Symposium on Neonatal Equine Disease

Nutritional Support of the Foal During

I ntensive Care

Anne M. Koterba, D.V.M.,* and

Willa H. Drummond, M.D. t

Provision of adequate nutritional support to the compromised

neonate is an essential part of critical care, but it often can become
a major management problem. Adequate calories, protein, vitamins,
minerals, and electrolytes must be provided for growth and healing
and to avoid catabolism of body protein. Despite the best intentions,
however, very often even the minimum caloric requirements are not
supplied, and the animal is inadvertently starved, occasionally to
death. The reasons for the common failure to provide adequate nu-
trition to newborns are numerous: (1) the needs and volumes re-
quired are underestimated; (2) the sick neonate rarely has a good
appetite and often will not nurse at all, necessitating other routes of
delivery for continued oral feeding; and (3) the gastrointestinal tracts
of many sick neonates will not tolerate milk diets, and bloating, colic,
diarrhea, and regurgitation are common complications.

NUTRITIONAL REQUIREMENTS

Nutrition of the premature or sick neonate is a science that is in

its early stages of development, even in human neonatology. Much
less is known regarding equine neonatal nutritional requirements:
The exact nutritional requirements necessary for optimal growth have
not been defined for the normal term foal, let alone for the prema-
ture, growth retarded, or debilitated animal whose caloric, mineral,
and vitamin needs might be very different. Some of the unique nu-
tritional requirements of premature humans (for example, Hexcess"
folate, vitamin E, cysteine) may well prove to be equally important
considerations in premature equine patients. For example, it may be

From University of Florida, Gainesville, Florida

* Diplomate, American College of Veterinary Internal Medicine; Graduate Research As-
sistant, Department of Medical Sciences, College of Veterinary Medicine
t Associate Professor, Departments of Pediatrics and Physiology, College of Medicine,
and Department of Medical Sciences, College of Veterinary Medicine

Veterinary Clinics of North America: Equine Practice-Vol. 1, No.1, April 1985 35

36 ANNE M. KOTERBA AND WILLA H. DRUMMOND

found that the premature foal will need calcium and phosphorus sup-
plementation to insure normal bone development; in the horse, how-
ever, an experimental data base is currently nonexistent.
C9nfusion regarding the average daily caloric intake necessary
for foal maintenance and growth is common. One equine text 7 rec-
ommends that 100 ml of milk per kg body weight per day, or about
10 per cent of body weight, be supplied to the term foal. This reg-
imen would provide 4500 ml of fluid and about 2250 kcal per day (50
kcal per kg) to a 45-kg animal. However, the caloric requirements
for adequate growth of premature and term human infants have been
estimated to be well over double this amount (104 to 120 kcal per kg
per 24 hours).2 Measurements of free choice milk intake in normal
orphan foals fed by bottle or in premature or term foals recovering
from various illnesses suggest that, in many foals, the figure of 120
kcal per kg per day is closer to the appropriate amount. All of these
recovering foals consumed between 20 to 28 per cent of their body
weight per day in the mare>s or goafs milk. For example, a 10-day-
old, 45-kg Thoroughbred foal (gestation age of 305 days) with re-
solving pneumonia consistently drank 25 per cent of his body weight
(11 L) of goafs milk each day (450 ml every hour around the clock).
This supplied about 7000 kcal per day or 160 kcal per kg per day.
He gained 2 to 3 pounds each day and developed normally without
becoming obese. In all cases, it is strongly advised that body weight
and condition be monitored diligently to provide a basis to assess the
adequacy of the nutritional support delivered.
ORAL ALIMENTATION

Choice of Fluids
The choice of fluid to supply orally is often an empirical decision.
Although mare>s milk would seem the obvious choice to most closely
approximate the foar s needs, it is possible that it will not provide
some of the specific requirements that a premature or small-for-ges-
tational-age foal may have. In addition, milking can be very time-
consuming, and it is often technically difficult to milk sufficient quan-
tities to feed a foal that cannot nurse from the mare itself. Therefore,
milk from other sources is frequently used, but the best choice has
not been determined. Table 1 lists some of the constituents or the
most commonly fed milks. Although the composition of goafs ~ilk
is significantly different from mare>s milk, a number of foals that
recovered from serious neonatal disorders and were raised on goafs
milk are equal to or larger than age-matched foals at 1 and 2 years.
Another important advantage of goafs milk is that most foals, even
the fairly sick ones, seem to like the taste and drink it readily.
In certain situations, administration of any kind of milk is inap-
propriate. The intestinal tract of some foals may be sufficiently im-
mature or damaged by a disease process that some milk components
will not be adequately digested and/or absorbed. In those cases, ad-
ministration of oral electrolyte and glucose solutions or parenteral
alimentation may be more appropriate therapy until the gut heals.
NUTRITIONAL SUPPORT OF THE FOAL DURING INTENSIVE CARE 37
Table 1. Composition of Milk from the Mare, Cow, Goat, * and Foal-Lac, t a
Commercially Available Mare's Milk Replacer
MARE COW GOAT FOAL-LAC

Protein (%) 2.7 3.8 3.7 3.9

Fat (%) 1.6 4.4 4.14 2.8
Carbohydrate (%) 6.1 4.3 4.2 10
CaiP ratio 1.6:1 1.3:1 1.2:1 1.13:1
Ash (%) .5 .7 .8 1.6
Total solids (%) 10-11% 13% 13% 20%
Kcal/100 gm 60 67 67 78

* Data from Roberts, S. J.: Veterinary Obstetrics and Genital Diseases. Edition 2.
Ithaca, Edwards Bros., 1971.
t Borden Inc., Hampshire, Illinois.

