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Cleft Palate Instructions
They Are Worth Saving

This information is going to deal strictly with the how-to of raising a cleft palate pup from day one to transfer time at 8 weeks or after.  A lot of caregivers of these kids get so attached that letting them be adopted by someone else becomes impossible.   Either way these instructions will give you the best possible chance for a positive outcome.

As a rule the only thing that kills these guys once born is setting up pneumonia.  So it is imperative to do all one can to prevent that and it is very much possible to prevent.  

Some of the information contained many may already know, but for those that don't,  I cover it here.  I do recommend reading this information a few times to be able to absorb it all.  I have found parties send me questions which the answers to their questions were in the information I had already sent them.

By reading over the info a time or two, it may help to prevent mistakes from being made.  One of the most important things to prevent is the regurgitation with feedings which  usually ends up with the pup aspirating some formula which frequently develops into the pneumonia that can and does kill them.   So please for this pups sake that you are willing to devote your time to, and likely already attached to, read this info thoroughly.

**One thing all parties will find with these special kids is due to the intensive handling from so early, they are so superior socially it will amaze you.  All parties that normally raise their pups inside see some of this improved social aspect in their pups normally, well multiply that 10 fold. So if you do allow this pup to be adopted, do be sure he or she goes to a home that will treat him or her as a true family member, as a person that is.  The intense care even overrides genetic traits such as with your protective aggressive breeds.  Those breeds even as adults absolutely do not know any strangers, they have a way of thinking the world is wonderful, and honestly with them in it, it is!

One disclaimer note, this information is to be used as one feels comfortable with and is not meant to be used in place of veterinarian advice in the case of meds for various issues.   The information is drawn from actual time and time again experience with these special pups and what has shown to work best for them.  One is more than welcome to copy this info to have it reviewed by your vet for their feedback before implementing.  Or one may share the website address for him or her to view if desired.   These are the steps and meds and dosages that I personally and others have used during the process of raising cleft palate puppies, successfully time and time again.  I will say time and time again how imperative it is to "prevent" pneumonia from occurring in the first place, as treating once it has set up is about futile.  More on the antibiotic later in the instructions.

The first 4 weeks

The first 4 weeks involve frequent feedings, being sure they are eliminating, preventing pneumonia and being sure they have "slow" steady weight gain.  Once you get into a routine things tend to go along easier.  I will cover trouble shooting issues towards the end of the information.

First 4 week goals are:  Slow steady weight gain, emphasis on slow and steady,
and preventing pneumonia.

FEEDING

I recommend if at all possible the pup should be given colostrum from the dam for the first two days.  To do this you will need to express colostrum from the dam.  It is not like milking a cow for those that know how to do that.  The best way I have found is to hold a breast with your hand wrapped around the upper portion towards the abdomen and squeeze firmly down towards the nipple with your thumb actually moving from up on the breast down towards the nipple.  This forces the flow of colostrum down out of the glands into the nipple.  Then with the other hand you will hold a small clean plastic container, or a small dixie cup to catch the colostrum.  The initial feedings will only consist of 5-6 cc, roughly a teaspoon of colostrum and that will depend on the size and breed of pup.   The reason colostrum is preferred is for the antibodies that it contains.  This special first milk provides protection for the newborn during the first several weeks of life, something formula can't do.  The colostrum is also the perfect food for the new digestive system of a newborn.

If you find it difficult to obtain enough colostrum, collect what you can and make up the difference with a commercial puppy formula.  There are several on the market and I have used several and have not noted any appreciable difference between them.   Commercial puppy formulas, or milk replacers as they are sometimes called, can be purchased through vet supply catalogs, or in their online stores, most all pet stores, and some vets.  Homemade formulas are "only" okay in my book, in "an emergency", but one should get formula as soon as feasibly possible.  Please do not give the pups just plain cows milk, their dietary needs are much more involved than just cows milk.  Goat milk I have heard is closer to canine, but still not a perfect match.  Below is the emergency only formula I have used, now whenever I expect a litter I make sure I have at least one can of formula on hand.  Just in case.
There are many variations to homemade puppy formula and I'm sure there are others that are just fine also, but just for an emergency fill-in until you can get a commercial puppy formula.  This is recipe I was given by a vet many years ago.

Emergency Puppy Formula

1 cup whole milk
2 egg "yolks"-do be sure to separate and dispose of the whites
1 Tablespoon vegetable oil
1/2 Tablespoon corn syrup
                                                                     2cc Liquid Vitamins if available-I have used regular baby vitamins here,
                                                                                                           either pet or baby will work

Mix the above together well.  Pour the amount needed for a feeding into another container and store the above mixture in the refrigerator.   Stored in an airtight container in the refrigerator the above is usually good for 5 days.  After the first week it is usually used up before it would spoil. It is just to tie you over until you can get commercially prepared formula.

In addition to formula I recommend getting Nutrical or its equivalent.  It is a high calorie paste that is available at most pet stores and through vet catalogs and online pet stores.  At the end I have listed some online sites to access some of the items you need for raising a cleft pup.   With the Nutrical you will add a "dab" to a couple feedings each day to boost calories without adding much volume.  Okay so what's a dab?  I would try about the size of an "orange seed" for each pound of body weight twice a day.  Instructions on how to give it are listed below under "How to tube feed".

If possible bottle feed, I previously recommended tube feeding, but I have found many parties are not comfortable with tubing and if ones technique isn't effective it can put the pup at very high risk of aspirating and developing pneumonia.  Pet bottles can be chased at pet stores and vet supply catalogs.  One may wonder why bottle feeding will work when the pup cannot nurse normally.  A suction is not necessary in bottle feeding for the formula to dispense.  A suction is necessary with normal nursing in order to allow the milk to let down.   Gravity works with bottle feeding.  One does need to be careful with bottle feeding that the formula does not dispense quicker than the pup can take it.   Hold the pup on his belly or slightly tilted back, try to mimic their position when nursing.  Tilt the bottle up at an angle to allow the formula to enter the nipple.   The pups head should be positioned so the formula will run immediately to the back of the mouth, so elevated and somewhat tilted back.  Small amounts of the formula will still likely make its way  through the cleft, so after feedings the pup needs to suckle on a finger.  

