Puppies and kittens make up a large part of the private small animal practice. Developing and implementing a pediatric wellness program and standard of care are important aspects of ensuring consistent, comprehensive health care for pediatric patients, as well as promoting a long-term, client-practice bond. One of the best ways to begin this process is to establish a pediatric standard of care that is unique to your practice. A properly developed standard of care ensures that all puppies and kittens receive consistent care during their individual office visits and throughout their long-term pediatric care. According to the *New England Journal of Medicine,* standard of care is defined as a diagnostic or treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance.

Importance of Standards of Care {#s0010}
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Having an established standard of care is an excellent reference for anyone (head technician, receptionist, new graduate, or newly hired yet experienced associate) to determine what should be done in almost any situation in a practice. This chapter focuses on the standards of care for pediatric wellness visits. These standards are not intended to be hard and fast rules but rather guidelines to follow in frequently encountered situations. These guidelines allow veterinarians to establish more consistent patient care and practice better medicine as a result of improved client understanding and compliance.

Consistent patient care will better aid clinicians in making sure every client is receiving similar information. Even clinicians within a practice have different interests and practice styles, which lead to similar cases being treated very differently within the same hospital. A written standard of care would ensure that every client, regardless of which doctor is seen, would be leaving the practice with a predictable set of information and recommendations. This is particularly important in pediatric cases because it gives each subsequent veterinarian confidence in what information and treatments were given in the prior visits. In the pediatric wellness examinations, an important part of the veterinarian\'s job is to educate the client. A client who hears the same or similar recommendations from different sources within the hospital is much more likely to comply with those recommendations. For example, one veterinarian in a three-doctor practice may feel that strictly indoor cats do not require feline leukemia virus (FeLV) testing. The second veterinarian may recommend testing only in multiple cat households. The third veterinarian may recommend testing for all cats but leave it up to the client to decide. Inconsistencies create confusion with clients, as well as support staff, and the client is much less likely to follow any of the recommendations given.

A pediatric standard of care allows clinicians to practice better overall medicine. Every private small animal practice experiences busy days, juggling multiple patients simultaneously. With an established set of guidelines and protocols, there is less chance of omitting a FeLV test, failing to recommend a fecal flotation, or forgetting to discuss a particular aspect of behavior and training on those busy days. The pediatric visits are more likely to become a complete health care program, both medically and behaviorally, rather than a series of vaccines and deworming.

Establishing Standards of Care and Protocols {#s0015}
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The most important aspect of establishing a standard of care is that it must be in written form. If it is not written, it does not exist. Everything must be documented within a medical chart, from recommendations (both accepted and declined) and treatments to telephone conversations with clients; thus a hospital must have written standards of care.

The first step is to schedule a doctor\'s meeting. Having the meeting outside of the hospital may be a good way to avoid distractions and interruptions. This is a team effort in which all doctors within the practice should contribute to create the pediatric standard of care. If everyone is able to contribute to the plan rather than having it dictated, there will be better success in following the plan that has been created. During the initial meeting, a list of areas that need standards to be developed can be generated and agreed on. The American Animal Hospital Association (AAHA), American Association of Feline Practitioners (AAFP), and Veterinary Information Network (VIN) are good resources for guidelines and can easily be tailored to fit a practice style.

Training the support staff on the newly created plan is a crucial part of the process. Each member of the staff needs to adhere to the plan to make sure the desired message is being delivered to the client at any point in their visit to your practice. Whether it is the receptionist, the veterinary assistant, or the technician delivering the message, the information given to the client should be the same. Regular staff meetings can be used to educate staff on the standards and to review and reinforce the protocols and standards of care. A list should be generated of the top 25 to 50 most frequently asked questions that are fielded by the receptionists and technicians, and the written answers to these questions can serve as a source or script for those staff members. Written protocols and standards of care guidelines aid in standardizing and enhancing the training of new staff members. A test bank of different topics from the pediatric wellness visits (or any other aspect of a practice) can be created, and staff members can be periodically tested on the information. For example, how often are vaccinations given, what are the available canine vs. feline vaccinations, or what are the common internal and external parasites of puppies and kittens? Once these tests are completed and scored, many practices will reward successful staff members. Rewards could be gift certificates, staff parties, or pay raises.

