Meet The AuthorS
September 2025
Manuel Boller Dr med vet, MTR, MANZCVS(ECC), DACVECC
I am a specialist in veterinary emergency and critical care, adjunct associated professor at the University of Calgary and chair of RECOVER Research. Clinically, I work as a criticalist in the ICU of the VCA Canada Central Victoria Veterinary Hospital on Vancouver Island, British Columbia.
Jamie Burkitt DVM, DACVECC
I live in Davis, California, and work at UC Davis as a faculty criticalist. I am also the Guidelines Chair of RECOVER, whose mission is to empower people to provide lifesaving care to animals through education, science, and community.
Boller M, Burkitt-Creedon JM, Byers CG, Fletcher DJ, Farrell KS, Davidson AP, Fricke S, Bassu G, Grundy SA, Lopate C, Veronesi MC, the RECOVER Newborn Resuscitation Domain Evidence Evaluators
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RECOVER Guidelines: Newborn Resuscitation in Dogs and Cats. Clinical Guidelines.
Boller M, Burkitt-Creedon JM, Fletcher DJ, Byers CG, Davidson AP, Farrell KS, Bassu G, Fausak ED, Grundy SA, Lopate C, Veronesi MC
The Rationale
About a decade ago, the RECOVER chairs identified key domains for the next round of evidence evaluation and treatment recommendations (RECOVER 2.0). We recognized significant uncertainty within the veterinary community regarding optimal resuscitation strategies for newborns. Given that puppies and kittens at birth differ physiologically from adult dogs and cats, resuscitation techniques cannot simply be extrapolated. Moreover, as in human medicine, we anticipated limited evidence to guide newborn resuscitation, highlighting the need to define critical knowledge gaps and establish a research roadmap. For these reasons, we considered newborn resuscitation an essential addition to the existing RECOVER domains, which include preparedness, BLS, ALS, monitoring, and post-cardiac arrest care. And, of course—who doesn’t love puppies and kittens?
The Process
For the 2012 RECOVER Guidelines, evidence evaluators conducted their own literature searches. While effective, this excluded contributors without library access and introduced selection bias based on individual search strategies. For the 2024 RECOVER Guidelines, including the newborn domain, we adopted a far more rigorous approach. A team of information specialists led by Erik Fausak, a Health Sciences Librarian from the UC Davis library system, designed and executed tailored search strategies for each PICO question. We also used Covidence, a systematic review platform, to streamline literature screening. Evidence evaluation followed the GRADE methodology, the same framework used for the 2024 RECOVER CPR Guidelines. Unlike the 2012 evidence grids, GRADE is outcome-centric: we first defined clinically relevant outcomes (e.g., survival to hospital discharge), ranked them by importance, and weighted evidence accordingly. High-priority outcomes (e.g., favorable neurologic outcome) were emphasized more heavily than less critical ones (e.g., ventilation parameters). The quality of evidence then informed the strength of recommendations:
• High or moderate quality → recommendation for or against an intervention
• Low or very low quality → suggestion for or against an intervention
These were in some circumstances further modified by considerations on feasibility (can it be implemented?) and complexity of implementation (is it worth the effort?), and a rationale for these decisions was presented in the justification for each recommendation. To minimize reviewer bias, two evidence evaluators independently assessed evidence for each PICO question. Huge shout out to all those that volunteered their time and energy as evidence evaluators, it was a big job. For us this also meant facilitating the process for a large group (56 evidence evaluators for the Newborn Guidelines). We held webinars, wrote an evidence evaluation manual to instruct evidence evaluators, screen-casted examples, and developed a purpose-built web-based GRADE system (i.e., RECOVER GRADE site) to operationalize the evidence evaluation process across 28 PICO questions. Despite these advances, progress was slow due to the project’s scale, its entirely volunteer-driven nature, and the COVID-19 pandemic, which diverted many contributors to urgent clinical demands. We wrote the first PICO questions in early 2018, but timelines stretched considerably. The greatest challenge was the paucity of direct evidence. We expected that to some extent from the previous work for the previous RECOVER guidelines, but we were still surprised how little evidence there was that concerned even human transitional newborns in the first moments after birth. Most experimental studies involved animals that were several hours to days old and thus had already transitioned. Veterinary clinical studies were essentially absent or of very low quality of evidence with a few exceptions. Human trials involving newborn infants were relatively plentiful in some areas (e.g., PPV with 100% oxygen versus room air), but absent or too indirect in others (e.g., doxapram, GV 26). Consequently, identifying knowledge gaps was straightforward, and addressing them remains a priority for future research. With very low quality of evidence or absence of any evidence being the norm, expert consensus became critical. We therefore assembled a group of subject matter experts (SMEs) who are small animal reproduction specialists very experienced in newborn resuscitation; these SMEs offered a different perspective than what we as emergency and critical care specialists bring to the table. Through anonymous surveys, each of the 59 treatment recommendations was iteratively refined until ≥80% agreement was reached. Unresolved disagreements were addressed via conference calls involving RECOVER co-chairs, domain chairs, and subject matter experts. Finally, all recommendations, supporting evidence summaries, and justifications were shared with evidence evaluators and the veterinary community for feedback prior to publication. This collaborative approach enabled us to achieve consensus on all but one recommendation—specifically, the use of GV 26 stimulation. We presented the findings of this project in two articles. The first pretty much presents the "raw" output from the study, summarizes the evidence evaluations, lists the treatment recommendations, the justifications for these recommendations and states the most important knowledge gaps. While essential, this article is very long and difficult to navigate for practitioners. A second article, the actual guidelines, condensed the information so that it is more user friendly and facilitates implementation in clinical practice. It also contains the algorithm and dosing chart.