On the small pups I offer the little finger first, no long nails please, and do be sure to have clean hands,  but thoroughly rinsed as they  don't like the taste of soap. Offer your finger with palm facing up so the finger nail will be against their tongue.  If you find the pup reluctant to "nurse" on your finger, then dip your finger in some of the formula/colostrum , or sugar water and offer it again, flavoring helps.

The purpose for nursing on your finger is two fold, one of course is the need all mammalian creatures have to nurse, and secondly, and very importantly it does help clear out the nasal passages of any formula that may have made its way up there.

Bottle feeding will be slow, but can work if one works at it.   The smaller clefts are the easiest to bottle feed as they have less come back out their nose.  As mentioned position the pup so its head is elevated and mouth tilted up so that the formula goes immediately to the back of the mouth.  Be sure the colostrum/formula goes very slowly into the pup's mouth, so there is only a small amount present at a time.  It will be more time consuming.   If you decide to tube feed, it is much quicker however it isn't without risks, actually it increases the pups risk for pneumonia, so if you are going to tube feed it is very important that the pup be run on antibiotics prophylactically.  Prophylactically means "given as a preventative, before there is an actual issue".  Once the pup sets up pneumonia they are very difficult to save.   So it is best to prevent it.  By having antibiotics on board you are covered for the mishaps that may happen with tubefeeding.   

If you haven't tubefed before it is best if you can have someone experienced with tubing show you and then you demonstrate it back to them to be sure you understand the how to.  I will cover some basics with tubing, but as mentioned it is better if you have never tubefed that you observe someone that has.  

I still remember the first time I tube fed a pup.  Even though I was quite experienced at passing tubes being an RN, all my patients had been "substantially" larger.  Most of them I could also tell what I was doing.  Now I was dealing with a little creature of roughly a pound.   It was a bit scary to say the least.

First you will need a feeding tube.  Most vets carry some feeding tubes, likely size varies with pup size,  a size 10 fr. is the normal for a pound size pup.  For your small breed pups double check with your vet for the correct size, likely an 8 fr.   You may also order them via vet supply stores, possibly even local pet stores.    As the pups grow you can increase tube size, after a couple pounds use a 12 or 14 fr.    The esophagus, the tube that leads from mouth to stomach is a much larger size opening than the trachea.  The trachea leads from nose and mouth to the lungs.  You want to pass the tube into the stomach not the lungs, so by using a little larger tube you decrease the chance of accidentally passing the tube into the trachea.   

You will also need a syringe to hold the colostrum  and eventually formula.   Start with a 12cc syringe, then you will be advancing to a 20cc, then 30cc, and if a large breed puppy, you will end with a 60cc syringe.  To help one understand  cc's:  5cc equals a teaspoon, 15cc equals a tablespoon, and 30cc equals an ounce or 2 tablespoons.

So to recap:   You will need..........
Commercially prepared formula, for use preferably after the first 2 days of colostrum.

A feeding tube, 8 or 10 french to start

KY jelly (not Vaseline) must be "water soluble" lubricant for lubricating the tube

Syringes 12 and 20cc to start.  Also a TB (Tuberculin) syringe for dosing the antibiotic.

Your antibiotic.  

As mentioned the one thing that kills these guys is pneumonia.  It is preventable.  Over the years have tried various antibiotics prophylactically-(for prevention), Penicillin family, Amoxicillin, Clavamox and Cephalexin.  Cephalexin was the only antibiotic that consistently prevented the pneumonia.  Clavamox and Amoxicillin are the two antibiotics that most veterinarians prefer. If your vet prefers something other than Cephalexin, something is usually better than nothing. Be extra careful with your tubing or syringe feeding technique to limit any chance of regurgitation and aspiration.

If you have received antibiotic from your vet, follow the vets dosage instructions, not mine. If you have your own stash of Cephalexin, use the info below.

The dosage on Cephalexin is 15mg/pound of body weight daily, in DIVIDED doses. Doses should be at roughly 12 hour intervals. Weighing needs to be done before a feeding, not after.  I suggest keeping a record of weights, amount of colostrum/formula taken, and dosage of antibiotic given.   The amount of antibiotic will be adjusted as the pup gains weight, usually weekly intervals for the change.

Preferably weighing should be done at the same time of day each time, and needs to be done daily or at least every other day.

It is acceptable in pediatric medicine to make a dilution using caps/mixed with water in order to be able to dose correctly, so if the soon to be described procedure is acceptable in "people pediatrics" I 'm sure it is fine for canines.  I have found most vets don't think this is an accurate way to get your dosage, but properly done, it is.

Choose a small container, a washed and dried pill bottle is perfect.  If using a  250mg. cap, add 10cc of tap H20 to the bottle.  If it is a 500mg cap, then you will add 20cc tap H20 to the bottle.  Do use your syringe to get the correct amount of water.  Add your water first, that way if you add an incorrect amount of water you can just dump it and start again.  If you add your med powder first, then the mix will not be correct if the amount of water is not correct.

Once you have the correct amount of water in the container, then open your capsule and add the powder from the cap to the water.  Recap the bottle and shake well to thoroughly mix the water and med.  Once thoroughly mixed you may draw up your dosage.   Each 1 cc of the mixture will yield 25mg.  This is where the TB syringe is important.  It has a total volume of 1cc, and has markings in 1/10ths of a cc and even smaller increments.  If your pup is just a pound then the dosage would be figured as follows.  So you know the abbreviations  "cc" and "ml" mean the same thing.

Dosage is 15mg. per 16 oz. (1 pound).   Med mixture is 25 mg. per 1cc

Each 1/10th or .1 on the TB syringe is 2.5 mg.

.6cc per 16 oz.

Below is an example of figuring dosage for an 8 ounce pup, set your calculation up with weights on the bottom.  You know
1 pound or 16 oz would receive .6cc of the above dilution.  That is a constant.    "x" denotes what you are trying to figure out, the dosage to give for a certain weight.  You place the amount of the pups weight in oz also on the bottom under the x.
Next you cross multiply, 16oz times x equals 16oz x and then cross multiply .6 times 8oz =4.8

You then divide...... 4.8 divided by 16x  =.3 and that is your daily dosage, which is then divided into 2 doses,
given at roughly 12 hour intervals, would be .15 cc twice daily.  One must use a TB syringe to be accurate on dosage.


.6 cc         x
---------  .    -------
16 oz      8oz

Another example pup weighs 10 oz.

