Nursing considerations for neonate and pediatric patients

Even with healthy puppies and kittens, client education is important in ensuring a strong immune system

A puppy in the intensive care unit receiving fluids. Photos courtesy Tami Lind
A puppy in the intensive care unit receiving fluids.
Photos courtesy Tami Lind

Neonates and pediatric patients can be challenging when it comes to nursing care. Their size, immune system, and fragility make it difficult to treat ailments. There are special considerations when it comes to dealing with neonate and pediatric emergencies.

Neonates are considered to be under two weeks old. Pediatric patients are considered to be two weeks to six months of age. During this time, these patients’ immune systems are still developing and they are susceptible to many diseases. Neonates should double their weight within 10 days if they are nursing appropriately. The first 48 hours of the new baby’s life are important, as it is the time where the mother is producing colostrum. Colostrum is rich with antibodies and is important in developing their immune system. After 48 hours, the neonate is unable to absorb immunoglobulins in colostrum.

Temperatures and body functions

Neonates from birth to seven days should sleep about 90 percent of the day. Their normal temperature is 96 to 98 F. After 10 days, neonates should be able to stand, open their eyes, and their body temperature normalizes to around 99 F. Around 14 days, they should develop a menace response, and pupillary light responses can be assessed around 21 days of age. This is also when they start urinating and defecating on their own; their temperature is around 100 F.

Neonates younger than seven days are unable to maintain their body temperature and can quickly become hypothermic simply by becoming separated from littermates and the mother. Their reflexes have not developed enough to cause shivering and vasoconstriction to help keep them warm. As they grow progressively colder, they will develop bradycardia.

A neonate jugular catheter.
A neonate jugular catheter.

A neonate can be critical if it presents to the hospital with a heart rate normal for an adult. Be aware of neonate normal temperature and do not warm them too aggressively. Accidentally warming a neonate to even 103 F can cause stress. Hypothermia can lead to ileus.

Do not feed a hypothermic baby. Always warm them to an appropriate temperature and then attempt to feed them. This is an important point to stress with clients who are bottle feeding at home, as ileus can lead to regurgitation and aspiration pneumonia.

Neonates and pediatric patients have a higher fluid need than adult patients due to their kidneys being immature, decreased body fat, a higher metabolic rate, and increased respiratory rate. Their bodies are made of approximately 75 percent water, and they have large evaporative losses through the skin. Pediatric patients can become hypovolemic very quickly. Unfortunately, it is difficult to assess hydration status because skin tent is always present, and their heart rates will not increase.

Neonates are born with hematocrits around 40 percent. Movement of fluid from the extracellular space into the vascular space also contributes to the decrease in hematocrit. White blood cell count is elevated in neonates, and growing puppies will have increased hepatic levels, and on a blood smear, puppies and kittens normally have polychromasia and nucleated red blood cells. The kidneys are still developing up to the animal’s first eight weeks, which results in a low specific gravity being normal. A specific gravity of 1.006-1.017. is normal, as well as dilute urine. Glucosuria is also normal in puppies and kittens less than eight weeks old.

Internal organ issues

Neonates also have an immature liver at birth. This leads to a higher incidence of hypoglycemia. Vomiting, hypothermia, diarrhea, and infection all quickly contribute to hypoglycemia. Once a neonate is hypoglycemic, it is lethargic, ataxic, has decreased suckle reflex, and becomes hypothermic. Hypoglycemia must not be prolonged due to possible brain injury and death.

A Labrador retriever puppy with bruising.
A Labrador retriever puppy with bruising.

If neonates present to the hospital and diagnostics are performed, nurses must know normal blood chemistry values and behavior of organ systems of babies will be different than those of adult dogs and cats. Nurses need to be aware of these differences to adjust care and be alert to problems. Blood draws should be limited to 10 percent of blood volume.

White blood cell count is elevated in neonates, and growing puppies will have increased hepatic levels (AlkPhos, GGT) and on a blood smear, puppies and kittens normally have polychromasia and nucleated red blood cells.

In patients less than four weeks old, their ability to absorb, metabolize, and eliminate drugs is not the same as in adult patients. Drug doses may need to be increased and time between doses decreased to ensure appropriate plasma levels are maintained. Care must be taken with drugs able to pass the blood brain barrier because neonates have a more permeable blood brain barrier.