Obviously, when a foal is healthy and will nurse vigorously, the

amount of milk and other food that he consumes free choice is prob-
ably a reasonable estimate of what his nutritional requirements are.
It is a relatively easy matter to supply via bottle or bucket the large
volumes of fluids he requires, even if the mother or a nurse mare is
not available. During most serious illnesses, however, food intake is
generally decreased, whereas metabolic needs stay the same or are
increased. In these situations, it is difficult to decide what the nu-
tritional needs are and how to go about meeting these requirements.
The normal foal can probably tolerate short periods of starvation with
few ill effects. However, the effects of starvation are apparent much
sooner in the premature or already debilitated animal with pre-ex-
isting depletion of glycogen and fat reserves and may have more
detrimental effects on a variety of body functions, includ~ng immu~
nologic response and wound healing. 5 Therefore, if an illness and
anorexia persist, force feeding is indicated to supply at least a portion
of the daily nutritional requirements.
Delivery of Oral Fluids to the Neonatal Foal
If a foal has a poor suckle reflex and will not nurse from the
mother, a bottle, or a pan, and if oral feedings are to continue, a
nasogastric tube can be used to provide nutrition. After a judgment
has been made that the animal -will be able to tolerate the enteral
fluids and the type of fluids has been selected, several other decisions
must also be made. These decisions include the type of tube to be
used, and whether it will be left in place or removed after each
feeding, the volume to be delivered at each feeding, and the assign-
ment of caretakers to stay up all night to do the feeding. Hopefully,
careful consideration of each of these points will help avoid some of
the complications that all too frequently accompany tube feeding of
the neonatal foal. Gas distension, colic, diarrhea, nasal and pharyn-
geal irritation, improper placement of the tube (for example, into the
t~achea), impaired swallowing after removal of the tube, and aspira-
tion pneumonia have all been observed with the use of indwelling
 38 ANNE M. KOTERBA AND WILLA H. DRl".\I\IO:\'D

nasogastric tubes. Therefore, when a suckle reflex returns, every

attempt should be made to discontinue tube feeding and to teach the
foal to nurse as soon as possible. Any aspirated milk must be quickly
suctioned from the trachea.
Stallion urinary catheters and similarly sized tubes have tradi-
tionally been used for this purpose. Many of these are excessively
large and rigid for a small foal, and although they may be easy to
pass, they often are unacceptably irritating to the foars mucous 111elll-
branes and gastric mucosa, whether or not left indwelling. There are
a number of more flexible tubes that are of smaller diameter and
were designed specifically for long-term enteral tube feeding in
human adults that may prove to be better choices for the neonatal
foal. *
The advantages of the use of an indwelling nasogastric tube in-
clude a reduced need for trained technical help and an improved
efficiency of the feeding procedure. Before each feeding, however,
the position of the tube must be verified. In our experience, the end
of the tube should be left in the stomach rather than in the distal
esophagus; in several foals, after feeding, regurgitation occurred
around the tube when it was placed in the esophagus, and aspiration
. pneumonia resulted. However, the detrimental effects of the long-
term presence of a foreign object on the gastric mucosa is not known.
The quantity of fluid delivered at each feeding and the interval
between feedings are very important considerations. The appropriate
treatment varies widely between foals, depending on factors such as
stomach size and gut motility. The best feeding schedule is probably
one that mimics the normal nursing behavior of the foal. A recent
study reported that foals of less than 1 week of age nursed frolll the
mare for an average of 137 seconds, 7 times each hour. 1 It is clear
that, in most farm situations, following this schedule would be ex-
tremely impractical, if not impossible, to accomplish, and IllOSt
normal foals can tolerate greater volumes of milk at much less fre-
quent intervals. However, the gastrointestinal tract of the COlllpro-
mised or immature foal is often much less tolerant of deviations from
the normal physiologic feeding regimen, and when fluid volu111e and
intervals between feedings are increased, colic, bloating, and gastric
reflux often result. Therefore, when instituting tube feeding in the
abnormal foal, we are very conservative, starting with a small volume
(25 to 100 ml) at hourly intervals, checking for gastric reflux before
each addition. As the foar s condition allows, the volume fed is slowly
increased with the goal of ultimately meeting at least the D1inilnal
maintenance caloric requirements of the foal (50 kcal per kg per day)
or about 200 ml mare>s milk per hour for an average-sized foal.
In many seriously ill foals with altered gastrointestinal function,
even small fluid volumes supplied at frequent intervals are- not tol-
erated; these situations, oral feeding is usually abandoned and SOlne

* Rockway Enterprises, Inc., St. George, ~1aine.