.6cc        x
------- . -------
16oz    10oz

So cross multiply .6 times 10 equals 6.    Then you divide that 6.  by 16 and that gives you .375   Now since that is so close to .4 that is what you would round the med dosage up to.  It is possible to dose .35 but the .375 is more difficult and it is okay to go up to the next higher  "tenth of a cc" in those cases.  So that pup would receive .2 cc twice a day for a total of .4cc a day.

Keep the mixture in the refrigerator, and shake the bottle well each time before drawing up your med dose.  The med and water parts tend to separate when the mixture sits. The mixture properly stored in the refrigerator is good for 10 days.  Any left after 10 days dispose of and rinse the container and mix up a new batch, following the above instructions again.   Be sure to give the med with the feedings that fall at roughly 12 hour intervals or as close to that as possible.

How often and how much to feed

Cleft pups, depending on size need to be fed roughly every 2 initially, possibly every hour if you are dealing with a small breed pup with a weight of only a couple ounces.  On pups that birth weight is about a pound, give or take a couple ounces, they can be fed every 2 hours around the clock for the first couple days, then as long as gaining weight can go to every 2 hours during the day and out to 3 hours at night.  After the first week, the pups can go 3 hours during the day if necessary-every 2 is best for steady weight gain, but at night can go to 4 hour intervals if the caregiver really needs more sleep.  So each week the night time intervals can increase some if needed.  

"All cleft pups lag behind in size to their littermates".  I want to stress that point as it is very important parties do not overfill the pups in an attempt to have them keep up with littermates, or to make up for not feeding more often.  I find myself frequently having to write parties that again and again when they write to say the pup is regurgitating after its feeding.  It never fails they are trying to feed way too much for the pup to hold.  I understand their thought, the need for the pup to gain at a somewhat normal pace, but that is not the best for these pups.  

 The reason they lag  behind is there is no way physically possible for most parties to feed often enough to allow them to keep up.  Nursing pups in the beginning may nurse every 15 minutes, or even more often, cleft pups have to settle for every couple hours.  Due to having to give a large amount-for them, in one feeding they are not able to consume as much as their littermates do, so you get the weight lag. If a party had the time to bottle feed the pup every 15 minutes, then yes they would keep up with littermates.  They could not be tubefed that often as it would cause terrible pharyngeal/throat irritation.

Normal weight gain is not important with these special kids.  Have found as long as they have slow steady weight gain, they will gain to normal for age size once on dry food for a few weeks.   They all also reach whatever their genetic potential is once an adult.  So your goal is "slow" steady weight gain.  It is better for the pup to be smaller, but slowly gaining than to be overfilled at a feeding, regurgitate since they can't hold the amount, and then aspirate which frequently occurs after they regurgitate.  That aspiration-inhaling some formula into the lungs, is what causes the pneumonia that can kill them.   

Amount to be fed will depend on the birth size.  Pups about a pound will start with 5-6 cc of colostrum each feeding for the first two days.  If your pup is smaller, adjust the amount accordingly.  So an 8 ounce pup hopefully will be able to take roughly 3-4cc.  Then after switching to formula the amount will gradually increase each day, or two.  Increase in increments of one or two ccs.   I like to see the pups looking fairly round after a feeding.  I try to make them as "round" as their littermates that are nursing.  If it is an only pup, then try to make a fairly round belly. Again do becareful not to overfill as they will regurgitate and run the risk of aspiration-inhale the formula into their lungs.   

I have yet to find a pup that can handle the large infrequent amounts that the formula cans says to feed, so please for the pups sake do not follow the cans instructions other than the mixing info if using a powdered formula.  The pups will regurgitate if you overfill and that sets them at high risk for aspiration pneumonia.   I likely write that a dozen times through this info as it is what ultimately will kill these pups.  If the pneumonia is prevented then there is no reason for the pup not to do wonderful
.
So frequent smaller feedings are definitely better for the pup.  The frequent feeding schedule is the part that is difficult for the caregiver, but just remember this is only going to be for roughly 3-4 weeks, then at 4 weeks you will be introducing dry food.
By week 3, feeding every 3 hours is okay during the day and out to 6 hour at night.  So every 3 hours until say 11p. and then again at 5 am and then resume the 3 hour schedule for the day.  Or midnight and  6 am.  Find what works best for you.  
By week 3, most parties are very tired of the night time schedule. But this little being that is so attached to you and growing with your extra care is soon going to be eating dry food on its own, and then uninterrupted sleep is yours once more.  So just keep remembering this is for a "definite" period of time and it is well worth the lack of sleep.  
The pup will be sure to let you know that.

 How to Tube Feed

As mentioned preferably have an experienced party show you how to tube feed.  It is imperative to the pups survival that it be done correctly.  If the formula gets dumped into the pups lungs-the tube ends up in the trachea instead of the esophagus, the pup will likely not survive.  The antibiotic cannot prevent pneumonia if a large amount of formula is dumped into the lungs.  If one is careful, uses the right size tube and pays attention to the pup while inserting the tube the above should be avoided.

First you will need to assemble all the equipment and formula, if Nutrical is being added to a feeding add it just prior to heating the formula.  The Nutrical being a paste type consistency needs to be liquified before giving.  If necessary add it to a "cc" of water and heat in the microwave, do so until you get a liquid consistency, then it can be given with the pups formula.  Nutrical should always be given via bottle or feeding tube, never directly into the mouth.  If placed on the tongue it has a high risk of ending up in the nasal passages and due to its high fat, high sugar content it is an excellent medium for growing bacteria. Please do warm the pups formula, the instructions on many of the formula cans say room temp, however that is hard for their gut.  When nursing they get the dams milk at roughly 100 to 101 degrees, much warmer than room temp.  Heat it as one would for a human baby, so it just feels lightly warm to the inside of ones wrist.  They tolerate the feedings better if the formula is warmed. If you have poured the amount you will feed into a plastic container or dixie cup, then a few seconds in the microwave will warm it adequately.  The time needed will vary on the power of the microwave.   Do not add the antibiotic prior to heating.  The med should be added last, drawn up with the formula just prior to giving.