The First Pediatric Visit {#s0020}
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The first pediatric visit generally occurs between 6 to 8 weeks of age. An adequate amount of time should be established for the first pediatric wellness visit. Creating 30- to 40-minute office visits allows doctors and technicians ample time to address all topics identified in the plan, as well as answer any questions the client may have. Some may contend that this amount of time is too much for a busy practice; however, if it ensures that the puppy is well socialized and trained, then the time will be recouped in future visits (instead of having to muzzle or deal with an unruly patient). Generally, there is too much information for the average client to digest on the first visit, especially if this is their first pet. It is recommended that information be divided into smaller sections to be discussed at each of the scheduled pediatric visits, so the client does not become overwhelmed. The pediatric visits are an opportunity to educate the clients, to make sure they understand the plan of care and recommendations, and to make sure their new puppy or kitten is going to be a good fit for their family and lifestyle.

A written handout should be created for the initial and subsequent visits. There are typically 3 to 4 pediatric visits between the ages of 6 to 20 weeks (corresponding with vaccination dates), depending on the age of the pet when it is first seen. Each visit and handout should cover different selected topics. A list of suggested topics can be found in [Box 7-1](#b0010){ref-type="boxed-text"} . Since there is a large volume of information to be given to the new puppy or kitten owner and the average client remembers about 25% of what they hear, alternative learning aids are helpful. Systematically transferring information into smaller, easier-to-digest sections in a written format for the client to take home is a significant tool in client education.BOX 7-1Suggested pediatric topics of discussionSupplies neededPuppy/kitten-proofing your homeIntroducing new puppy/kitten to other pets and family membersSocializationHousetraining/litterbox trainingPet identificationZoonosesParasite controlInfectious disease and vaccinationVaccine reactionsHeartworm diseaseBarking/vocalizationBitingChewing/digging/destructive behaviorNail care and scratching postsInappropriate scratchingTrainingExerciseNutritionBody condition scoreSpay/neuterDeclawing/tendonectomyPet insuranceMicrochipGroomingGroomers/kennelsDental careEar careEmergencies

Specific website and book recommendations should be established as a source of additional information for clients. Rather than simply suggesting books or the Internet in general, find specific sites and titles that mesh with the practice\'s style and philosophy and supply clients with a list of those sources.

Risk Assessment {#s0025}
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The office visit should begin with a history, followed by the physical examination and any treatments deemed necessary. The client should complete a pediatric history and a Risk Factor Evaluation, which is an excellent method of determining the type of environment from which the new puppy or kitten came and the environment and lifestyle that it is now entering ([Figures 7-1](#f0010){ref-type="fig"} and [7-2](#f0015){ref-type="fig"} ). Based on this information, appropriate testing, vaccination, deworming, and other parasite control recommendations can be made.Figure 7-1Kitten history and risk assessment form.Figure 7-2Puppy history and risk assessment form.

Physical Examination {#s0030}
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After risk assessment, a complete physical examination is performed and should be emphasized not only at the first pediatric visit but also each time the pet enters the hospital. Over the years, veterinarians have excelled at promoting annual vaccinations, and as a result, clients perceive vaccination as the most important reason for their annual visit. Clients should understand that vaccinations are medical procedures that should be individualized based on history, physical examination, risk, and lifestyle of the individual animal. Placing emphasis on the physical examination at the first visit helps ensure that clients will return in the future for annual check-ups and recommended vaccinations, as opposed to returning simply for "yearly shots."

Based on the information obtained from the risk assessment, physical examination, and the geographic location, the clinician can determine the appropriate vaccinations and anthelmintics and at what interval they will be administered and assess the need for any other internal or external parasite control (e.g., heartworms, fleas, or ticks).

Vaccination and Deworming {#s0035}
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Vaccination and internal and external parasite control protocols will all vary within a given geographic region (see Chapters 14 and 19). Using the regional incidence of disease, as well as AAHA canine vaccination guidelines, AAFP feline vaccination guidelines, and Companion Animal Parasite Control (CAPC) guidelines, appropriate standards and protocols can be established to suit the practice.

