For discussion of the normal physiology of neonates, and what may causes them to 'fade' see lecture: Small Animal Neonatology: They look normal when they are born and then die. However, the most common health problems in young kittens are hypothermia, hypoglycaemia, dehydration, diarrhoea, and constipation.
Recognition of Illness
It is important to realise that while an individual kitten may be presented for investigation, trying to find a specific cause can be difficult as most cases are multifactorial. It is often only be taking a complete history of the kitten, the rest of its litter, their birth, their mothers health, and the overall health and management of the other cats in the cattery that the true nature of the problem can be determined. In the long term, a number of factors may need to be addressed to reduce overall mortality within a cattery:
Causes of 'fading' or sick kittens:
Birth-related factors (anoxia, trauma, hypothermia)
Low birth weights
Inappropriate environment (temperature, humidity, hygiene, overcrowding, over-handling)
Neonatal isoerythrolysis (NI)
Infection (viral, bacterial, parasitic)
If sick kittens are not to die, they must be detected and treated early as their health status can deteriorate rapidly. All neonates need to be closely observed and, without over-handling, checked for congenital defects, and monitored for weight gain. Failure to gain weight over 24h requires attention.
Normal kittens eat or sleep 90% of the time for their first 2 weeks. Unfortunately, neonates tend to show limited responses to disease, so their presenting signs are rarely indicative of a particular condition. Regardless of whether they are hungry or ill they typically cry excessively, and/or fail to suckle. Common signs of illness include weakness, hypothermia, lethargy, restlessness, and/or regurgitation of milk. Sick kittens respond poorly to their environment, and typically have either very thin abdomens from lack of food or very swollen abdomens from swallowing air. They often lay separated from the other kittens and are ignored by the queen. Sick kittens need to be treated immediately as they cope very poorly with anorexia or hypothermia. They, and their mother, should be examined.
Examination of a conscious kitten can be difficult as they often wriggle, and can be aggressive if poorly socialised. They should be assed for:
Weight and body condition, and signs of trauma, congenital defects, or disease. (While some congenital defects, such as cleft palate or atresia ani should be readily evident, others, like congenital heart defects, are only evident on a careful post mortem examination [PME] or following further investigation). It is important to be aware of normal age-related changes and not over-interpret normal findings e.g., neonatal joint instability or cardiac murmurs. The coat should be checked for quality, cleanness and parasites. The thorax and head should be checked for normal shape and feel; HR ~200-220 beats per minute; respiration ~15-35 breaths per minute. The abdomen should feel gently full, not swollen, tight or empty. The intestines and bladder should feel soft, mobile and non-painful. The extremities should be pale pink (extremity erythaemia is often associated with sepsis).
Eyes and nose--kitten's eyes should open between days 5-14; a mild cloudiness is normal and should resolve quickly. While a small amount of sticky discharge is not of major concern, closed eyelids that are swollen or matted with pus is.
Gums--until about a week old healthy neonates have dark pink or red gums. However, sick neonates often have pale, grey or bluish gums.
Umbilical cord--this should be dry and free of discharges, and normally falls off between 3-7 days of age. It is of concern if it is still moist, painful, inflamed or discharging.
Defaecation and urination--since stimulation of the perineal area in kittens of <3 weeks of age results in defaecation and urination this technique can be used to look for the presence of diarrhoea or constipation (present in ~60% of sick kittens), and to check urine colour (see below).
The small size of kittens makes collection difficult. It is usually only possible to take very small volumes of blood (max 1.5ml because total blood volume = ~75ml/kg, so at 1 week a kitten of 200g only has ~15ml total). Blood should be collected from the jugular vein. Care should be taken not to induce a large haematoma. This can result in significant loss of circulating volume, and can, if severe, obstruct the airway. Collect samples into 0.5ml EDTA and heparin tubes, run glucose on a single drop using a glucometer, and run packed cell volume (PCV) and total protein (TP) on a micro-haematocrit tube. It is often only possible to assess PCV, TP, urea, glucose, and blood smear cytology.
In order to correctly interpret the results it is important to know what is normal for kittens of that age (Chandler 1992; Hotston Moore and Sturgess 1998). For example, normal neonatal kittens have mild normochromic normocytic anaemia, and blood urea and creatinine levels in kittens are considerably lower than adults.