Remember for the first two days preferably express colostrum for the pup.  If you are only able to express a couple cc's each time, even a little bit is better than none, do make up the difference in formula, but if at all possible try to express enough colostrum.  For the first few days while giving colostrum, wait to express the colostrum until right before you are ready to feed, then heating is not required.  Remember on two feedings a day, preferably at 12 hour intervals, add the dosage of Cephalexin to the formula, or colostrum *again add it after you have warmed the formula, not before". These instructions are also appropriate for bottle feeding.  If using premix, ready to use formula, measure out the amount you will be giving, refrigerate the rest.  If using powder formula, mix enough formula for a day.  You will refrigerate any unused portion.  

Next you will need to determine how far you will be inserting the tube to feed the pup.  The way to do this, holding the tube alongside of the pup head, do keep the tube clean, with the tip held near the tip of the pups muzzle/nose, then follow a path back towards the ear, then down along the neck, and ending at the point level with the tip of the sternum. The "tip" of the sternum or breast bone is the point on the upper abdomen where the ribs come up and meet.   Using a permanent marker, or a pen, make a black mark on the tube at this point.   That will be your guide for how far to insert the tube.   As the pup grows the distance to insert will increase, but not before around the two to three week mark.  At that time just remeasure and re-mark the tube, do a double line this time so you can tell which line is the one to follow.

This is not a sterile procedure, but does need to be kept as clean as possible.  So assemble your formula, or colostrum, your syringe, and tube, you can place all on a paper towel.    Also on a corner of the towel place a dab of KY jelly to lubricate your tube.  DO NOT use Vaseline, or petroleum jelly.  Those are petroleum products and should never be taken internally.  They are not water soluble as KY jelly is.  Try to be careful not to contaminate the tip of the KY tube.  Squirt the dab without touching surfaces and do not use your finger to wipe the tip.  A clean paper towel would be better.  Hands, etc. tend to carry lots of bacteria, and if the tip is touched the bacteria is deposited there.

Draw up the formula, or colostrum in the syringe.  Do that by placing the end of syringe in the formula/colostrum and draw back on the plunger until all the liquid is drawn up in the syringe, also draw up about 1.5 - 2 cc of air.  The air will displace any formula in the tube once you finish feeding, this way the pup gets all the formula, it also clears the tube to prevent tracking formula back up as you withdraw the tube.   If the syringe is held in the upright position that it should be, the air will remain at the top, just below the plunger until you are finished and then the air will as mentioned displace any liquid in the tube.  The air does not go into the pups stomach, it remains in the tube.  

That is sometimes a concept parties have a hard time grasping.  As mentioned with being an RN, I apply a lot of the techniques we use with people.   Also so one knows, air in the stomach is not a major deal, it will amount to a burp to expel it. But if one does as I instruct, the air will not reach the stomach, it will be in the tube.  Since the plunger/syringe is not removed from the feeding tube at anytime during the feeding process, it then remains as a "closed system" so the air cannot leave the tube unless something else is there to be pushed through the tube.
So you have drawn up the liquid, a couple cc's of air and you will then attach the open end of the feeding tube onto the end of the syringe.  Now dip/roll the end and last inch or two of the tube into the KY jelly.  You are lubricating the tube in order for it to pass more easily, and help decrease the chances of developing throat  irritation due to frequent tubing.


I do this sitting on the floor with everything  in easy reach, with a towel on my lap, I sit the pup in my lap and holding the pup's head with one hand, left hand if you are right handed, muzzle tilted up, using your index finger on either hand, you gently open the pups mouth, you can slip the index finger of the hand holding the pups head into the side of its mouth to keep it open, and with the other hand insert and feed the tube into the back of the mouth and beyond.   I actually hold the end of the syringe plunger in my teeth as to free up my hand for advancing the tube. Works quite well.  It keeps the syringe and tube in an upright position and makes advancing the tube easy.  Once the tube is inserted up to your mark, I use a couple fingers from the hand holding the pups head to hold the tube inbetween them while the other hand works the plunger on the syringe.  By doing so it allows one person to feed.  Until you get the hang of the above it maybe a good idea to have someone else there to hold and hand you things.  The more comfortable you get with tubing you may get to the point where you can do it yourself.  Those getting up with you during the night will appreciate that.

A few notes about when you are inserting the tube.  The pup will likely squirm some and if inserting the tube too slowly the pup will try to gag.   They have what is called a "gag reflex", we all do.  It is at the very back of the mouth, or pharynx area.  So we try to pass by that area fairly quickly to reduce the amount of gag response we get.  The tube should actually pass quite easily, and continue inserting it until you get close to your mark on the tube.  If you are inserting it correctly you will not encounter resistance.  If you do encounter resistance and you have not reached close to your line, withdraw the tube, allow the pup to settle, relubricate the tip and insert again.  If you continue to have resistance get someone experienced with tubing to help you.  If by chance you encounter resistance just as you come upon your mark, just back the tube about an inch, be sure the pup is breathing okay and give a little of the formula/colostrum. Watch for any reflux-the liquid comes back up into the mouth or out the nose.  If no reflux, give the rest of the feeding and remark the tube to the new measurement.  If reflux happens, then withdraw the tube totally, allow the pup to settle, relubricate the tip and reinsert.

A couple things that will cause resistance is if the end of the tube is trying to curl, that can happen in the end of the esophagus just before the stomach.  Another possibility is if you have measured incorrectly and are inserting the tube too far, it can enter the stomach and curl back around on itself and possibly back up towards the esophagus.   NEVER force the feeding tube, get help instead and  bottle feed or even use drop by drop from a syringe on the pups tongue until you can get someone experienced to help you.   If the insertion is done correctly there will be no resistance upon inserting or removing.

Keep the mark on the tube just outside of the pup's mouth.  Once the tube is inserted, take a moment to watch the pup's respirations.  If the tube was placed into the trachea, the pup will be in respiratory distress.  If the pup is able to breathe with the tube in place, it is in the esophagus/stomach, where it is supposed to be.   A trick I learned to "occupy" the pup while you are doing this is to blow puffs of air in their face  Chew mint gum, the scent seems to work well to distract them.   I also "gently"  bounce them in my hand to distract them from what is going on, I do mean gently, they never leave contact with my lap.  If the pup is in respiratory distress, not able to breathe, you can hold a wet finger close to their nose and see if you can feel any breaths, also watch their rib cage/upper abdomen.  If you see regular rise and fall, they are able to breathe.  If you can't feel or see breaths, then pull the tube back out, and try reinserting again.  Give the pup a moment to settle first.   It is very unlikely you are going to end in the trachea.  The opening is very small and that is the reason for using a larger feeding tube.

