American Association of Feline Practitioners

2017 Conference ● October 19 – 22, 2017 ● Denver, CO

How to Treat the Small & the Sick: Part 1 & 2

Susan Little, DVM, DABVP (Feline)

INTRODUCTION
Most veterinarians have been presented with kittens that have failed to thrive or that are ill. These patients are
challenging due to their small size, unfamiliar physiology, and the tendency for their status to deteriorate quickly. The
most common general causes of illness and failure to thrive involve maternal, gestational, environmental, genetic,
and infectious factors.1,2 In much of the veterinary literature, the neonatal period is defined as the first 4 weeks of life.
However, it is clinically useful to consider defined risk periods: the first 4 days of life (when many problems are
related to labor and delivery or the environment), days 21 to 28 (when important changes leading to neurologic and
behavioral maturation take place), and the weaning period (4 to 6 weeks of age) where morbidity and mortality rates
may be high due to nutritional problems or infectious disease.2

EXAMINATION OF SICK KITTENS

Sick kittens should be examined promptly using a systematic approach that includes:
• Complete history of the kitten as well as the littermates and queen, if available
• Examination of the kitten and the queen if available
• Diagnostic tests

Medical history
Begin with a complete medical history for the affected kitten, littermates, and queen (e.g., illness, nutrition,
vaccinations). Information on littermates and the queen, if available, can be helpful.
• Gather information about labor and delivery, especially for kittens under 2 weeks of age.
• Inquire about previous litters if it is not the queen’s first litter, including any problems with labor and delivery.
• Investigate the kitten’s home environment, paying attention to:
o Environmental temperature and humidity
o Sanitation and ventilation
o Population density
o Presence of other pets and small children
o Prevalence of infectious diseases and parasites.

Clinical examination
When examining kittens less than 4 weeks of age, keep the queen present, if possible (unless prohibited by the
queen’s temperament). Wash your hands and wear gloves, and handle kittens gently on a clean warm surface. Basic

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equipment needed for neonatal examinations includes:
• Otoscope with infant cones
• Pediatric rectal thermometer
• Penlight
• Kitchen gram scale
• Stethoscope with an infant bell and diaphragm

Observation
Before handling the kitten, observe its body condition and response to the environment, including alertness, posture,
locomotion, and respiratory rate and character. While healthy neonatal kittens have a strong suckle reflex, it is
typically not as strong as that of a healthy puppy.

Temperature
Normal body temperature for neonates is 97oF to 98oF (36oC–37oC). Rectal temperature rises slowly, reaching 100oF
(38oC) by about 4 weeks of age. For the first 2 weeks of life, kittens are essentially poikilothermic and lack a shiver
reflex. They gradually become homeothermic after 14 days of age, but are still susceptible to environmental
conditions and may easily become hypothermic.

Establish age
If the kitten’s birth date is unknown, attempt to establish an estimated age by using body weight, dentition, and
developmental milestones.
• Weight: Typical kitten birth weight is 90 to 110 g (range 80–140 g), although, there is considerable variation
by and within breeds.3 Normal kittens gain 50 to 100 g per week (10–15 g/day) and should double their birth

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 weight before 2 weeks of age. Low birth weight is a common cause of mortality, with kittens weighing under
75 g at birth at highest risk.
• Dentition: The incisors and canines, which erupt at 3-4 weeks of age, are the first deciduous teeth to appear,
while the premolars erupt at approximately 5-6 weeks of age. The dental formula for deciduous teeth is 2 x
(i3/3, c1/1, p3/2); there are no deciduous molars.
• Developmental milestones: Important milestones include: eyelids open (7-10 days), crawling (7-14 days),
uncoordinated walking (21 days), voluntary elimination of urine and feces (21 days). Note that delayed
development may occur in kittens with low birth weight and poor weight gain.