Few biochemical and haematological results are specific for a particular disease. Severe anaemia may be seen with NI, or a heavy flea or hookworm infestation. Panleukopenia may be seen with FPV, FeLV, or sepsis. Hypoglycaemia is common, regardless of the cause of illness. Hyperbilirubinaemia may be seen in NI or liver disease. Hyperammonaemia may occur with hepatic encephalopathy and a congenital portosystemic shunt.
Stimulating the kitten's perineum with a warm moist cotton ball is a useful method for collecting a urine sample. Urinalysis can be helpful in the diagnosis of NI, where brown-staining urine results from haemoglobinuria. Pyuria is suggestive of a urinary tract infection, while a specific gravity of >1.017 indicates dehydration. Glucosuria is not abnormal in neonates.
More specific tests include serology (e.g., FeLV, FIV), slide agglutination or Coombs' test for NI, pharyngeal swabs for the cat flu viruses, or ocular swabs for Chlamydophila felis. If a bacterial infection is suspected swabs, blood or urine can be taken for culture and sensitivity. In cases of septicaemia, it is difficult to obtain sufficient blood to perform blood culture. It is usually more rewarding to sacrifice a moribund kitten, and then send fresh samples of heart blood, heart tissue, liver, lungs, etc. for culture. Survey radiography or ultrasound examination may be considered, but there is little radiographic contrast in kittens (so reduce the kV by half of that used in an adult of the same body thickness), and ultrasound examination may require a 'stand-off' for the probe.
Faecal cultures can be examined for the presence of pathogenic bacteria, Giardia spp., Tritrichomonas foetus, coccidia, and intestinal parasites.
PME: Despite best attempts sick neonates often die, so it is important to gain as much information as possible. Gross changes can be helpful in determining the cause of some illness: Kittens with an empty or gas filled stomach, a full gallbladder, and a full urinary bladder may indicate maternal neglect or lack of nursing. A stomach filled with milk may indicate sudden death (peracute infection or trauma), or gastrointestinal dysfunction. Kittens with NI show various changes depending on the duration and severity of disease. The bladder may be full of dark brown urine, the body may be pale and/or jaundiced, the liver and spleen may be enlarged (due to extramedullary haematopoiesis and erythrophagocytosis), and acute tubular necrosis may be present in the kidneys. Septic kittens may show petechiation of internal organs. Atelectatic lungs (dark red lungs that do not float in water) indicate stillbirth.
When collecting samples, be it by mouth or eye swab, blood, faeces or urine collection, coat brushing, skin scrapping, or at PME, it is essential to discuss the procedure with the laboratory that will be undertaking the analysis. Incorrect sample handling can result in erroneous results.
Treatment of Individual Kittens
I. Peri-natal Kitten Revival
Hypoxia related to dystocia is probably the single most significant factor in neonatal mortality. Since the healthy mother cat will generally make a good job of nursing her kittens, it is important not to interfere unless necessary. However, intervention is recommended when a kitten is not breathing, or on the few occasions when maternal instinct appears to be lacking. The aim is to imitate the cat's own methods; she ensures that the kitten's nose and mouth are clear, then, with a nipping/licking action, she chews through the umbilical cord. This, and more vigorous licking of this area, provides stimulation of respiration. The cat then gives the kitten a more general drying lick, then concentrates on the perineal area in order initiate bowel and bladder functions. Human intervention should follow this plan, with additions in cases of emergency.
Tear the membranes from the nose, wipe the nose and open the mouth, tilt the kitten's head down and clear away any fluid.
If the umbilical cord has not broken on delivery, separate it using 2 haemostats >1 inch from the kitten. Complicated cutting and tying are not usually necessary. Dip the stump in chlorhexidine.
Clearing the airways: If the kitten is not breathing, or if it has come tail first and possibly inhaled fluid, it is necessary to clear debris and fluid from the airway. If suction equipment is available this can be done by sucking the debris out of the airway. This can also be achieved using a Jackson cat urinary catheter attached to a 5-10ml syringe as a gentle suction apparatus. The catheter can also be used to induce the kitten to sneeze and cough by stimulating its nose/throat. One of the traditionally used methods involves swinging the kitten. To do this, place the kitten in the palm of your hand, its back towards your palm and neck between your forefinger and third finger, its head protruding between your fingers. Enclose the kitten in your fingers and, turning your hand palm downwards with your arm extended, give a gentle swing several times; make quite sure first that you are not too near any protruding edges or disaster will follow. The swing will have the effect of forcing fluids out of the kitten's airway and a further wipe of its nose and mouth will clear any debris away. The swing will also serve to stimulate respiration. Take care; if performed too vigorously this method can result in brain haemorrhage.