Additionally, drugs undergoing enterohepatic circulation can disrupt the normal bacterial colonization of the gastrointestinal tract, leading to diarrhea and more complications.

Beta-lactam antibiotics, such as ampicillin and amoxicillin, are considered safest for antibiotic use. Tetracyclines can lead to developing skeletal changes and quinolones can cause cartilage lesions in developing puppies. If these antibiotics are needed, MIC cultures should support their use.

If newborn puppies or kittens do not nurse immediately, become ill and cannot nurse, or are not getting enough to eat (too many in the litter, weak, etc.), it is up to humans to intervene and supply nutrition. The stomach capacity of a puppy or kitten four weeks of age and under is 50 to 80 ml/kg daily; the amount should be divided into feedings every two to four hours.

Babies can be weighed daily to measure their progress. Puppies should gain 1g/lbs of anticipated adult body weight per day, and kittens should gain 7-10g/day. If possible, these babies should be fed with a bottle and encouraged to nurse as well. If the neonate is not suckling at all, an orogastric tube is easily passed and the liquid diet can be fed via the tube.

Parasites

Parasitism is very common in neonates and pediatrics. They can be acquired by fecal/oral transmission or transplacental.

Parasitism can be fatal if left untreated. It can cause dehydration, anemia, diarrhea, impaction, or neurologic disease.

Puppies are susceptible to parvovirus if they have not been vaccinated or have been under-vaccinated. These puppies require intensive nursing care. They can quickly become hypoglycemic, hypovolemic, hypothermic, and hypoxic from the constant loss of fluids and not enough nutrition. Nutrition can be supplemented via a nasoesophageal or nasogastric tube via trickle feeding. Nurses must keep these patients clean and dry, and adhere to proper infectious disease protocols.

Fading puppy/kitten syndrome is a condition where the clinical signs are very unclear. The patient does not gain weight, becomes weak, and, over time, dies. There is not a clear cause of fading puppy/kitten. Some clinicians believe it is due to congenital defect of hypoxia.

This puppy being treated for parvo.
This puppy being treated for parvo.

Neonatal isoerthrolysis occurs when a female cat with type B blood breeds with a type A tomcat. When blood type A or AB kittens are produced, they are at risk of hemolysis from the mom’s antibodies in the colostrum. Hemolysis leads to anemia, icterus, and pigmenturia. They eventually die from disseminated intravascular coagulation.

Septicemia

Septicemia can occur in neonates. This can be caused by bacteria entering the blood stream in some way. This can be via the GI tract, respiratory tract, urinary tract, skin, umbilical cord, or when a puppy’s tail is docked.

When drawing blood from these patients, it is important to remember a few points. The jugular is the most reasonable vessel. Do not collect more than 10 percent of the patient’s blood volume in a 24-hour period. Try not to use alcohol because it can cool the patient down too much.

Even with healthy puppies and kittens, client education is important in ensuring a healthy first year and a strong immune system. The American Animal Hospital Association (AAHA) has published vaccine guidelines for both young and adult cats and dogs and owners should be encouraged to research, in conjunction with education from the veterinary team, appropriate vaccines and the importance of boosters. Core and non-core vaccines are defined and may differ according to geographic location.

Tami Lind, BS, RVT, VTS (ECC), is the current ICU and ER supervisor at Purdue University Veterinary Teaching Hospital. Lind has been at the university for 10 years. She went to veterinary technology school at Purdue and graduated in 2010 with her bachelor’s degree in veterinary technology and has never left. She started as a veterinary technician in the ICU, and has been the supervisor at Purdue since 2012. Lind received her VTS in emergency and critical care in October 2016.

References

  • Lopate, Cheryl. “The critical neonate: under 4 weeks of age” Clinician’s Brief November 2009
  • Lee, Justine A; Cohn, Leah A. “Pediatric critical care” Clinician’s Brief January 2015
  • Lee, Justine A; Cohn, Leah A. “Pediatric critical care part 2: monitoring and treatment” Clinician’s Brief February 2015
  • Silverstein, Deborah C., and Kate Hopper. Small Animal Critical Care Medicine. St. Louis, MO: Saunders/Elsevier, 2009

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