in neonatal foals (Castagnetti et al.
2010). Blood lactate may be elevated in apparently normal
foals at birth, but stabilises at 2.1 mmol/l (range 1.0–3.7 mmol/l)
by 24 h of age. Because of the variation in blood lactate levels
in normal neonates, lactate clearance has proven to be
the more useful indicator for survival. The persistence of
hyperlactataemia in the face of appropriate treatment has
been associated with nonsurvival (Henderson et al. 2008) and
can be used to determine the prognosis of a sick foal.
Hypoglycaemia can be a potentially fatal problem that
can be rapidly identified by use of a stall-side glucometer.
Periodic monitoring can identify the problems in glucose
metabolism and allow rapid corrections in the field. A
glucometer designed for veterinary use is preferable, as
devices designed for human glucose measurement may
be highly variable when utilised to measure equine blood
glucose. If a human POC device is used, it should be
periodically compared to laboratory standards to evaluate
performance for stall-side monitoring (Hackett and McCue
2010). An in-depth discussion of laboratory derangements is
available in an article by Wilkins (2011).
Imaging
The availability of diagnostic ultrasonography has greatly
improved the ability of the ambulatory practitioner to
evaluate the potentially sick foal. Rib fractures are common
over the cranioventral region of the chest overlying the
heart (Bellezzo et al. 2004) and ultrasound has proven to be
better than either physical examination or radiography for
detection of these potentially fatal fractures (Jean et al. 2007).
Ultrasound examination of the umbilicus is indicated in the
investigation lethargic, febrile foals or those that develop
patent urachus. The size of umbilical structures should be
compared to normal values to help determine if infection is
present (Table 3) (Reef and Collatos 1989; Franklin and Ferrell
2002). When abdominal enlargement is present, ultrasound
TABLE 3: Dimensions of normal umbilical structures
Structure Location Dimensions (cm)
Umbilical vein Caudal to umbilicus 0.61 ⫾ 0.20
Mid abdomen 0.52 ⫾ 0.19
At liver 0.60 ⫾ 0.19
Umbilical arteries Single artery 0.85 ⫾ 0.21
Both arteries plus urachus 1.75 ⫾ 0.37
Modified from Reef and Collatos (1989).
© 2013 EVJ Ltd
Assessment of the equine neonate in ambulatory practice
can be used to assess intestinal motility, identify retained
meconium, and determine if distention is the result of free
fluid within the abdomen vs. fluid accumulation within the
gastrointestinal tract.
Final assessment of foal
The goal of the initial examination is to determine if the foal
is normal, has adequate passive transfer of antibodies, and
to ensure that the foal is nursing adequately to maintain
strength. If the foal is abnormal, it must be determined if the
foal can be treated on the farm or be referred to a hospital for
treatment. Many foals can be successfully treated on the farm.
Early identification of abnormalities and prompt institution of
appropriate therapy greatly improve outcome. The decision
to refer requires a frank discussion regarding the possible
abnormalities, the prognosis for use, the value of the foal, the
insurance status of the foal, availability of referral facilities,
experience of the practitioner, experience of farm personnel
and a determination that the foal’s needs can be met on the
farm.
Author’s declaration of interests
No conflicts of interest have been declared.
Manufacturers’ addresses
1Lane Manufacturing Co, Denver, Colorado, USA.
2SensLab, GmbH, Leipzig, Germany.
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