Once the tube is down, the pup may not be happy, but is breathing, then inject the contents of the syringe.  I give the 5-6 cc of formula/colostrum in about 2-3 seconds.  As the amount increases so will the time to give it, but it is never more than roughly 15 seconds for a large 30cc feeding.  This is an area you will have to learn what works.  If you give the feeding too slow, the pup will start gagging in response to having the tube inserted.  If you give  it too fast, you run the risk it will back up in the esophagus into the mouth and nose and run the risk of the pup aspirating.    It only takes a feeding or two to get some idea of what timeframe the pup will tolerate.

As soon as finished giving the formula/colostrum, the plunger is totally depressed; I pull the tube "quickly".  If you stay down too long, or pull the tube too slowly the pup will gag and regurgitate which as mentioned is what puts them at risk for pneumonia.   If you blow breaths vigorously in the pup's face as you pull the tube, it does help distract them.  You want the pup to keep everything down.  As soon as you pull the tube they settle, and so you know, after a few times of feeding this way, the pup learns that the tube means a full tummy of warm food, and will actually start swallowing the tube on their own.  I have had them act like guppies, repeatedly opening their mouths trying to grab at the tube knowing it means a full tummy.

After finished with the feeding, the pup will need to "nurse".  This is as important as almost anything else is.  The nursing on your finger is quite fulfilling for them.  Remember clean hands,  no residual soap, and no long nails.  But allow the pup to suckle on your finger after feeding for as long as he or she wants, or as long as you can allow.  This is the longest part of tube feeding a pup.  The entire feeding takes less than a minute, but I have found some pups will "nurse" for 10 minutes or so.  This nursing helps fill the nursing need, and also helps clear the nasal passages and sinus of any formula.   As mentioned before, if you find the pup doesn't want to nurse on your finger, try dipping it in a small amount of formula or colostrum for "flavoring". On the newborn pups I start with the little finger and then as they grow they move up in size finger they want.  My first cleft was still wanting to nurse on fingers for months after she was on dry food.   It was cute to watch her fascination with fingers and it was not unusual to see her at 6-7 months of age go up to anyone, strangers included and try to partake of a finger. :-)
Elimination

Either before or after, before is actually better, you need to stimulate the pup to urinate.  Puppies will not urinate on their own until around 10-12 days of age.  If the pup is able to be with its litter, the dam will likely take care of this need, however don't assume that she is.  Formula fed pups have a different scent to their urine and stool, and the dam may not take care of their elimination needs because of it.   So to be sure the pup is eliminating, using a damp warm cloth or paper towel, wipe over the penis or vulva area to encourage urination.  They will eliminate bowel wise without stimulation.   The suggestion for doing the stimulation before, it wakes up the pup makes it ready to nurse, and it will do better if it doesn't have a full bladder while you are trying to feed.  Check this need everytime before you feed, unless you have personally seen the dam taking care of the pups elimination needs on a regular basis.

So elimination, feeding, nursing on a finger and the pup is set until the next feeding.  I try to leave a cleft pup with its litter.  If it is not a possibility, then some suggestions follow.

The pup needs to have external warmth.  When with their litter they lie side by side or even on top of one another, plus they have the warmth of their dam.   So if that is not the situation, you will need to improvise.   Use a smaller size box to start with, with preferably a heating pad on low under one side of the box.  The bedding should be soft and padded.  You can also put a 2-liter plastic soda bottle filled with hot water on one side of the box.  You can fill the bottle with cold water and microwave to heat, wrap it in a towel and prop it so it can't move.  Warmth is crucial to the well-being of a young pup.  Hypothermia can set up easily on an only pup without its dam.  The pup should always feel warm to your touch, if it feels cool, then more of a heat source is needed.  Preferably do not place the box at floor level unless it is warmer time of the year, or the floor is warm.   Floor level is the coolest and without enough additional warmth, hypothermia can set up.  I prefer securely on a large table, makes an easy work area also.  The pup will need the external heat sources also with being on a table.  If the pup is too warm you will find it trying to pant, mouth open and restless.   

 A trouble shooting note with any pups, if you have one or a few that are restless, crying check elimination first.  A full bladder makes them miserable, rightly so.  The other issue if not elimination is usually too warm an environment.  The later isn't something one has to worry about usually the first week or so, but once they put on a fairly good fat layer they do tend to get too warm easy in a household environment.  If too cold and more than one pup you will see them in a pile, trying to derive warmth from littermates.

I just added that as I have had numerous parties over the years ask me "what could be wrong, the pups keep crying", all but one case the above was the issue.  The one time it wasn't, it was a case of Herpes Virus.  We won't discuss that here, other than keeping the pups environmental temperature warm enough is the best way to prevent an issue with Herpes Virus which is usually fatal on pups up to 3 weeks of age.  Also it runs through a litter very quickly and no real treatment once it has infected.  So keep the pup(s) warm enough, definitely better to prevent issues.

Pups like to lie next to others, so for an only pup a plush stuffed animal may help.   I also recommend placing a "worn" item of your clothing, such as a tee shirt in with the pup.   The pup is learning that you are its surrogate mom, and recognizes your scent as the one that cares for him or her, so an item of clothing with your scent will be comforting to the pup.   

But if at all possible leave the pup with its litter.  Do watch that the dam and littermates are not at risk of hurting the cleft pup.  Since the cleft kids lag behind in weight, they are more likely to end up at the bottom of the puppy pile, so watch.

Weeks 4 through 8

Once 4 weeks rolls around it is time to introduce DRY food.  These pups bypass the mush, gruel or pabulum stage.  Remember anything entering the mouth has the potential of ending up in the nasal passages and sinuses.  Dry food does not go up through the cleft and the plain water they are soon to drink does not pose any issue going up into the nasal passages, as a matter of fact it can be beneficial-that aspect will be explained shortly.