Stimulation of respiration: If the kitten is still not breathing, some form of artificial respiration may be necessary. Mouth-to-mouth respiration can be useful, but only if very carefully performed. There are several points to remember. It is no use blowing fluids and debris further down the airway; these must be cleared away first (see above). Secondly, the capacity of kitten lungs compared to humans is minute. Blow very gently and allow a pause for expiration. Repeat this cycle every 3-5 seconds. Breathing into the kitten's airway through a small endotracheal tube or drinking straw may help to reduce the risk of over-inflating the kitten's lungs, and be more hygienic than direct mouth-to-mouth. Various methods have been used to make the new-born animal gasp, including the administration of brandy or other spirits to the kitten's tongue, flicking its chest sharply but gently with a fingertip, alternate warm and cold water applications, or the insertion of a 25-g needle into the nasal philtrum. However, it is more reliable to apply a drop of doxapram hydrochloride (20mg/ml) sublingually. A strong regular heart beat should be easily palpable, if not; external cardiac massage can be attempted. It is important to note that unlike adults neonatal heart rates fall in a protective response to hypoxia, and this should not be misinterpreted. If the dam was given opioids prior to delivery naloxone hydrochloride (0.4mg/ml) can be administered to the offspring (1 drop sublingually) to reverse respiratory depression.
If in doubt persist with stimulating the kitten; some can still be revived after >30 minutes from birth. That said, the longer the duration before breathing the higher the risk of hypoxia causing brain damage or blindness. Hypoxic bradycardic puppies may respond to the administration of atropine into the umbilical vein. While the author has not used this method in kittens, it may be worth considering. Since premature kittens often have very poor pulmonary development the administration of dexamethasone (0.1mg) may help to stimulate surfactant production. Supplementary oxygen should be given until the kitten is breathing regularly and is obviously vigorous. This can be done using a small face mask, an oxygen box, or using a fine urinary catheter to administer intranasal oxygen (the adapter to a 3 French endotracheal tube can be used to connect the oxygen supply to the catheter). The kittens tongue is a reliable indicator of respiration. If the kitten is receiving sufficient oxygen its tongue will be pink, if not it will have a bluish tint.
Provide warmth: The kitten should then be rubbed all over with a clean towel. This further stimulates respiration and dries the kitten. It should then be kept warm. If the mother is ill or uncooperative, place the kittens in contact with a warm, well-covered hot water bottle and conserve the heat by covering the bed with a blanket. Great care must be taken not to inflict contact burns on the kittens by having the bottle too hot.
II. Treatment of Neonatal Kittens
Sick kittens need to be treated immediately. Supportive therapy is aimed at re-warming, maintaining blood glucose levels, correcting dehydration and, when required, supplying additional oxygen.
1. Drug metabolism: Care should be taken when medicating kittens as the pharmacokinetics of drug metabolism can be quite different from those of adults. Neonates often have increased absorption, decreased protein binding (due to lower serum albumin concentrations), and altered drug re-distribution (due to a higher percentage body water and decrease fat). They are also more likely to show toxic side effects as they have increased permeability of the blood-brain barrier, and a reduced ability to detoxify drugs by metabolism or excretion. Few drugs have been evaluated in neonates so great care should always be taken when considering administering medications to this age group. As a general guide give 30-50% of the adult dose e.g., with opioids; however, many drugs are strongly disadvised, including many antibiotics (see later), and NSAIDS (if <6weeks of age; because to renotoxicity).
2. Hypothermia: Neonatal kittens cannot thermo-regulate, they lack insulating fat and thermogenic brown, and they cannot react to cold by shivering. They loose heat rapidly, especially if left wet. Body temperature generally falls from ~36°C at birth, to 30°C within a few hours, then increases to 38°C over the first week. It is important that these temperatures are maintained as hypothermia can initiate a number of other problems: e.g., A week-old kitten should have a temperature of 35-37°C and a HR of 200-250bpm, but if its temperature falls to 30°C, its HR will fall to 40-50 bpm. While this is a protective mechanism, if persistent, it can results in a decrease in respiratory rate that may in turn leads to cardiopulmonary failure. Also, a hypothermic kitten will not suckle effectively; it may develop gastrointestinal ileus, and will have an increased susceptibility to infection. It is important to check the temperature of any potentially weak or ill kittens, however, if their temperature is <34°C they are likely to die.