Anatomic abnormalities
The kitten should be inspected for any gross anatomic abnormalities (e.g., cleft lip or palate, umbilical hernia or
infection, open fontanel, limb deformities, chest wall deformities, nonpatent urogenital or rectal openings). Inspect the
eyes for abnormalities of the globe or eyelids, and for ophthalmia neonatorum (infection before the eyelids open) or
conjunctivitis (after the eyelids open).
• Menace reflex and pupillary light responses do not appear until after 28 days of age.
• A mild divergent strabismus may be present and is normal until about 8 weeks of age unless the kitten is
affected by hydrocephalus, in which case it will be persistent.
• Evaluation of the fundus is difficult until after 6 weeks of age.

Signs of disease
Identify whether diarrhea, hematuria, or pigmenturia is present:
• Diarrhea is present in about 60% of sick neonatal kittens, and may cause significant fluid loss.
• Hematuria or pigmenturia may be signs of urinary tract infection, trauma, or neonatal isoerythrolysis.
o Neonatal isoerythrolysis may be a common problem in some breeds with a high percentage of blood
type B individuals (e.g., British Shorthair, Cornish Rex, Devon Rex).

Healthy neonatal kittens may have somewhat hyperemic mucous membranes until 7 days of age (although
hyperemia may also be a sign of dehydration), whereas sick neonates often have pale, gray, or cyanotic mucous
membranes. Kittens with cyanotic mucous membranes have a poor prognosis.

Inspect the hair coat and pinnae for evidence of trauma, parasites (e.g., fleas or ear mites), and skin disease. The
neonate’s hair coat should be clean and shiny. Note that the ear canals are not easy to inspect with an otoscope until
after 4 weeks of age. Flea infestations should be treated aggressively as they can cause life-threatening anemia.
Young kittens can be bathed in pet-safe shampoo, followed by thorough drying (beware of hypothermia), and
combing of the hair coat to remove fleas. Alternately, a water-based pyrethrin spray may be used if available. Many
flea control products are labelled for use from 8 weeks of age, although anecdotally, selamectin (Revolution,
Stronghold) has been used in kittens as young as 6 weeks of age. Nitenpyram (Capstar) is labelled for use in kittens
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from 4 weeks of age that weigh at least 0.9 kg (2 lb). Ear mite infestations are best treated with topical ivermectin.
One product (0.01% ivermectin; Acarexx) has been demonstrated as safe in kittens as young as 4 weeks of age.

Cardiovascular function
In neonates, the cardiovascular system undergoes dramatic changes as the heart takes over the functions previously
performed by the feto-maternal circulation. One important difference between feline neonates and adults is the higher
neonatal heart rate, which can be over 200 beats per minute (range 220–260 beat/min). Normal respiratory rate for
neonates is 15-35 breaths per minute.

Functional murmurs may be present in neonates due to anemia, hypoproteinemia, fever, or sepsis. Innocent
murmurs not associated with disease are more common in puppies than kittens; investigate murmurs present after 4
months of age as they may be associated with cardiac disease. Congenital heart disease may be associated with
murmurs that are loud and accompanied by a precordial thrill. The most common congenital heart diseases in kittens
are tricuspid valve dysplasia and ventricular septal defect.4

Abdominal palpation
Abdominal palpation can be performed with care; in the first few days of life, abdominal pressure during palpation
may induce regurgitation of stomach contents and aspiration. A full abdomen is normal in well-fed kittens, but an
enlarged abdomen in an ill kitten may indicate aerophagia. Abdominal organs are variably palpable in neonates:
• Intestinal tract: palpable, fluid-filled bowel loops should be freely moveable and nonpainful
• Kidneys: frequently palpable
• Liver: may not be palpable if normal
• Spleen: may not be palpable if normal
• Stomach: may be palpable if full

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 • Urinary bladder: palpable, should be moveable and nonpainful

