Equine Veterinary Journal ISSN 0425-1644
DOI: 10.1111/j.2042-3306.2011.00520.x
The impact of peer-reviewed literature on equine neonatal care
In the preface of the first equine neonatology book edited by Koterba,
Drummond and Kosch in 1990 it is stated that ‘Regardless of the
sophistication of equipment and facilities of neonatal intensive care, the
factor that still saves the most foals is careful and intensive nursing care’.
This probably still holds true more than 20 years later, manifested by the
continued presence and use of the book in many neonatal care facilities all
over the world. However, the authors also point out that ‘in many areas of
major and minor importance, gross deficiencies in species-specific
information exist’ (Koterba et al. 1990). And it is this area, the
evidence-based or at least peer-reviewed species-specific literature, where
the greatest advances have been made since publication of the book. A
literature search using PubMed (http://www.ncbi.nlm.nih.gov/
sites/entrez?db=pubmed) and the broad search terms ‘foal or equine
neonate’ confirms this impression. Prior to 1970, 93 publications were
named. Over the next 4 decades publications increased to 281 in the
1970s, 496 and 477 in the 1980s and 1990s, respectively, and in the last
decade 544 publications were listed. In the new decade (up to September
2011) 98 publications are already are listed, and this Equine Veterinary
Journal supplement, containing 25 articles, will aid in increasing our
understanding of physiology, pathophysiology and treatment of the equine
neonate even further. There is some, albeit indirect, evidence that this
cumulative increase in knowledge over time has been paralleled by an
increase in survival, at least in bacteraemic foals (Fig 1).
Some of the articles presented here will confirm our clinical impressions
and reinforce current clinical practice, whereas others might change the
way we view and treat hospitalised foals. Indeed, particularly in equine
neonatal care, it appears that scientific evidence, rightly or wrongly,
occasionally lags behind clinical developments, as demonstrated by the
contributions of Jose-Cunilleras et al. (2012), Sanchez and Elfenbein (2012)
and Furr et al. (2012) in this supplement.
Nutrition is a key element of neonatal intensive care; however, direct
measurements of the resting energy expenditure (REE) of healthy and
diseased foals have long been lacking. The study by Jose-Cunilleras et al.
(2012) in this supplement corroborates earlier findings by Ousey et al.
(1996, 1997) and Paradis (2001). Results of the study indicate that critically
ill neonates have a lower REE than healthy controls and provide more
support for the current practice of feeding 40–50 kcal/kg bwt/day to sick
neonates. Methods of introducing enteral feeding to the recuperating foal
vary, but many clinicians prefer to initiate feeding via nasogastric tube
owing to fears of milk aspiration, rather than attempting to bottle feed or
allowing the weak foal to nurse (McKenzie and Geor 2009). Although widely
recognised, the description of dysphagia due to pharyngeal dysfunction in
neonatal foals in the peer-reviewed literature has so far been limited to a
series of 4 cases (Altmaier and Morris 1993). The report of pharyngeal
80
Nonsurvivors
P = 0.0001
70
Survivors
60
50
Percentage
40
30
20
10
0 on the most appropriate terminology for neonatal maladjustment
1980–1989 1990–1999 2000–2007
(n =102) (n =144) (n =177)
Fig 1: Survival of bacteraemic foals treated in a neonatal intensive care unit over 3
decades. Figure adapted from Sanchez et al. (2008).
Equine Veterinary Journal 44, Suppl. 41 (2012) 5–6 © 2012 EVJ Ltd
dysphagia in 16 foals by Holcombe et al. (2012) presents the first step into
further investigations of dysphagia in this age group.
Concerns over the severe and potentially fatal consequences of gastric
and duodenal ulcerations, perforation and duodenal outflow obstruction,
have led to routine use of anti-ulcer medications in a large number of
equine neonatal intensive care units. However, during the last 2 decades
this attitude has gradually changed and many clinicians no longer
supported their indiscriminate use (Barr et al. 2000). The article by
Sanchez et al. (2012) provides further evidence supporting the
impression that, despite decreasing use of acid-suppressive medication,
the prevalence of gastric ulcers has not increased. A reduction in the
gastric barrier function and increased risk of colonisation of the intestine
by potential pathogens has frequently been quoted as an argument
against blanket use of antacid medication. The article by Furr et al. (2012)
documents for the first time an increased risk for development of
diarrhoea in neonatal foals receiving antiulcer medications in intensive
care units. Interestingly, the use of not only ranitidine and omeprazole but
also sucralfate alone increased the risk of diarrhoea. Furthermore, the
proportion of foals with gastric ulcerations receiving no antiulcer
medications did not differ from those of treated foals. The findings of both
studies strongly suggest that the indications for use of anti-ulcer
medication in critically ill equine neonates need to be reviewed, as
prophylactic administration to every neonate may not be appropriate
and potentially harmful. The results also highlight that further
investigations into the pathogenesis of gastric ulceration in neonatal foals
are needed.
