The Modern Equine Vet
March 2024
Vol 14 Issue 3 2024
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Cover Story | Foal Health

Referring a Neonatal Foal

By Marie Rosenthal MS

An early referral may give a neonatal foal a better chance at survival than treating some problems in the barn, but how does a veterinarian decide which to do when a foal can quickly go from doing okay to not doing so well?

Trust your instincts when assessing a young foal, recommended Emily F. Floyd, BVSc, DACVIM, MRCVS, an internal medicine specialist in neonatology, at Rossdales, in England. Dr. Floyd listed some red flags at the BEVA Congress 2023, held in Liverpool.

Right off the bat, some issues are well-suited for farm care, and some are not, she added. “There are some things that you’re probably not going to treat in the field successfully to start with,” she said.

For instance, most veterinarians can manage a neonatal maladjustment syndrome, infection, colic, diarrhea or isoerythrolysis, if they are mild cases, but if they worsen, don’t hesitate to refer, Dr. Floyd suggested.

“If you are identifying them as a mild case, it may well be something that you can just monitor at home,” she said. “But there are definitely things that are not suited to at-home care.”

The conditions that could be difficult to manage at home include sepsis or organ dysfunction; neurological issues, including persistent seizures; severe colic or diarrhea; inability to tolerate enteral feedings; and issues that may require surgery or recumbency.

“This is not an exhaustive list, but these are the sorts of things that I think personally are difficult to manage at home,” Dr. Floyd said, so it’s a good idea to start talking with the client about a referral early.

“When we think about identifying the need for referral, I think it helps to be logical,” she said. To her that means going through the initial foal examination in a logical fashion to identify any red flags.

The mare’s history can be the biggest red flag, she said. If the pregnancy was difficult or the mare had an illness during the pregnancy, she is less likely to produce a healthy foal, and it might be a good idea to suggest the client call you when the mare begins foaling, so you can address an issue immediately.

“If you’re having any signs that the mare had placentitis or has had premature lactation, there’s going to be greater risk for sepsis in that foal. So, you want to be on the ball before you even get there,” Dr. Floyd said.

Ask the client whether the foal met the milestones of the 1-2-3 rule—healthy foals should stand within 1 hour, nurse within 2 hours and pass the meconium within 3 hours after birth.

“Often you will get a story like this from a client—I think it’s one of the most common things I hear —’The foal was a bit slow and then it had been nursing.’ If the foal didn’t meet those marks, your alarm bells already should be going,” she said. Sometimes a foal will put its head up to the mare’s nipples, but won’t nurse, and clients mistake that for suckling, she warned.

Entropion, even if the eyes are slightly sunken, is a sign the foal is becoming dehydrated and probably is not nursing.

A dystocia foal is more likely to have at least 1 problem and should be referred.

Look the foal over to see if everything from the hair coat to the eyes and legs look normal.

“When you’re looking for the red flags, work through the process. It might be in the history; it might be in your physical exam or maybe the foal’s not doing what you expect. And don’t be afraid to refer because you haven’t got the facilities to [take care of the foal],” she said.

If the foal is living on the outskirts of your practice, it’s probably better to refer because you might not be able to get to it if it starts having problems. “Foals go wrong very quickly,” she warned.

“Even if the foal’s not going to need advanced care, it still might be better to give the fuller care it needs straight away” in a referral hospital rather than the barn, she said.

Making the Decision
“You’re using your history, you’re using your clinical exam, and you’re thinking to yourself, ‘Well, I think I’ve probably got this’, or ‘I haven’t got this, and this is what I’m going to do,’” she said. “This is the really critical point.

“If you decide, ‘I’ve got this, I can treat this foal at home and know what’s going on,’ you want to be critical of what’s happening when you treat it,” she said. Is the foal progressing the way you expected? If you are going to treat, what do you hope to see to demonstrate the foal is improving?

If not, alarm bells should again be ringing loudly, according to Dr. Floyd.

If you aren’t sure, it is entirely appropriate to run some routine blood tests. If any of the ranges are abnormal that could help you make your decision faster. The results could “prompt you to say, ‘Actually I think I might be underestimating this foal’s severity of disease.’”

