Neonatal Maladjustment syndrome
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JUL 31, 2024
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This is a descriptive term for a set of symptoms. Foals may show signs of being a “dummy foal” associated with septicemia, bacterial meningitis (rare), hypoxic encephalopathy from unobserved birth asphyxia, brain edema or hemorrhage, reversion to fetal cortical status, or congenital lesions in the CNS (hydrocephalus).
Editorial comment
It is impossible for most clinicians to perform a full battery of tests to sort these etiologies out and some treatment must be administered without a conclusive diagnosis. Always treat concurrently for infection until absolutely proven otherwise. While the cause has previously been considered to be hypoxic encephalopathy, our studies suggest it is caused by persistence of sedative neurosteroids post birth.- this is when the biochemistry required to keep the foal sedated and quiet in utero persists and at birth the ‘wake up’ call does not occur.1 The Madigan Squeeze is used worldwide. Blood progesterone may be elevated as marker.
Clinical Signs
- May or may not be associated with an apparently normal birth. Signs develop within 72 hours of birth.
- Loss of awareness of environment, recumbency, inability to stand, disorientation, struggling randomly, loss of affinity for mare and nursing, poor suck reflex, blindness, seizures, opisthotonos, airway origin bark (“Wander-barker”) may be heard in some foals although this is rare.
- Duration of symptoms last 1-3 days in most cases (with early treatment) and up to 5 days or more in others.
Suspected Originating Factors2
- Persistent elevations of sedative neurosteroids found in majority of cases
- Previously thought to be hypoxic encephalopathy in earlier study.2
- Placental problems 55%, gestational problems 21%, premature placental separation 34%, dystocia 30%.
- Overall, 59% had delivery that included dystocia or premature placental separation.
- These events can trigger neurosteroid elevations.
- Septicemia
- Earlier studies indicated up to 50% develop a component of bacterial infection if no antibiotic treatment.
- Recent studies all incorporated aggressive antimicrobial treatment and reported good outcomes with supportive care.
- Meningitis (rare cause) (See Infections; Chapter 28).
- Congenital lesions - hydrocephalus most common.
- Reversion to fetal cortical status
Editorial comment
This is a term I have used to describe the brain activity of these compromised foals. Signals that “wake” the foal up from an in utero or “fetal cortical state” have failed in some of these foals and repeating birth canal pressures via the Madigan Squeeze can be added to supportive therapy. (See treatment).
- CNS hemorrhage or edema
- Metabolic insults - hypoglycemia, electrolyte alterations, acidosis, hypothermia
- Endotoxins
- In utero infection
Prognosis
- Excellent prognosis (80% survival) reported with intensive care and lack of significant bacterial component.2
- Older study reported if any one of the following, only 30% survival.3
- Positive blood culture.
- <400 mg serum IgG.
- Diarrhea.
- Occult blood in feces or gastric reflux.
- Abnormal thoracic radiographs.
- Abnormal behavior at birth.
- After 5 days, if no improvement, prognosis is poor; after 6 days even worse in one study.3
- If they recover, “are they going to be normal?” a farm manager or owner often asks.
Editorial comment
Best guess answer is ‘Yes’ with example being Kentucky derby winner Strike The Gold who was a “dummy” foal.
Diagnostic Workup
- Work up as described in Chapter 19 - Initial Evaluation and Minimum Data Base
- Serum creatinine kinase elevated in 61%, which may reflect birth hypoxia and muscle damage.2
- Serum Creatinine elevated in 32%.2
This is not due to kidney damage but reflects difficult birth and entry of fetal kidney waste products found in allantoic and fluids into foal circulation.
Editorial comment
Check urine to be sure. If there is significant kidney disease you will usually find abnormalities with increased blood or glucose or casts etc.
Elevated blood progesterone is a marker for elevated neurosteroids
Therapy
- Don’t over-hydrate and contribute to CNS edema- be careful with fluid volumes (Chapter 22 - Fluid and Electrolyte Balance).