Since the cleft pups are smaller at 4 weeks than normal, if at 2 pounds or more a small breed puppy food will work. The pups do not chew the food, they mouth it and then swallow it whole.  So the morsel needs to be small enough that they can swallow it but large enough as to not go up into the cleft.  Prefer a round morsel, as morsels with pointed edges can get the ends caught in the larger clefts.   If the pup is under 2 pounds then start with a good quality Kitten food-yes Kitten food.  One in particular I suggest, that is Purina ONE Growth for Kittens.  Can be purchased at many grocery stores, Walmart and Kmart and some pet stores.  It is one of Purina's top of the line foods for kittens.  It is a very small morsel, meant for pound or smaller sized kittens, is a chicken base and other than a little higher in protein than some puppy foods it is great.  The guys do well on it and just stay on it until they have enough size to go onto a small breed puppy food.  If outside the US, I would check into what good quality kitten foods that are available.  A high 20's to 30% protein, and upper teens to 20%  fat is a fairly common analysis on quality puppy foods, so try for a similar analysis.

To introduce the food, just sit the pup down,  sprinkle a few morsels in front of her or him and watch. If the pup doesn't scent it right away you may have to about put the pups nose down on a morsel so they can scent it.  The pup will take a morsel mouth it back and forth, back and forth and eventually swallow it and then be on to the next.

The only restrictions clefts have for life is DRY food and plain water.  Otherwise they can do everything else any dog can and they live a full great quality life.  Once on dry food their weight will pick up quickly.  Allow the pup to eat as much dry food as he or she wants 5-6 times a day.  This is also the time to introduce water. The easiest way to start them on water and to be sure they are drinking enough is to use a rabbit or hamster type waterer bottle.  It is a bottle that hangs upside down on a crate door or whatever you wish to suspend it from, but it allows the pup to lap water slowly from an elevated level which prevents the water from going up through the cleft.  Also makes it easy to see just how much water they are taking.   

It is advisable that all clefts learn to drink from a bowl at floor level.  Reason being if for any reason they get loose and someone finds them, the person finding them will not know they are a cleft and will offer water as for any other canine.  But drinking out of a bowl can be introduced later, 8-10 weeks or later.  At that time all you do is sit a bowl of plain water in front of them and watch.  The pup will sniff, possibly stick its nose in it, but then he or she will lap, some will likely come out its nose, he or she may sneeze, and then they will lap again, lift their head and swallow.  They learn the how to of drinking water very quickly, as they do with dry food.

Water does not cause an issue when it goes up in the nose, formula or gruel will set up a nasty sinus infection so that is why they totally skip that part.  As mentioned the water up into nasal passages can actually be beneficial.  If there is any debris up in the nasal passages, dirt, etc. a common occurrence as pups learn the great outdoors, the water actually helps rinse out the nasal passages for a better description.  They also develop a total tolerance to it, the more they drink the better they do as far as any out the nose and they get so it is of no issue at all.  I think of how it feels to get water up in my nose, but evidently with regular exposure their nasal passages adapt.  Just another great way of Mother Nature.  

While the pup is getting the hang of eating dry food and drinking plain water, you may need to supplement some with formula.  As long as one is tubefeeding the pup should be on the antibiotic.  Once no longer tubing with formula or water then the med can be stopped.

Allow the pup to take as much dry food as it wants, offer it 5-6 times a day and if they only take a few morsels then give some formula.  Be "'EXTREMELY" careful giving formula if tubing.  The reason being you can easily overfill them and risk regurgitation.  Bottle feeding is much safer as they will only take how much they want. Use a measuring cup when putting out the food, a quarter cup measure is a good place to start so you will be able to actually measure how much the pup is taking.  After they eat, put any remaining food back in the cup so you can see the amount of consumption.  If the pup is able to take a fair amount of  food, then don't give any formula.  Just give more morsel in a few hours.  Remember to keep water available at all times via the waterer bottle.  If they drink enough, "usually" they do, so you do not need to tube or bottle with any water either.  On the waterer bottles, please be sure to change the water everyday.    

To be sure the pup is staying hydrated-taking enough water,  you can do a couple checks.  One is check skin turgor, do this by pinching up the skin about midway down the back.  As soon as you release the pinched skin it should immediately return to normal.  If it goes down slowly the pup is a little dehydrated and you will need to tube with more water.  If it stays pinched up the pup is very dehydrated and you need to tube the pup immediately with water and again every hour until the pinch test improves.

Another check is to look at the inside of the mouth.  It should appear moist and the tongue should be with a moist smooth appearance, no signs of "cracking or lining".    So check those two areas as you are switching the pup over to dry food and water.  Once you are done tubing, do the checks a couple times a day to be sure the pup continues to take in enough water on its own.  If for a week the checks are normal then the pup is doing fine on its own.   Also weighing is important.   Weigh the pup the same time each day, before feeding, and it should be gaining well.   If  you see a drop off in weight, offer food more often or resume supplementing with formula for another week, then monitor again without supplementing.   

The pups normally are taking enough food and water within one week, frequently within one to two days, of starting on both. But they can vary so do monitor them.

Well that is it as far as special caregiver care.  At this point they become as any other pup.  

Puppy Vaccinations and Dewormings

With puppy vaccinations, if the pup received colostrum the first 2 days then follow your normal puppy vaccination schedule.  If the pup did not then it is advisable the pup receive a "killed" parvo vaccination with or without distemper at 4 weeks.  Without the dams colostrum they are not protected against those two potentially deadly viruses, so it is important to vaccinate them early for those.  After the initial vaccination they can go to a normal puppy vaccination schedule.

The dewormings should be added to their formula and be given at 2 and 4 weeks as normal, to cover for any parasites that may have passed in utero or were contained in any colostrum given.  They can then just receive it as any other pup.  The need is not as great due to the fact the pup hasn't nursed, the main route for transfer of roundworms etc. is via the dams milk.

Troubleshooting

Difficulty Breathing

There will be things come up they you may not be sure what to do about them.  One of the first problems frequently encountered is rattling sound with breathing and one is not sure if it is nasal or a lung issue-pneumonia.
If your pup is sounding noisy with breathing, open its mouth and listen, if the respirations are easy and without noise, the noise you were hearing is nasal. If the noise continues the pup is likely developing pneumonia.  If that later is the case the pup needs to see the vet immediately and be given injectable antibiotics and continued on oral antibiotics-preferably Cephalexin if not already on it.  Pups have a difficult time making it once pneumonia starts to set up.  Catching it early increases their survival chances.  Gum color is a good indicator of how compromised the pup is.  The gums should be pink and when pressed on with your finger, the area pressed will "blanche" whiten in color, and then will repink once the pressure is removed.  The repinking should be immediate.  The longer the time to repink the more compromised the pup is.