Ultrasonography is useful, she said. “Your ultrasound machine is your friend; it’s so quick, it’s so easy,” she said.

If you aren’t sure what to do, reassess and get the client to call you in about 30 minutes to see how the foal is doing. “If things aren’t going the right way, don’t just keep persevering,” she said. If you still aren’t sure, pick up the phone and talk with a colleague, she suggested.

If you do decide to refer, talk with the center and ask about costs to help with the client’s expectations, Dr. Floyd suggested.

There are always exceptions, Dr. Floyd said. Larger breeding facilities with state-of-the-art facilities and highly trained staff might be able to manage a difficult case, but for the most part, a quick referral means the best chance for the foal, she added.

“Trust your instincts. If it doesn’t seem right, it probably isn’t right. Act on it straight away,” Dr. Floyd said. MeV

6 Red Flags Signaling a Referral
Here are the red flags for Emily F. Floyd, BVSc, DACVIM, MRCVS, an internal medicine specialist in neonatology, at Rossdales, in England.

1. Sepsis
“Sepsis is a big red flag,” Dr. Floyd said, “We still recognize that sepsis is probably the leading cause of foal death across the UK, but it’s actually often a complicating factor of other things.”

The obvious signs are cardiovascular compromise, but sometimes the first sign is just a foal that is lying around. “We had a shire foal this year that came in with early sepsis. You could get this foal up, and it would get on the mare, but as soon as you turned around, it would just flop in a heap,” she said.

Signs of hypoxia and vasodilation are signals that the foal has a more severe sepsis. “If you’re seeing a coronary band hyperemia even before the foal has collapsed in a heap, it’s a good sign to you that you’ve got inappropriate vasodilation. You’re starting to have cardiovascular dysfunction. So that to me is always a real red flag. Those foals could have bigger problems developing that you may not be seeing,” she said.

2. Organ Dysfunction
“If you’re seeing obvious signs of problems in any of the big organ systems,” such as abnormal respiratory problems, it’s time to refer. These problems are prevalent in premature foals.

“If they’re not able to maintain their thoracic inflation, they’re very difficult to treat,” she said.

3. Neurologic Problems
If the foal has nystagmus; seizures; does not reach its milestones; or the client thought the foal was doing well but now is not; and it has increased muscle tension, rigidity and has trouble with its balance, it should be referred.

“You’re picking up first neurologic signs in a foal that has perhaps a history of dystocia or something else, this is a point to intervene and say, ‘This foal is getting on the slippery slope of downwards,’” Dr. Floyd said. “If you act now, you’re much more likely to be successful.”

Neurological problems and seizures, even partial seizures are difficult to manage at home. It’s better for the foal if you can intervene before it has full seizures.

4. GI Issues
If a foal has a small amount of diarrhea that is not typically a problem, but if it’s got a marked abdominal distension or goes beyond a “normal” meconium impaction, “don’t keep persevering. Either do some more diagnostics or think about what you can do to help this foal.

“I think one of the other common things that people get tricked is that you have these foals that are maybe a bit immature or they’ve got mild maladjustment, and they do have a meconium impaction, and GI delayed transit, but they also maybe have a small bladder tear. And so, you get sort of trapped in thinking this foal’s got a meconium impaction, and you’re treating it for that for the first 24 hours. But the foal may have [have another issue, too].”

It is important to be critical about reassessing the foal to assure you are not missing other signs that this isn’t just a simple problem.

“I think if they’re refluxing—and we do get that syndrome in foals that are a few hours to 24 hours of age—this sort of syndrome of ileus after, maybe it’s part of maladjustment, maybe it’s an inflammatory thing, but they don’t tolerate milk well.

“And I think if you have a foal that’s not tolerating milk well for more than a day, it’s very difficult to give them adequate nutrition at home,”
Dr. Floyd said. “I would get them into the clinic.”

5. Severe Rib Fractures
Rib fractures are common, but if there are several cracked ribs and the rib cage is unstable, the foal should be referred for surgery.

6. Recumbency
“The final red flag for me for referral is a foal that’s recumbent for whatever reason, if they’re recumbent and they stay recumbent, it’s hard to keep them at home,” she said. There are many reasons for recumbency from orthopedic to neurologic to gastrologic issues, so get them into the clinic.