The Modern Equine Vet
November 2023
Vol 13 Issue 11 2023
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Foal Health

Should You Refer That Foal?

By Paul Basilio

A neonatal foal can take a turn for the worst quickly in the field, and knowing when to refer them to a fully outfitted clinic can make all the difference.

“You cannot monitor a foal too closely,” said Emily Floyd, BVSc, DACVIM, MRCVS, at the 2023 BEVA Congress in Liverpool. “If you’re not sure, examine them again, and then examine them again. But don’t be afraid to ask for advice.”
But how can a veterinarian be sure when the foal needs more treatment options than what’s available on the truck? As with everything else in life, just make a note of the red flags.

To begin the decision process, it’s nice to rule out the low-hanging fruit. Conditions like moderate-to-severe sepsis/SIRS, severe colic or diarrhea, or orthopedic abnormalities that prevent the foal from standing are most likely going to require a facility with more resources.

However, foals with early or mild signs of those conditions could be successfully managed in the field, provided the signs don’t become too serious.

“When we think about identifying the need for referral, I think it helps to be logical,” said Dr. Floyd, clinical director at Rossdales Equine Hospital in Newmarket, UK. “Going through a list in a logical fashion will help you pick up the red flags when they’re there.”
1. Can I maintain tissue perfusion?
2. Can I provide nutritional support?
3. Can I treat or prevent sepsis?
4. Can I treat the primary disease?
5. Can I provide adequate nursing care?

If the answer to any of these questions is “No,” then a referral to a clinic is probably a good idea.

While it’s nearly impossible to compile an exhaustive list of conditions that will require referral, Dr. Floyd ran through some examples where her ‘Referral Alarm Bells’ would immediately start to ring.

RED FLAG #1: Sepsis and/or organ dysfunction
Sepsis is 1 of the leading causes of death in foals, and it’s often a complicating factor of other conditions, Dr. Floyd said.

“If there’s a foal with mild neonatal maladjustment but the client says that the foal has been getting up and nursing, the client is likely not appreciating the fact that the foal could also be developing early sepsis,” she explained. “This is a confounding factor, and you’ll go from having a foal that is sort of doing ok to having a foal that is definitely not doing ok.”

One of the big red flags to look out for with sepsis is an obvious sign of cardiovascular compromise, but often the first sign of sepsis is as simple as a foal that’s just lying around. For example, if a foal can stand and nurse from the mare but flops into a heap when left unattended, that’s a red flag.

“Don’t dismiss these early signs,” Dr. Floyd said. “If you’re picking those up early, you’re more likely to have success.”
Entropion is another one of the early signs that a foal is not nursing well and may be becoming dehydrated.

One of the more profound signs of sepsis is inappropriate vasodilation, which can manifest in coronary band hyperemia. It’s a sign of sepsis, but it can also indicate systemic inflammation. Some foals that experienced dystocia can have a hypoxic event that can trigger a marked vasodilatory process.

“If you see the coronary band hyperemia even before the foal collapses, that’s a good sign that the foal has inappropriate vasodilation, and it could start to have cardiovascular dysfunction,” she added.

RED FLAG #2: Neurologic signs
An early sign of neurologic dysfunction is increased muscle tension, including rigidity of the neck—something Dr. Floyd calls “the motorbike.”

“It’s when you go to get them up and they lean on you,” she said. “You can’t step away from them because they’ll fall.”

Sometimes, a foal can equilibrate once you get them standing for a few minutes. But even still, these early neurologic signs—particularly in a foal that experienced dystocia—could indicate that the foal’s health could easily plummet if no intervention is provided.

If these neurologic signs persist, seizures could result. Seizing foals can be difficult to treat on the farm.

RED FLAG #3: GI signs
“Generally, I think we tend to be quite complacent about what GI issues we can treat,” Dr. Floyd said. “We look at a foal and think, ‘Oh they’ve just got meconium impaction or a little diarrhea. I can manage this at home.’”

However, she added, it’s important to think of clues that may indicate that the GI signs could be outside of the normal spectrum. The presence of abdominal distension, for example, could indicate that the foal is beyond a simple meconium impaction.

“If you see that, don’t just keep persevering,” Dr. Floyd said. “Either do some more diagnostics or think about other help that you can provide for the foal. [Veterinarians] can get tricked into thinking that the foal is just a little dysmature or has a mild maladjustment in addition to the meconium impaction, but the foal also may have something like a small bladder tear. If you’re not being critical about re-assessing the foal, there may be all sorts of things that you can miss that indicate it’s not a simple issue.”

RED FLAG #4: Recumbency
If a foal is persistently recumbent, field management may not be the best option. Recumbency can be a sign of sepsis, or the foal could have an orthopedic issue such as a muscle rupture or congenital defect.

“If you conduct a thorough history and physical exam and you think you can provide treatment yourself, then you want to be critical of what’s happening during treatment,” Dr. Floyd added. “If the foal [doesn’t respond], then your alarm bells should be ringing quite loudly. Be critical. Don’t just keep going. Think about referral or think about whether there’s other diagnostics you can perform.”

RED FLAG #5: Lab abnormalities
Clinical assessment of foals is extremely important, but some laboratory abnormalities can indicate whether this foal should be treated at a facility.
• Hemoconcentration or anemia
• Leukopenia/leukocytosis or increased inflammatory markers
• Evidence of organ dysfunction or multisystemic disease
• Electrolyte abnormalities

“Some basic bloodwork can be an accentuation of your physical examination,” Dr. Floyd said. “If you have a foal that looks hemolytic or jaundiced, then sometimes you can underestimate that. But then you get the lab work back and it turns out that the foal has a PCV of 12%, and then you’ve possibly got more on your hands than you expected.”

For measuring lactate, Dr. Floyd doesn’t necessarily have a hard cut-off for what constitutes a referral red flag.

“I wouldn’t say that a lactate of 3 is fine and a lactate of 4 needs to go to the hospital,” she explained. “But if you’re thinking about whether you can manage the foal [in the field] and you have a POC lactate monitor that is showing a 4 or 5, then that’s just another indication of severe disease.”

One of the biggest laboratory red flags is an elevated creatinine level with a high urea concentration. Many of these foals will have several signs of perfusion abnormalities, and they will be predisposed to renal problems or acute kidney issues.

As with all red flags, Dr. Floyd has simple advice.

“Trust your instincts,” she said, “If it doesn’t seem right, then it probably isn’t. If the foal isn’t doing quite what you expect, then don’t dismiss that. You’re probably right. Just don’t be afraid to ask for advice.” MeV


Caring for a sick foal.
Image courtesy of Dr. Emily Floyd