DIAGNOSTICS
Blood analysis
Blood chemistry and hematology normal values for neonates differ from adults; most values normalize to adult levels
by 4 months of age. See Table 1. For venipuncture, position the kitten in dorsal recumbency, with the forelimbs
drawn back toward the abdomen and head and neck extended. Draw blood from the jugular vein using a 1-mL
syringe with a 25-26G needle. Slow aspiration of blood is essential to avoid collapsing the vein. A small volume (0.5
mL) of blood can be used for the most critical tests:
• Packed cell volume and total solids: using microhematocrit tubes and refractometer
• Complete blood count: one drop of whole blood directly into a Unopette for white blood cell and red blood cell
counts; differential from a drop of blood on a slide to make a smear
• Small volume blood analyzers may be used for critical chemistries (e.g., BUN, creatinine) as well as blood
gases; a portable glucometer can be used for blood glucose measurement

Urinalysis
Collect urine for chemistries, sediment examination, and specific gravity by stimulating the perineum in young kittens;
perform cystocentesis with great care in the very young as the bladder wall is easily damaged. Umbilical vasculature
may still be patent and can be traumatized. Urine specific gravity is 1.020 or lower in the first few weeks of life; adult
concentration is reached by about 8 weeks of age.5

Fecal analysis
A fecal sample should be examined for common intestinal parasites, such as Giardia, Isospora, and roundworms
using zinc sulfate centrifugation, direct saline smear, and Giardia fecal antigen test. Kittens as young as 2 weeks of
age may be treated with pyrantel pamoate (5–10 mg/kg PO) every 2 weeks until broad spectrum regular broad-
spectrum parasite control begins.

Retrovirus testing
Testing for feline leukemia virus (FeLV) and feline immunodeficiency virus (FIV) is an important part of both
preventive healthcare and investigation of illness. Recommendations for FeLV and FIV testing in kittens have been
published and should be reviewed:
1. European Advisory Board on Cat Diseases (ABCD): feline infectious disease guidelines (updated 2012).
http://www.abcd-vets.org/Pages/guidelines.aspx
2. Little S, Bienzle D, Carioto L, Chisholm H, O'Brien E and Scherk M. Feline leukemia virus and feline
immunodeficiency virus in Canada: recommendations for testing and management. Can Vet J. 2011; 52:
849-55. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3135027/
3. Levy J, Crawford C, Hartmann K, et al. 2008 American Association of Feline Practitioners' feline retrovirus

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management guidelines. J Feline Med Surg. 2008; 10: 300-16. http://www.catvets.com/guidelines/practice-
guidelines/retrovirus-management-guidelines

Imaging
Radiography
Radiography is more difficult to evaluate than in the adult cat due to the small size and often uncooperative nature of
kittens. If required, the author has used mask induction and maintenance with isoflurane as a method for
immobilization. It is also difficult to interpret radiographic images of kittens as contrast is poor from lack of body fat
and mineralization of the skeleton is incomplete. The quality of images can be improved by setting the kilovoltage to
about half of that used for an adult and using high detail film or screens.

Quality thoracic images may be difficult to obtain due to the high respiratory rate of kittens and greater chest wall
motion. Absence of motion and good positioning are critical. Common indications for thoracic radiographs are
evaluation of heart murmurs and diagnosis of pneumonia. Thoracic radiographs of kittens show a generalized
increase in pulmonary interstitial opacity because of the increased water content of the lung parenchyma. The
thymus may appear as a sail sign in the cranial left hemithorax and the cranial mediastinum will appear wider than in
the adult cat. The heart appears proportionately larger in the thoracic cavity due to decreased alveolar volume.

Interpretation of skeletal radiographs presents difficulties due to decreased mineralization, open physes, and
secondary centers of ossification. Trauma and infection are the most common lesions found, and are often
associated with soft tissue swelling. It can be helpful to radiograph the corresponding unaffected limb at the same
time for comparison to aid in interpretation.

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 The usefulness of abdominal radiography in kittens is hampered by poor abdominal detail due to lack of intra-
abdominal fat, a small amount of normal peritoneal fluid, and a higher proportion of total body water. The liver
appears larger than in the adult. The most common diagnoses are radiopaque foreign bodies and intestinal
obstruction.