When attempting to re-warm hypothermic kittens it is important to do so gradually, ideally over 1-4h, depending on the severity of chilling. Rapid re-warming can lead to cardiovascular collapse and death. Importantly, overheating can also be detrimental, and can quickly lead to dehydration and death. Because hypothermia can markedly reduce the absorptive ability of the intestines concurrent hypoglycaemia and dehydration cannot be corrected using oral solutions; parenteral fluids are needed.
3. Hypoglycaemia: This results from inadequate or infrequent feeding. It can cause severe depression, muscle twitching and occasionally lead to convulsions and death. If a kitten refuses to feed, prompt action is required. Kittens have no energy reserves and will deteriorate rapidly. If a kitten is showing signs of hypoglycaemia, a few drops of glucose syrup placed on its gums can be life saving. However, if the kitten is cold, glucose solution should not be given by mouth as it will not be adsorbed from hypothermic intestines. More severe cases can be corrected by the parenteral administration of isotonic glucose solutions. It is important to correct any hypothermia at the same time. When giving supplemental glucose it is important to monitor glucose blood concentrations as kittens can easily become hyperglycaemic. Once recovering the kitten can be fed a small amount of glucose solution, and either the amount and/or frequency of routine feeding should be increased. Note: the nutritional requirements of a septic kitten are increased (~1.5x maintenance) so in these cases it may be necessary to provide nutrition al support by tube feeding (see later).
This is not the lecture for a detailed discussion of the nutritional requirements of kittens, the pro and cons of different types of milk replacement formulation, or the various methods of supplemental feeding. Sufficient to say that is generally best to feed commercially available kitten formula, and to make it up and feed it as per the manufacture's recommendations as for either supplemental or full replacement feeding.
Tube feeding: If kittens are too weak to suckle for themselves, then tube feeding is perhaps the cleanest and most efficient method by which to deliver nutrition. However, it requires proper equipment and good technical skills. Also, as the kittens have no control over how much they are fed, they can easily be given too much (or too little). Stomach tubes must be soft, flexible, blunt-ended and generally not more than 2-3 mm wide. A premature human infant feeding tube is ideal (6-10 French feeding tube for neonates and 8-10 French for kittens over 300g), or a soft rubber canine urethral catheter may also be used. The tube must be measured to the correct length (from the kitten's nose to the last rib), and an indelible mark should be made on the tube at this point. The tube should be lubricated with K-Y jelly before it is used. To place the tube the kitten's mouth must be opened by pressing gently at the corners, and, keeping the head flexed downwards, the tube is then slid along the roof of the mouth and down the back of the kitten's throat into the oesophagus. The tube is passed down the oesophagus until the mark on the tube is level with the kitten's nose. The other end of the tube will then be in its stomach. A syringe containing pre-warmed milk can then be attached, and the milk can be delivered slowly, directly into the stomach. If the kitten's head is kept flexed forward, it is quite difficult to miss the oesophagus and so pass the tube into the airway by mistake. Many kittens mew loudly throughout the whole procedure, and it is useful to note that they cannot do this if the tube is in the airway. If the tube does not pass easily or if coughing occurs withdraw the tube from the kitten's mouth and try again.
Frequency of feeding:
0-2 weeks: 6-10 feeds/24h at 2-4h intervals
2-4 weeks: 4-8 feeds/24h at 3-6h intervals
4-5 weeks: 3-5 feeds/24h at 5-8h intervals
4. Diarrhoea and dehydration: Diarrhoea is common in kittens, particularly those fed milk replacement formula. It may also be caused by over feeding; giving too concentrated a solution of milk replacement formula; or as a result of infection (usually caused by poor hygiene). Treatment must be prompt as dehydration can develop rapidly, followed by collapse, hypothermia, and death. Looking for skin tenting is an unreliable method of assessing dehydration in neonates. Instead, dehydration should be assessed by weight loss, dryness of mucus membranes, and urine specific gravity (>1.017).
Mild cases respond well to dilution of the milk replacement formula 50:50 with boiled water, which can then be given until the diarrhoea stops. Treatment with SQ fluids may be required (see below, but starting with ~1ml/30g is reasonable).