The availability of third- and now fourth-generation cephalosporines
with an extended Gram-negative spectrum has lead to an increased use
of this class as single-drug treatment for neonatal sepsis. Many clinicians
have opted to use higher doses of ceftiofur than recommended by the
manufacturer, with the aim of extending its efficacy against
Enterobacteriaceae even further. However, until recently (Meyer et al.
2009; Hall et al. 2010) this practice was not supported by published
evidence. A similar pattern has emerged with the availability of
cefquinome and doses of up to 5 mg/kg bwt have anecdotally been
administered to neonatal foals twice daily. The pharmacokinetic study of
cefquinome in neonatal and 6-week-old foals reported by Smiet et al.
(2012) provides a scientific basis for clinical use of higher doses in
selected cases.
Owing to the small size of foals and their relative ease of handling, the
more widely available imaging modalities of magnetic resonance imaging
and computed tomography (CT) are likely to gain importance as diagnostic
tools for neonatal conditions in the coming years. The case reported by
Haggett et al. (2012) demonstrates how advanced imaging, in this case CT,
can aid in describing the extent and nature of musculoskeletal lesions and
complement the often equivocal or incomplete information provided by
radiographic and/or ultrasonographic examination. Ultrasonography
remains an invaluable tool for evaluation of critically ill foals and, as
described by Navas de Solis et al. (2012), may aid in establishing disease
severity and prognosis in foals where pneumatosis intestinalis is detected.
Although necrotising enterocolitis, a common cause of pneumatosis
intestinalis, has been reported in foals (Cudd and Pauly 1987; Wehrli
Eser et al. 2002) and anecdotally described in several texts, further
studies are needed to delineate this fascinating syndrome further in
the equine species.
Sepsis is the leading cause of morbidity and mortality in young foals. The
term sepsis is defined as systemic inflammation caused by microbial
invasion of normally sterile parts of the body. The diagnosis of sepsis does
not require laboratory evidence of bacteraemia and is preferred to the
previously more commonly used term septicaemia (Lever and Mackenzie
2007); therefore, this terminology is used throughout this issue. Consensus
syndrome has not yet been reached and it is also known as
hypoxic–ischaemic encephalopathy, neonatal encephalopathy, perinatal
asphyxia syndrome and dummy foal syndrome. Throughout the issue,
authors have used their preferred term. Madigan et al. (2012) present
preliminary evidence that, in addition to hypoxic and ischaemic events,
5
The impact of peer-reviewed literature on equine neonatal care
the neurobehaviour displayed by these foals may be associated with
increased circulating progestagen concentrations, and Armengou et al.
(2012) highlight the need for a high index of suspicion that meningitis may
be present in young foals showing neurological abnormalities.
The ability to give a more accurate prognosis based on published
literature, rather than clinical impressions and anecdotal reports,
continues to increase. Two studies reported in this issue investigated the
association between foal-related factors and subsequent performance in
life and both reached encouraging conclusions. Low birthweight has
previously been associated with decreased racing performance (Platt
1978). In contrast to these earlier findings, the study presented by
Whittaker et al. (2012) did not identify a significant correlation between
birthweight and racing performance. Although these results are
encouraging, it remains to be established whether these findings can be
extrapolated to foals with very low birthweights (<8% of their dam’s weight),
the population Platt (1978) focused on, and to those judged small for
gestational age. Corley and Corley (2012) showed that treatment at a
referral hospital within the first 125 days of life did not affect sales outcomes
at public auctions and no differences in the mean sales prices between
treated foals and controls could be established. This information can be
used as guideline for owners and trainers questioning whether it is
financially viable to invest in treatment of a foal intended for sale.
Other aspects of neonatology have not changed over recent decades.
Dystocia and prolongation of Stage II labour still have a significant impact
on foal morbidity and mortality, and increased times to standing and/or
nursing remain good indicators of a compromised newborn foal (McCue
and Ferris 2012). The findings confirm yet again observations by Koterba
and Drummond published almost a quarter of a century ago that close
observation by educated personnel and rapid intervention are
essential to maximise the chances of a successful outcome (Koterba and
Drummond 1988).
In summary, the articles included in this supplement represent a
significant contribution to the evidence base needed to underpin clinical
practice of equine neonatology. Peter Rossdale has, throughout his career,
championed clinical research in many and all aspects of equine medicine,
but in particular in relation to the foal, and we are delighted
to have contributed to the production of this supplement honouring
his achievements.
Conflicts of interest
The authors did not declare any conflict of interest.
B. Dunkel and S. Giguère
Department of Veterinary Clinical Sciences, Equine Referral Hospital,
Royal Veterinary College, North Mymms, UK
†
Department of Large Animal Medicine, University of Georgia,
Georgia, USA.
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