Ultrasound
Ultrasound is an effective imaging modality for pediatric patients, especially for the abdomen. Machines with a
curvilinear variable frequency scan head (6.0–8.0 MHz) have been recommended. Sedation is rarely required for the
procedure, and the kitten is best positioned in dorsal recumbency in a padded trough. Common indications for
abdominal ultrasonography include gastrointestinal foreign body, intussusception, congenital hernia, congenital renal
disease, and urolithiasis.

BASIC THERAPEUTICS
Often the exact cause of a kitten’s illness is not apparent at the time of presentation and initial therapy is focused on
supportive care, including supplemental warmth, hydration, glucose administration, and nutritional support.

Hypothermia
Severe hypothermia occurs when a kitten’s rectal temperature is <94oF (<34.4oC) and is associated with depressed
respiration, impaired immune function, bradycardia, and ileus. Hypothermic kittens should be rewarmed slowly, over
2-3 hours or more, to a maximum rectal temperature that is age appropriate. Warming too rapidly increases
metabolic demand, resulting in dehydration, hypoxia, and loss of cardiovascular integrity. Rewarming can be
accomplished with a small animal incubator or oxygen cage. Hot water bottles and heat lamps can be used with very
careful monitoring to prevent overheating and burns. Fluids warmed to 95-98oF (35-37oC) can be administered to
severely hypothermic kittens via the intravenous (IV) or intraosseous (IO) route. Never attempt to feed a hypothermic
kitten as aspiration pneumonia due to gastrointestinal hypomotility and regurgitation is a significant risk.

Hypoglycemia
Clinical hypoglycemia occurs when the blood glucose is <3 mmol/L (50 mg/dL) and is common in sick neonates due
to immature liver function and rapid depletion of glycogen stores. Hypoglycemia may be caused by vomiting,
diarrhea, sepsis, hypothermia, or inadequate nutrition. Dehydrated kittens are often weak and lethargic and may be
anorexic. If the kitten is not hypothermic or dehydrated, 5-10% dextrose (0.25-0.50 mL/100 g body weight) can be
given orally by gastric tube until the kitten is stronger and able to eat or nurse. Critically ill neonates may require a
bolus infusion of 12.5% dextrose IV or IO (starting at 0.1-0.2 mL/100 g body weight) followed by a constant rate
infusion of 1.25-5% dextrose in a balanced electrolyte solution to prevent rebound hypoglycemia.6 Hypertonic
dextrose solutions should not be given subcutaneously (SC) because tissue sloughing may occur.

Dehydration
Dehydration occurs easily in neonatal kittens with hypoxia, hypothermia, diarrhea, vomiting, or reduced fluid intake.
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Neonates have poor compensatory mechanisms and immature kidney function as well as higher daily urine output
and fluid intake requirements than adult cats. Hydration status may be difficult to assess in the youngest patients.
Skin turgor is not always reliable in kittens less than 6 weeks of age as they have lower body fat and higher body
water content than adults. Mucous membranes should be moist and either slightly hyperemic or pink. Pale mucous
membranes and a decreased capillary refill time indicate at least 10% dehydration. Neonatal urine is normally
colorless and clear; a urine specific gravity <1.020 indicates dehydration.

If the kitten is normothermic and not in shock or cardiovascular collapse, warmed SC fluids can be administered
although absorption may be slow. Warmed oral fluids can be given if there is no vomiting. If the kitten is moderately
to severely dehydrated and large enough to facilitate IV access, IV fluid therapy is most effective. The cephalic or
jugular vein can be catheterized with a 24G, ¾ inch or 22G, 1-inch catheter. Lactated Ringer’s solution is ideal
because lactate can be used as an energy source; 1.25-5% dextrose can be added if needed.