For nasal congestion, if the pup gets to where it is having difficulty breathing and you have done the above test to see if it is nasal or lung and you have found it is nasal, you can place a tiny dab of Vicks Vapor Rub or its equivalent on the pups muzzle alongside its nose, or on top of the muzzle.  Do not put it on the pups sensitive nose tissue.  Put it on the fur and do be sure it is placed so the pup cannot lick it and watch to be sure the dam doesn't lick it off.  It is a petroleum base product which should not be taken internally.   It is likely that the scent will be enough to keep the dam from licking it off.  But the vapors will help open the congested nasal passages.  If you are one into aromatherapy, mix a few drops of Eucalyptus, Peppermint, or Tea Tree oil with a little vegetable oil and rub a drop or two on the pups fur on the side or top of its muzzle.

Regurgitating (Bringing formula backup)

This is something that needs to be prevented at all costs.  It is the one thing that greatly increases the pups risk of aspiration pneumonia.  Regurgitation occurs usually due to overfilling the pup, this applies to tubefed pups.  So the solution is to back down the "amount" you are feeding.  One needs to maintain the frequent feeding schedule, but with smaller amounts.  It is possible for the pup to hold a certain amount for a few feedings and then not for others.  Usually that means that the previously given amount was large enough that it had not emptied enough out of the stomach before time for the next feeding.  This is a problem only encountered with tube feeding, as with bottle feeding the pup only takes however much it wants and can hold.  

The pups can regurgitate in this case during the feeding, as you pull the tube, or right after you pull the tube. Some
may try to gag and possibly regurgitate some earlier given formula when inserting the tube if it is inserted too slowly setting off their gag reflex.

** What you should do if the pup regurgitates enough that  formula comes back out its mouth or nose.  Immediately pull the tube if it is still inserted, turn the pup upside down, head straight down towards the floor and keep it is this position for a couple minutes.  You are trying to get any formula that may have been inhaled/aspirated to come back up into the pups mouth and out.  Thoroughly wipe away any formula from around the pups mouth and nose, put it down and allow it to settle.  It will be very important to monitor its respirations for the next several days, and hopefully the pup is on its antibiotic-preferably Cephalexin so any formula residual that is still in the lungs will not progress to pneumonia.  You may also monitor gum color as noted above.

Slow weight gain

As mentioned through the information, this is not an issue.  I find parties question it constantly so I thought I would put it in the problem area so I can reinforce that all you want them to do is have "slow steady weight gain".  
They should gain a small amount just about everyday.
Most cleft pups tend to weigh in at a half to a third of their littermates weight.  Most of them closer to half.  So if you have a breed that normally weighs 5 pounds at 4 weeks, expect the cleft pup will likely weigh closer to 2 or 2.5 pounds.  They all catch up once on dry food for a few weeks.  You want to get them to the point to be able to eat dry food and if you overfill the pup trying to keep their weight up close to that of littermates or the normal for your breed, you will likely have a pup that regurgitates, aspirates and may very well die.  So smaller is fine, a little weight gain every day-that is after the first couple days after birth,  but after that point it maybe a quarter or half ounce a day on small breed and that is fine. On larger breed kids it is usually closer to 3/4-1 ounce every day or two, and that is JUST FINE.

Dry flaky skin, constipation

These symptoms that the party emailed about are actually due to one problem.  The apparent issue is lack of sufficient fluid intake.  The puppies need adequate fluid in order for bodily functions to remain normal and for them to grow and thrive.  It is also imperative since the antibiotics are excreted by the kidneys that there be sufficient fluid for the kidneys to be able to do the job without being stressed.   Constipation and dry flaky skin, sometimes itchy skin due to the dryness are side effects of inadequate fluid intake.

Please be sure to monitor pups hydration status, even from the beginning of this journey.  It is crucial when changing them over to dry food and plain water, but it is also very important from day one when giving them colostrum and formula.  The formulas given are mostly water, but one needs to be sure the pup is being fed "often enough" to stay properly hydrated.  Each day when weighing, take a look at the inside of the pups mouth, see that it looks moist and no signs of lining or cracking on the tongue.  Do the skin turgor test as noted above in the info.  Monitor bowel movements.  Puppies normally have several stools a day.  Granted these cleft kids because their intake is not as much as littermates, they will not have as many stools.  But they should stool at least once or twice a day minimum.  If you note no stools, due to either the pup not having any or the dam is cleaning them up, check the pups belly.  It should be soft, without any firmness or signs of rigidity upon palpating, and no sign of any discomfort.

If the pup is painful around its abdomen and/or has vomiting contact your vet immediately.  Discuss what you should do prior to doing any of my suggestions.  If the pup is behaving normally, eating, playful, etc. but no stools and abdomen is a bit firm then you likely are dealing with constipation.  Not to the point of "obstipation", which is obstructive  constipation which needs to be dealt with by the vet.

If you suspect constipation, there are a couple things one can do.   First one to try is lubricate a rectal thermometer generously with Vaseline, this is the one place we use Vaseline, then gently insert the thermometer into the pups rectum about a half inch,  possibly up to an inch on a large or older pup.  Very gently, let me stress that over and over-there should be NO resistance.  If any withdraw the thermometer.  What you are doing is two fold, one, some of the Vaseline is going to be left and will lubricate and just the action of inserting the thermometer usually acts as a stimulus to make them move their bowels.

If that does not work, you can give a small dose of "plain" mineral oil, and "only if given via a tube".  Do not give it on their food, or just syringe in their mouth as you do not want mineral oil to go up through the cleft into the nasal passages, or sinus.    A small dose will of course depend on the size of the pup.   Usually  1cc on a small breed pup, or up to 2cc on a larger breed pup, this is on a 4 week or older pup.  If the pup is younger or you are not sure what the issue is or if you should try the above, discuss your options with your vet prior to doing anything.  
Only give one dose and if no stools and the pups abdomen remains firm be sure to contact your vet.

I will be adding to this info as it is warranted.   Parties are always welcome to contact me if they have an issue not covered in the info or they have tried my suggestions and are still having difficulties.