Severe cases should be given no milk at all. Instead they can be given oral support with 5-10% glucose solution, glucose-saline, or isotonic electrolyte solution (e.g., "Lectade") until the diarrhoea stops. While oral supplementation may help, it is generally better to give parenteral fluids. If the neonate is cold, do not give any oral medication/fluid.
Intravenous (IV) or intraosseous (IO) routes are used most frequently for parenteral access. IV access can often be gained using a 23-25-g catheter placed in the cephalic or jugular vein. However, kittens' short legs can make catheter placement difficult and flow hard to maintain. IO access can be easily gained using the proximal femur (see separate notes). Subcutaneous (SQ), intramuscular and intraperitoneal (IP) routes are less advisable as the absorption is slower and less reliable than in adults, especially if dehydration or shock is present. In addition, the IP route requires strict asepsis, and carries a small risk of puncturing viscera. If the IP route is to be used the daily fluid requirement is calculated (see below) then the volume is divided, and given 2-3x daily.
Fluid requirements per kg are higher in neonates than adults but total volumes required are low. Immature kidneys lack the ability to concentrate urine so fluid losses cannot be controlled, especially if there is concurrent vomiting and/or diarrhoea. Maintenance fluid rates in kittens <2 weeks of age are 130-220ml/kg/24h (ave. 180ml/kg/24h), by weaning ~120ml/kg/24h, and adult levels of ~50-65ml/kg/24h from 6 months. e.g., 1 week old kitten, 200g, needs 36ml fluid/24h maintenance; 1.5ml/h (~1 drop/40 seconds using a paediatric giving set). If 7% dehydrated; deficit = 14ml. Fluid rate ~2.5ml/h over 6h (1 drop/20sec), then reduce to ~2ml/h (1 drop/30sec); but always monitor for over-hydration.
Use fluid pumps, syringe pumps, or a burette with a paediatric giving set (60 drops/ml) to reduce the risk of over-hydration to which all neonates are particularly susceptible (in part because of their immature kidneys).
While sick neonates are often acidotic their reduced hepatic ability to metabolise lactate to bicarbonate means that lactated Ringers should not be given. Saline or Ringer's are better choices in kittens <7 weeks of age. In severe acidosis bicarbonate can be given as per known acid-base status, or ~2mmol/kg can be given over 10-15mins. Hypoglycaemic kittens should be given 5% dextrose solution mixed 50:50 with saline, or 1-2ml of 10-25% glucose in very severe cases. All fluids should be carefully warmed prior to administration and kittens should be closely observed for signs of over-hydration.
Once the kitten has been warmed up and given fluid therapy it must be allowed to recover quietly. Feeding can only begin once the kitten is warm and able to suck. Stomach tubing is not helpful here, since when a kitten is cold and collapsed its intestines stop functioning, so stomach contents can be easily regurgitated and then aspirated. As soon as the kitten is able to suck, it should be given isotonic glucose or Lectade solution (~1ml/100g body weight) given every 15 minutes until it is rehydrated and can urinate when massaged. If all goes well, diluted milk replacement formula can then be introduced after 24 hours, and full strength milk 24 hours after that.
The administration of antibiotics is not recommended, particularly for the treatment of diarrhoea. Antibiotics severely disrupt the process of normal colonisation of the gut by harmless bacteria, and can therefore make the situation worse. Antibiotics cannot be used as a substitute for colostrums and good hygiene.
5. Constipation: This is a very common problem, particularly in hand reared kittens, probably due to the difficulty in stimulating defecation sufficiently frequently. Normal kitten faeces have the consistency of toothpaste. If the faeces become very hard, making the kitten strain excessively, or if a kitten does not pass any motions for 2-3 days, small doses of liquid paraffin or "Katalax" should be given, (about 0.5 ml per feed for 2-3 days should have the desired effect). Severe cases may require de-impaction.
6. Treatment for NI: For the cause of NI see notes on Neonatology. Kittens showing signs of NI, if <24h old, should be immediately removed from their mother to prevent further absorption of anti-A antibodies. In kittens, most colostral antibodies are absorbed by 12-24h of age. Once removed, the kittens can either be fostered to a type-A queen, or fed milk replacer for 24 hours. After this time it is generally safe for them to be returned to their dam.
