RECOVER Guidelines: Newborn Resuscitation in Dogs and Cats. Clinical Guidelines

Abstract

Objective: To present evidence- and consensus-based guidelines for resuscitation of newborn puppies and kittens.

Design: Prioritized clinical questions pertaining to newborn resuscitation and in the Population-Intervention-Comparator-Outcome (PICO) format were used to inform systematic literature searches by information specialists, to extract research findings from relevant publications and synthesize them into evidence, to assess this evidence for quality, and, finally, to develop draft treatment recommendations. These steps were followed by a consensus process and a community commenting period prior to finalization of the project. These RECOVER Newborn Resuscitation Guidelines are a concise summary of the newborn resuscitation process to provide clear and actionable clinical instructions to veterinary professionals.

Setting: Transdisciplinary, international collaboration in university, specialty, and emergency practice.

Results: A total of 28 PICO questions pertaining to resuscitation of puppies and kittens at birth were addressed in this project. This resulted in 59 treatment recommendations that delineate an iterative approach to newborn resuscitation starting with airway clearance, tactile stimulation, and temperature control, as well as positive pressure ventilation, and instruct on more advanced measures such as CPR. An algorithm displays the flow of assessments and actions over the course of the resuscitation process.

Conclusions: These RECOVER Newborn Resuscitation Guidelines present a concise and comprehensive framework for resuscitation of puppies and kittens at birth. These works serve to support veterinary professionals and breeders, educational systems, and research initiatives in conducting, implementing, and advancing newborn resuscitation in puppies and kittens.

Keywords: Cesarean section; birth; cardiopulmonary resuscitation; consensus guidelines; evidence‐based veterinary medicine; neonatal resuscitation.

FIGURE 1

Transition of the cardiorespiratory system at birth. (A) The cardiorespiratory system prior to birth. Gas exchange occurs exclusively in the placenta. Its vascular bed is of low vascular resistance and receives the majority of the fetus's aortic blood flow. The lung is filled with fluid and has high vascular resistance. This leads to a relatively higher pressure on the right side of the heart than on the left side. This pressure gradient drives approximately 50% of oxygenated caudal vena cava blood to transit directly through the foramen ovale into the left atrium. This well‐oxygenated blood then perfuses the brain. The remaining 50% of caudal vena cava blood comingles with cranial vena cava blood that is of low oxygen saturation and leaves the right ventricle through the pulmonary artery, with most of it directly entering the descending aorta via the ductus arteriosus. As a consequence, the two ventricles function in parallel to generate aortic blood flow, with the preductal arterial oxygen saturation being markedly higher than the post‐ductal arterial oxygen saturation. (B) After the completion of cardiorespiratory transition, hours following birth. At birth, the placenta is removed, and the lungs are aerated. The removal of the placenta increases peripheral vascular resistance and consequently pressures in the aorta and the left ventricle. In contrast, the vascular resistance in the now air‐filled lungs decreases, pulmonary arterial blood flow through the lungs markedly increases, and blood flow through the ductus arteriosus ceases. This leads to an increase in left atrial pressure, to the functional closure of the foramen ovale, and to the cessation of the blood shunting from the right to the left atrium through it. Consequently, the two ventricles now function in series, with only the left ventricle generating aortic blood flow and with uniformly high oxygen saturation present throughout the arterial vascular system. PA, pulmonary artery; PV, pulmonary vein; LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle. Artwork by Chrisoula Toupadakis Skouritakis, Ph.D., MediaLab Services Director, Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis. Copyright: The RECOVER Initiative 2025. All rights reserved.

FIGURE 2

Newborn resuscitation algorithm for puppies and kittens. C:V, compression:ventilation ratio during bag–mask ventilation and chest compressions during CPR; IO, intraosseous; GV 26, needle stimulation of the Governing Vessel 26 acupoint; PPV, positive pressure ventilation; RR, respiratory rate. Artwork by Chrisoula Toupadakis Skouritakis, Ph.D., MediaLab Services Director, Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis. Copyright: The RECOVER Initiative 2025. All rights reserved.

FIGURE 3

Newborn resuscitation dosing chart. Drug volumes are provided by body weight in 100‐g increments to reduce the risk of calculation errors. Depending on the drug route, different drug doses and thus drug volumes are recommended. ET, endotracheal; IM, intramuscular; IN, intranasal; IO, intraosseous; IP, intraperitoneal; SC, subcutaneous; SL, topical sublingual. Copyright: The RECOVER Initiative 2025. All rights reserved.

FIGURE 4

Positive pressure ventilation is a critically important intervention in newborn resuscitation and requires early initiation. We suggest the use of a tight‐fitting face mask and a suitable self‐inflating resuscitator bag to deliver effective breaths. Snout, neck, and back should be aligned, and dorsal recumbency should be avoided for easier air passage into the lungs. Signs of effective ventilation are a visible chest rise and an increase in HR. PPV should be initiated with room air, and 100% oxygen should be considered if there is no response after 1–2 min (e.g., no increase in HR observed). Artwork by Chrisoula Toupadakis Skouritakis, Ph.D., MediaLab Services Director, and Kailee Suess, Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis. Copyright: The RECOVER Initiative 2025. All rights reserved.

FIGURE 5

Chest compression techniques for newborn puppies and kittens. Compressions should be applied directly over the ventricles regardless of technique and animal position. The preferred animal position is lateral recumbency, but sternal compressions might be preferable in some instances (see text). (A) Compress the chest over the ventricles with one or two fingers toward the table surface (rate, 120–150/min; depth, 1/3–1/2 of chest width). (B) Compress the chest wall over the ventricles between one or two fingers and the opposing thumb (rate, 120–150/min; depth, 1/3–1/2 of chest width). (C) Compress the sternum with the newborn in dorsal recumbency (rate, 120–150/min; depth, 1/3 anterior–posterior chest diameter). Artwork by Chrisoula Toupadakis Skouritakis, Ph.D., MediaLab Services Director, and Kailee Suess, Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis. Copyright: The RECOVER Initiative 2025. All rights reserved.