I hope all that read and use my info have a positive outcome for their work.

Best wishes,  Anne

Copyright 2001, revised 2002

As stated previously this information is for the party working to save a cleft palate pup.  It is for their personal use only and is not to be reprinted in any form or by any means without my express written permission.

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About the Author

I thought I would include a note about myself so parties will know where my expertise in this area comes from.   First if you entered the site on the cleft palate page, then you may not know I have been active with Labradors for 18 years.   My Labs have been active in conformation, obedience and hunt tests.  Most of my pups go out to be family companions first, along with being helper dogs, guide dogs, service dogs, SAR dogs, etc.  The list goes on.  I also do canine and feline rescue, I don't have 2 legged kids, mine are all 4-legged and hairy.

 In my people life I have been an RN for 25 years, working in numerous areas of nursing, including ICU, CCU, ER, Surgical, Medical, Home Health, HIV nursing-my favorite and most fulfilling.   So I have a varied nursing background and found over the years also being involved with the canines that the care between species-human and canine is not much different at all.  Main difference is they tolerate adversity better than we do.

My first cleft was born 12  years ago, she is the daughter of an English Import boy.  I didn't even realize she had a cleft for the first 2 weeks.  That is a common thing I have found, unless one has had a cleft pup before or know of a breeder that has had a cleft pup most don't think to check palates.   I did note soon after she was born that she seemed to not know how to nurse.  She would chew and mouth at the nipple but not make a suction on it.  So I just thought she didn't know how to nurse and took up syringe feeding her.  For those that do not know this method, you use a syringe, draw your formula up in it and slowly squirt a little at a time onto the pups tongue, they swallow it, and you continue drop by drop until they take enough.  It takes forever but I would have done it no matter how long it took.

Well at roughly 2 weeks this little pup that sometimes sneezed some of the formula out her nose, gave me a big yawn, and lo and behold here was a full length wide cleft palate.  Now it all made sense.

I contacted my vet and he had no information to share reference clefts other than everything he had learned said to just euthanize.  He knew me better than that, so he was supportive of whatever I wished to do.   I was able to have one of the surgical instructors at the local university-they have a vet program, look at her, and he was very blunt.   He said once she was large enough-5# he would do grafting to attempt repair and when it didn't take, he would repeat the surgery again and when it didn't take and I had spent thousands and the pup was even more compromised I would have to put her down.   He followed that by asking me if I would be willing to donate her to the university so they could practice on her, that she would be adopted by one of the students or professors and once her life was miserable after numerous surgery attempts they would put her down.

Any guess what my answer was.  He was blunt, honest but blunt.  I contacted likely every breeder, of various breeds even, around the country and even out of the country and no one had successfully raised a cleft palate pup to adulthood, those that did raise them large enough to have surgery had to euthanize post attempting surgery as the issue was made worse.  (I am referring the larger clefts that would require larger areas of grafting.) The small ones can at times be repaired successfully.   

So with no instructions to follow I decided somehow I would save her, she wouldn't have surgery and god willing she would be just fine.   

So I started tubing, and we had our mishaps.   One day she decided she didn't want the tube in and jerked her head back as I injected the formula, the unexpected jerking back pulled the tube up high enough that she aspirated a fair amount of formula.  I believe if I wasn't an RN in my people life I doubt she would be here.  It took running IV's on her, injectable antibiotics, round the clock chest PT  to facilitate drainage to get her through the pneumonia she set up-all done at home.  I had a very sick Lab pup, that at this point-6 weeks only weighed 2 pounds, her littermates were all 10 pounds by that age.  But I had a wonderful vet and he allowed me what I needed to work on her at home.
So Red was a huge learning experience, I tried gruel on her once she was older and I knew she had to go onto puppy food, well that just went up through the cleft and set up nasty sinusitis.  She ultimately ran almost 3 months solid of antibiotics.  She wasn't on dry food until almost 5 months.  So when the next cleft kid came along 6 months later I implemented a lot of changes.   Strange, breeder for 6 years, no clefts, then 2 in a 6 month time frame.  So you know Red is now 12 years of age, huge full length cleft - not repaired and she is still doing fine. No special care other than DRY food and plain water.

Pete my second cleft, certainly benefited by Red being before him.  To prevent issues I put him on Amoxicillin prophylactically, well needless to say I didn't have a mishap with him like I did with Red, but he did upchuck for no apparent reason inbetween feedings, evidently aspirated some and within hours was wheezing.  So I changed his med from Amoxicillin to Cephalexin and within 24 hours he was sounding almost clear.  I do lung sound assessments on all my own clefts, since I have that ability.  

With him I skipped the gruel attempts, learned how that didn't work with Red and tried him on small morsel dry food as soon as he had some teeth breaking through at 4 weeks. Worked great!  Now I did continue tubing him with water as I wasn't sure how to get him onto water.  Well he showed me how one day, by walking over to the water bowl for the other puppies and drinking.  How about that!  No fancy introduction needed.  He did sneeze some, and yes some came back out his nose, but within seconds he was lapping, lifting his head and swallowing.    So by 6 weeks Pete was the same as any other pup.  He too is a full length cleft, not quite as wide as Reds, my first cleft kid.

Since the first two back in 1990, I have raised a few more cleft kids and have helped local parties and friends raise theirs and with the help of the internet over the last almost 2 years have been able to help another 5 dozen plus.   With each one of the earlier kids I learned something new, a new issue, a new way to do things until it has developed into a type of protocol to follow if one has a cleft.  There have been likely close to a dozen that haven't made it-none of mine or ones that I had hands on contact with, but ones belonging to parties away and all but a couple died due to pneumonia and they were either on no antibiotic prophylactically or were on Amoxicillin.
To me that stresses the importance of the med and the right med, or stick with bottle feeding-carefully.  

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So my first cleft child Red was a journey without a map and fortunately she was a fighter and we made it.  But due to having no one to let me know the way to go with my first cleft is the reason for making this information available for those that are traveling that road I did so long ago.

This information is copyrighted, all rights reserved.  No portion or part of this information may be reproduced in any manner or by any means except as noted below, without my express written permission.  Only allowed use is for parties raising a cleft palate puppy, they may print/copy the above information for their use only and not to be reproduced as stated above for any other use..
Hennwood Labradors 2002-2008

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