NUTRITIONAL SUPPORT OF THE FOAL DURING INTENSIVE CARE 39
type of parenteral nutrition is substituted. In certain human infants,
continuous nasogastric feeding is tolerated much better than inter-
mittent feeding. :JThis feeding regimen may prove to be an alternative
to parenteral nutrition in some equine neonates as well. A constant
delivery of fluid to the gastrointestinal tract is provided by an infusion
pump, and the efficiency of utilization of nutrients has been reported
to be enhanced by this method. 4

PARENTERAL ALIMENTATION

Parenteral alimentation can be a very effective technique to pro-

vide nutritional support to the foal that cannot be fed orally or to
supplement oral feedings in the debilitated animal. It is beyond the
scope of this article to provide an in-depth discussion of intravenous
nutrition, so the reader is referred to Gideon's report of total par-
enteral nutrition in the foal 5 and human review articles 2 ,3,6 for further
information. The basic idea, however, is to utilize solutions of dex-
trose, amino acids, and electrolytes to provide ample caloric intake
without excessive fluid volumes. In order to accomplish this, solu-
tions must be markedly hypertonic, and a large number of compli-
cations can and do result from parenteral administration of hyperos-
molar fluids intravenously. Parenteral alimentation is not a simple
matter, and for proper administration, several important points must
be kept in mind.
1. Hypertonic fluids should be administered into a large vein;
in the foal, the jugular vein is preferred. Strict aseptic techniques in
catheter placement and maintenance must be followed in order to
minimize the risk of infection. No blood should ever be withdrawn
through the alimentation line. The entire infusion set should be
changed every 24 hours and the catheter every 48 to 72 hours. A
Millipore filter is commonly placed in line to further reduce the
likelihood of infection.
2. All mixing of fluids should be done under a laminar flow
hood.
3. It is important to maintain a constant rate of fluid adminis-
tration around the clock so that metabolic processes can optimally
adapt to the osmotic load. By gradually increasing the amount and
concentration of infused glucose, greater insulin secretion can be
stimulated for more efficient utilization of the carbohydrate, 5 thus
reducing the common tendency for hyperglycemia, glucosuria, os-
motic diuresis, and subsequent dehydration. To avoid rebound hy-
poglycemia, it is important that hypertonic glucose solutions not be
discontinued abruptly.
4. Nutrient intake should be initiated at a rate to supply well
less than maintenance requirements and then be gradually increased
over a few days to eventually supply optimal caloric needs. For ex-
ample, during the first day, a 10 per cent glucose solution alone may
be administered at a rate of around 80 ml per kg per day, which
40 ANNE M. KOTERBA AND WILLA H. DRUMMOND

provides about 32 kcal per kg. If oral feeding remains contraindicated

on day 2, a protein source* would be supplemented at 1.5 gm per
100 ml in combination with the 10 per cent dextrose and given at a
rate gradually increasing from 80 to 150 ml per kg per day as needed.
This regimen will provide between 60 to 80 kcal per kg per day. 3
The concentration of the glucose solution may be slowly increased
up to around 25 per cent if tolerated by the foal.
5. Foals receiving intravenous alimentation require frequent
metabolic monitoring because disturbances in fluid and electrolyte
balance, liver function, and glucose homeostasis are quite common. 3
6. The suitability of intravenous fat emulsionst as a more iso-
tonic calorie source for the neonatal foal has not been determined,
nor has the need for specific vitamin, amino acid, or trace mineral
supplementation therapy.

REFERENCES
1. Carson, K., and Wood-Gush, D. G. M.: Behavior of Thoroughbred foals during
nursing. Equine Vet. J., 15:257-262, 1983.
2. Dweck, H. S.: Feeding the prematurely born infant. Clin. Perinatol., 2: 183, 1975.
3. Fanaroff, A., and Klaus, M.: The gastrointestinal tract-feeding and selected disorders.
In Klaus, M. H., and Fanaroff, A. A. (eds.): Care of the High-Risk Neonate. Phil-
adelphia, W. B. Saunders, Co., 1979.
4. Fanaroff, A. A., and Martin, R. J.: Methods of nutrient delivery for the low birth
weight infant. In Behrman's Neonatal-Perinatal Medicine: Diseases of the Fetus
and Infant. Edition 3. St. Louis, C.B. Mosby, 1983, pp. 308-310.
5. Gideon, L.: Total nutritional support of the foal. Vet. Med. Small Anim. Clin.,
72:1197-1201, 1977.
6. Heird, W. C., and Winters, R. W.: Total parenteral nutrition: The state of the art. J.
Pediatr., 86:2-16, 1975.
7. Rossdale, P. D., and Ricketts, S. W.: The Practice of Equine Stud Medicine. Balti-
more, Maryland, The WillialTIs & Wilkins Co., 1974.

Department of Medical Sciences

College of Veterinary Medicine
University of Florida
Box J-126
J. Hillis Miller Health Center
Gainesville, Florida 32610

* Aminosyn 7 per cent. Abbott Laboratories, North Chicago, Illinois.

t Liposyn, 10 per cent. Abbott Laboratories, North Chicago, Illinois.