For both dogs and cats, vaccinations are generally divided into core, noncore, and not recommended categories. Core vaccines are recommended for all animals. Noncore vaccines should be administered to animals only in specific risk categories. Generally, vaccines not recommended are those that do not induce a clinically meaningful immune response or have been associated with an adverse event, resulting in the risk outweighing the benefit. A list of these vaccines can be seen in [Table 7-1](#t0010){ref-type="table"} . The initial core vaccination series is begun at the first visit, with boosters given at 3 to 4 week intervals. For example, the core puppy vaccinations (distemper-adenovirus type 2, parvovirus \[DA~2~P\]) may be given at 8, 12, and 16 weeks, and core kitten vaccinations (feline viral rhinotracheitis, calicivirus, panleukopenia \[FVRCP\]) given at 9 and 13 weeks. State requirements may vary, so rabies vaccines may be given at the final pediatric visit or at the time of the ovariohysterectomy or castration.TABLE 7-1Vaccinations**Feline Vaccinations**CorePanleukopeniaFeline viral rhinotracheitis (FHV-1)CalicivirusRabiesNoncoreFeline leukemia virus (FeLV)Feline immunodeficiency virus (FIV)*Chlamydia psittaciBordetella bronchiseptica*Not recommendedFeline infectious peritonitis (FIP)*Giardia lamblia***Canine Vaccinations**CoreDistemperParvovirusAdenovirusRabiesNoncoreParainfluenza*Bordetella bronchiseptica*Lyme borreliosisLeptospirosis*Leptospira canicolaL. icterohaemorrhagiaeL. pomonaL. grippotyphosa*Distemper-measlesNot recommendedCoronavirus*Giardia lamblia*Adenovirus-1

Intestinal parasites common to puppies and kittens are acquired via transplacental, transmammary, or environmental routes. A list of the most common pediatric intestinal parasites and their treatments can be found in Chapter 19. Puppies and kittens should be treated early and often to prevent patent infections and potential zoonotic concerns. Generally, deworming should take place at 2, 4, 6, and 8 weeks of age. CAPC guidelines are as follows: "Puppies and kittens require more frequent anthelmintic administration than adult dogs and cats, because (1) they often are serially reinfected via nursing and from the environment, and (2) they often harbor parasite larvae in migration that later mature and commence laying eggs. Intestinal parasite infections in puppies and kittens may cause serious illness or even death before a diagnosis is possible by fecal examination. Puppies and their mothers should be treated with appropriate anthelmintics when puppies are 2, 4, 6, and 8 weeks of age, then put on a monthly preventive. Because prenatal infection does not occur in kittens, biweekly treatment can begin at 3 weeks of age, and they can be put on a monthly preventive at 8 or 9 weeks of age. Nursing bitches and queens should be treated concurrently with their offspring since they often develop patent infections along with their young."

Because geographic, seasonal, and lifestyle factors substantially affect parasite prevalence, veterinarians should tailor prevention programs to fit the needs of individual patients. More complete recommendations can be found in the CAPC guidelines at [www.capcvet.org](http://www.capcvet.org).

Topics of Discussion {#s0040}
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Once risk assessment is completed, physical examination is performed, and vaccinations and anthelmintics administered, the educational portion of the visit can be continued. Using the handout that was created for the first pediatric visit as a guideline, the client can be guided through each topic selected for discussion (see [Box 7-1](#b0010){ref-type="boxed-text"}). Many topics have multiple visual aids and informational materials available from distributors and drug companies for clients to see and take home in an effort to emphasize and reinforce the information you are providing. For example, both Hill\'s and Purina provide Body Condition Score charts for use when discussing nutrition and healthy body weight. CAPC provides many charts and diagrams illustrating parasite life cycles and life stages when discussing parasite control and zoonoses. Clinicians can use anatomical models when discussing breed-related dental or orthopedic concerns pets may encounter. People learn and process information in many different ways, so using all of the tools available to enhance the client\'s learning experience is recommended.

Subsequent Pediatric Visits {#s0045}
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The remaining 2 to 3 pediatric visits take place at 3 to 4 week intervals after the first visit. These visits consist of making note of any lifestyle changes for the pet (i.e., the strictly indoor kitten becoming an indoor/outdoor cat), the physical examination, recommended vaccinations and anthelmintics, and discussion of the next set of topics as outlined in the already established client handouts. The veterinarian has an opportunity to evaluate how housetraining and behavior issues are progressing and address any questions or concerns the client may have encountered in the past few weeks. At the conclusion of each visit, the pediatric agenda should be updated, and an appointment scheduled for the next visit.