Warmed fluids may be given as a slow IV bolus of 1 mL/30 g body weight (30-45 mL/kg), followed by a maintenance
rate of 8-12 mL/100 g body weight (80-120 mL/kg) per day plus any ongoing losses.6 Fluid therapy should be
monitored closely as it is easy to overhydrate kittens with immature kidney function. Hydration status can be
monitored by weighing the kitten every 6-8 hours as well as serial packed cell volume and serum total protein
measurements. Electrolytes and blood glucose should also be monitored.

IO access is an alternate to IV access; using the trochanteric fossa of the proximal femur is best in larger kittens from
about 4 weeks of age. A 20-22G, 1-inch spinal needle or 18-25G hypodermic needle can be used as an IO catheter.
Use of cold fluids, too large a volume in a short time, or hypertonic or alkaline solutions can cause pain. IV access

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should be established as soon as possible. Potential complications of IO catheterization include infection,
extravasation of fluids, and bone and soft tissue trauma.

Table 1: Serum chemistry and hematology values for kittens from birth to 8 weeks
0-2 weeks 2-4 weeks 4-6 weeks 6-8 weeks
Albumin (g/L) 20-24 22-24 -- --
ALP (IU/L) 68-269 90-135 -- --
ALT (IU/L) 10-38 10-18 9-41 23-50
Bilirubin (μmol/L) 1.7-17.1 1.7-3.4 -- --
Calcium (mmol/L) -- -- 2.1-2.75 2.2-2.8
Cholesterol (mmol/L) 4.2-11.5 5.7-11.2 -- --
Creatinine (μmol/L) 17.7-53.0 26.5-44.2 17.7-106.1 35.4-88.4
Glucose (mmol/L) 4.2-7.2 5.5-6.2 -- --
Phosphorus mmol/L) 2.2-3.0 2.4-3.1 2.5-3.2 2.5-3.1
Total protein (g/L) 35-47 41-47 41-59 51-57
Urea (mmol/L) 7.8-19.3 6.1-10.7 5.3-12.8 8.9-13.6

PCV (%) 33.6-37.0 25.7-27.3 26.2-27.9 28.5-31.1

RBC (x106/μL) 5.05-5.53 4.57-4.77 5.66-6.12 6.31-6.83
WBC (x106/μL) 9.10-10.24 14.10-16.52 16.08-18.82 16.13-20.01
Neutrophils 5.28-6.64 6.15-7.69 7.92-11.22 5.72-7.78
Lymphocytes 3.21-4.25 5.97-7.15 5.64-7.18 8.02-11.16
Monocytes 0.0-0.02 0.0-0.04 0 0.0-0.02
Eosinophils 0.53-1.39 1.24-1.56 1.22-1.72 0.88-1.28
Adapted from Moon P, Massat B, Pascoe P. Neonatal critical care. Vet Clin North Am Small Anim Pract
2001;31:343-367; Hoskins J. Clinical evaluation of the kitten: from birth to eight weeks of age. Comp Contin Edu
Pract Vet 1990;12:1215-1225; Chandler M. Pediatric normal blood values In: Kirk R,Bonagura J, eds. Current
Veterinary Therapy XI: Small Animal Practice. Philadelphia: W.B. Saunders, 1992;981-984.

References
1. Grundy SA. Clinically relevant physiology of the neonate. Vet Clin North Am Small Anim Pract 2006;
36(3):443-459, v.
2. Freshman JL. Evaluating fading puppies and kittens. Vet Med 2005; 100(11):790-796.
3. Sparkes AH, Rogers K, Henley WE, et al. A questionnaire-based study of gestation, parturition and neonatal
mortality in pedigree breeding cats in the UK. J Feline Med Surg 2006; 8(3):145-157.
4. MacDonald KA. Congenital heart diseases of puppies and kittens. Vet Clin North Am Small Anim Pract 2006;
36(3):503-531.

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5. Macintire DK. Pediatric fluid therapy. Vet Clin North Am Small Anim Pract 2008; 38(3):621-627, xii.
6. McMichael M. Pediatric emergencies. Vet Clin North Am Small Anim Pract 2005; 35:421-434.

NOTES:

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