If the anaemia is severe or progressing a blood transfusion should be performed. While kittens can survive with very low PCV (6-8%) they are very unstable, and should be pre-oxygenated prior to intervention. New born kittens lack anti-erythrocyte antibody, so at this time the only circulating antibody is that which was gained from the queen (anti-A antibody). Therefore, if the kitten is transfused with A-type blood, these cells will also be destroyed by the queen's antibodies, exacerbating the clinical signs. In the first 3 days of life it is therefore most appropriate to give a transfusion of the queen's erythrocytes as these will not be destroyed by her antibodies. It is advisable to wash the queen's erythrocytes prior to transfusion. To do this it is necessary to collect 2-5ml of the queen's blood (anti-coagulated with EDTA or heparin), centrifuge it at 1000 rpm for 1 minute, discard the supernatant, restore it to its original volume with normal saline, centrifuge as before, discard the supernatant, then re-suspend again in saline. The cells can then be transfused, via a 22-g needle via IO access (see separate notes). The kitten will start making its own anti-B antibodies soon after birth. After the first day the level of maternally derived anti-A antibody will fall. If the kitten needs a transfusion after 3 days of age it is usually safer to use washed type-A erythrocytes. Despite removing the kittens as soon as clinical signs are noted, most kittens that develop NI die within their first week of life.
e.g., 200g kitten with a PCV of 8%. If the PCV of the donor is 30% and target PCV for the kitten is 20%, then the volume of blood needed is:
Blood should be given at 7-15ml/kg/h.
7. Infections: Treatment of bacterial infections: Ideally, antibiotics would be selected according to culture and sensitivity testing. However, it is often not possible to wait for laboratory results as illness in neonates can progress rapidly. In many situations antibiotics must be selected empirically. The penicillins are generally less toxic than most other antibiotics, and are often used as a first choice. However, oral ampicillin must be given with caution as it can alter the gastrointestinal flora and cause diarrhoea. Generally, the parenteral administration of antibiotics is preferred, because oral medications may not be absorbed efficiently. Cephalosporins are often used as a second choice, with perhaps azithromycin as a third (although extensive studies have not been performed with this drug).
Other antibiotics may be considered depending of the nature of the infection. In all cases consult the data sheets. Trimethoprim-sulphonamide combinations may be used at reduced dosages, but should be avoided in kittens with anaemia or leukopenia. Macrolides (erythromycin, clindamycin and lincomycin) and metronidazole (MZL) should be used with caution in kittens with impaired hepatic function (and in the case of MZL should be give at much reduced doses ~5mg/kg/12h).
Antimicrobials that should be avoided in neonates include aminoglycosides (renal damage and ototoxicity), tetracyclines (binding to bone causing dental damage), chloramphenicol (bone marrow suppression) and, perhaps, quinolones (damage to growing cartilage--risk probably overstated in kittens, but should be avoided in pregnant animals).
Sepsis is common in neonates, and very difficult to treat. In addition to parenteral fluids and broad-spectrum antibiotic cover, plus good nursing care, the increased energy requirements in these cases (x1.5 neonatal maintenance requirements), means that supplemental feeding is essential in patients that typically have vomiting and/or diarrhoea, necessitating the use of anti-emetics (which are not licensed and not without risks in neonates) or the use of parenteral nutrition (which is incredibly difficult to do). If failure of passive transfer is suspected, consider giving adult serum IV (volume as per fluids).
Treatment of viral infections: Treatment of viral disease is often very difficult, which is probably why in a large study of causes of kitten death 75% of cases occurred post-weaning, and most of these resulted from viral infection (FCV, FHV-1, FPV and FIP). Neonatally FeLV, FIP, or FPV-infected kittens rarely survive. In all cases supportive therapy is essential; including fluids, nutrition, and covering antibiotics.
Treatment of parasitic infections: Toxocara may be treated with pyrantel or fenbendazole. Giardia may be treated with fenbendazole or metronidazole. T. foetus may be treated with ronidazole (not licensed). Coccidial infections may be treated with trimethoprim/sulphonamide and improved sanitation. Toxoplasma infections may be treated with clindamycin. Neonates from 2 days of age may be treated with fipronil for fleas and lice. Ivermectin is not recommended for the treatment of ear mites as idiosyncratic reactions can occur. For more information on the use of therapeutics in neonatal infections see Hotston Moore and Sturgess (1998).
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