Evidence evaluation process overview for the RECOVER Newborn Resuscitation Guidelines.
M. Boller, J. M. Burkitt-Creedon, C. G. Byers, et al. “ RECOVER Guidelines: Newborn Resuscitation in Dogs and Cats. Evidence and Knowledge Gap Analysis With Treatment Recommendations.” Journal of Veterinary Emergency and Critical Care 35, no. S1 (2025): 35, 3–59. https://doi.org/10.1111/vec.70012
Key Recommendations
The primary goal of these guidelines is to support newborn puppies and kittens during the transition from intrauterine to extrauterine life. The most critical event in this process is lung aeration, making early positive pressure ventilation (PPV) the top priority for non-vigorous, apneic, or gasping newborns. To help veterinary professionals decide when to initiate specific interventions and escalate care, the guidelines propose heart rate thresholds that trigger defined actions. Accurate heart rate monitoring is therefore essential for guiding resuscitation. Chest compressions are reserved for newborns without a heartbeat or those with a heart rate <50/min unresponsive to PPV alone. The guidelines provide instructions on compression techniques and on coordinating compressions with ventilations. Finally, a newborn resuscitation algorithm summarizes the sequence of decisions and actions, serving as a practical tool to prepare veterinary teams for and guide them through the resuscitation process.
Newborn resuscitation algorithm for puppies and kittens
M. Boller, J. M. Burkitt-Creedon, D. J. Fletcher, et al. “ RECOVER Guidelines: Newborn Resuscitation in Dogs and Cats. Clinical Guidelines.” JVECC 35, no. S1 (2025): 35, 60–85. https://doi.org/10.1111/vec.70013
Implementation Considerations
The newborn resuscitation algorithm can be used to prebrief resuscitation teams before deliveries, such as during C-sections, and a dosing chart supports accurate drug administration. To facilitate effective implementation of the guidelines in clinical practice, we are developing both didactic resources and hands-on training, similar to existing RECOVER BLS and ALS training for adult dogs and cats. Additionally, given the extremely small size of newborn puppies and kittens, we are designing a newborn resuscitation kit to address the technical challenges associated with performing resuscitation in these patients. We anticipate these educational resources and modules will be available by 2027.
Looking Forward
An important outcome of this project was the identification of key knowledge gaps encountered during the evidence evaluation. These gaps highlight critical research questions that must be addressed before future treatment recommendations can be made with greater confidence. We identified substantial knowledge gaps for nearly all PICO questions, underscoring that while these guidelines are the best currently achievable, many recommendations will likely evolve as new evidence emerges. A notable example is needle stimulation of acupoint GV 26 for stimulating non-vigorous newborns with bradypnea, apnea, or gasping—a practice widely used in veterinary medicine. We found no studies of acceptable quality (e.g., with a control group) supporting or refuting its efficacy. Consequently, we could not issue a recommendation for or against GV 26 stimulation but included it as an adjunctive intervention in the algorithm. Well-designed trials in the target population are feasible and could directly influence future recommendations. Similarly, the use of doxapram, another common practice, is not supported by direct evidence in newborn puppies or kittens. A recent randomized controlled trial by Hyndman et al. (2023) involving 171 puppies from 45 elective C-sections found no effect of doxapram versus placebo on 7-day survival or APGAR scores. However, this study included all puppies delivered via C-section, not specifically those that were non-vigorous, apneic, gasping, or bradypneic. A follow-up trial targeting these high-risk newborns would be required to clarify doxapram’s role. Other available studies on doxapram involved neonatal infants with apnea of prematurity treated in NICUs or adult animals. Clinical studies of doxapram in calves either involved post-transitional healthy animals and/or did not include a placebo group. The indirectness of these findings limits their applicability to newborn puppies and kittens in the immediate postnatal period. Until high-quality, species-specific data become available, doxapram remains listed as an adjunctive intervention rather than a recommended treatment. There was also a lack of observational studies in newborns requiring resuscitation during the first minutes after birth to address fundamental questions: how many animals require PPV, how quickly does the HR increase with PPV, for how long is PPV required until HR >120/min, what percentage of non-vigorous newborns require chest compressions and for how long, and many more. Studying these first 10-20 minutes after birth would be extremely valuable to further our understanding of what happens to puppies and kittens in distress during the first minutes after birth.