- Antimicrobials always because of open gut and high risk of infection. (Chapter 70 - Guidelines for Drug Use in Equine Neonates).
- Nutrition: Tube feed with colostrum and milk. Parenteral nutrition if needed and nursing care (Chapter 23 - Parenteral Nutrition & Chapter 24 - Enteral Nutrition).
- Oxygen insufflation, respiratory stimulants if needed (Chapter 66 - Respiratory Therapeutics).
- Perform the Madigan Squeeze - Apply 20 min of thoracic squeezing (See foal restraint page and reference 6 & 7). Recent studies reveal it allows many foals to nurse within 1 hr of the squeeze. With traditional therapy- few nurse within 1 hr. 7 Can repeat the squeeze 4 times daily as needed.
Contraindications are fractured ribs. The squeeze is safe in wandering foals and if no response, advise clients to seek immediate veterinarian involvement. If the foal nurses and 'wakes up'- Why not try it? - Step by step instructions here: search UC Davis Comparative Neurology- step by step Madigan squeeze.
Editorial comment
The squeeze procedure is being used successfully in lambs, cattle, crias. To learn more, listen to podcast on YouTube Rood and Riddle- Madigan Squeeze.
- Mannitol - 0.25 gm/kg IV q 6-8 hrs. for 24 hr.
Editorial comment
This drug does not enhance brain hemorrhage and we use it in many NMS foals.
- Flunixin meglumine 0.5-1.0 mg/kg q 12 h for 24 hr.
- Treat seizures (Chapter 31 - Neonatal Seizures).
- Inotropes and vasopressors (Chapter 18 - Shock (SIRS)).
- Ileus, colic, gastrointestinal ulcers (Chapter 34 - Gastroduodenal Ulcers).
References
- Madigan, JE, Haggett, EF, Pickles, KJ, Conley, A, Stanley, S, Moeller, B, Toth, B, Aleman, M. Allopregnanolone infusion induced neurobehavioral alterations in the neonatal foal: I is this a clue to the pathogenesis of neonatal maladjustment syndrome? Equine Vet J. 44 S41 109-112, 2012.
- Bernard, WV, Reimer, JM, Cudd, T, Hewlett, AA. Historical Factors, Clinicopathologic Findings, Clinical Features, and Outcome of Equine Neonates Presenting, with or Developing Signs of Central Nervous System Disease. Proceed Amer Assoc Eq Pract 41:222-223, 1995.
- Clement, S.F.: Behavioral alterations and Neonatal Maladjustment Syndrome in the foal. Proceed 31st Amer Assoc Eq Pract 145-148, 1985.
- Ting, P, Pan, Y. The effects of Naloxone on post-asphyxia cerebral pathophysiology of newborn lambs. Neurol Res 16:359-364, 1994.
- Milligan, C, Webster, L, Piros, ET. et al. Induction of Opioid Receptor-Mediated Macrophage Chemotactic Activity After Neonatal Brain Injury. J of Immunology. 154:6571-6581, 1995.
- Toth, B, Aleman, MA, Brosnan, RJ, Dickinson, PJ, Conley, AJ, Stanley, SD, Nogardi, N, Williams, DC and Madigan JE. Evaluation of squeeze induced somnolence in neonatal foals. Am J Vet Res 73(12)1881-9, 2012.
- Aleman, MR, Welch, K Madigan, JE. Survey of veterinarians using a novel physical compression squeeze procedure for foals with Neonatal Maladjustment Syndrome. Animals, 2017, Sept 5;7(9):69.
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How to reference this publication (Harvard system)?
(2024) “Neonatal Maladjustment syndrome”, Manual of Equine Neonatal Medicine - Revised. Available at: https://www.ivis.org/library/manual-of-equine-neonatal-medicine-revised/neonatal-maladjustment-syndrome (Accessed: 11 October 2024).
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