# Influence of Breed Size, Age, Fecal Quality, and Enteropathogen Shedding on Fecal Calprotectin and Immunoglobulin A Concentrations in Puppies During the Weaning Period

Aurélien Grellet, R. M. Heilmann, Bruno Polack, Alexandre Feugier, Corine

Boucraut-Baralon, Dominique Grandjean, N. Grutzner, J. S. Suchodolski, J.

M. Steiner, S. Chastant-Maillard

► To cite this version:

Aurélien Grellet, R. M. Heilmann, Bruno Polack, Alexandre Feugier, Corine Boucraut-Baralon, et al. Influence of Breed Size, Age, Fecal Quality, and Enteropathogen Shedding on Fecal Calprotectin and Immunoglobulin A Concentrations in Puppies During the Weaning Period. Journal of Veterinary Internal Medicine, 2016, 30 (4), pp.1056-1064. 10.1111/jvim.14255. hal-01608115

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# Influence of Breed Size, Age, Fecal Quality, and Enteropathogen Shedding on Fecal Calprotectin and Immunoglobulin A Concentrations in Puppies During the Weaning Period

A. Grellet, R.M. Heilmann, B. Polack, A. Feugier, C. Boucraut-Baralon, D. Grandjean, N. Grützner, J. S. Suchodolski, J.M. Steiner, and S. Chastant-Maillard

**Background:** Fecal calprotectin and immunoglobulin A (IgA) are markers of intestinal inflammation and immunity in adult dogs.

**Hypothesis:** Fecal calprotectin and IgA concentrations in puppies are not influenced by fecal moisture in puppies but by enteropathogen shedding.

**Animals:** Three hundred and twenty-four puppies.

**Methods:** Fecal consistency was assessed by gross examination. Fecal moisture was evaluated before and after lyophilization. Canine parvovirus and coronavirus were detected in feces by qPCR and qRT-PCR respectively. *Giardia intestinalis* antigen was quantified by ELISA. The standard McMaster flotation technique was used to detect eggs and oocysts in feces. Fecal calprotectin and IgA concentrations were quantified by in-house radioimmunoassays.

**Results:** For each marker (IgA and calprotectin), a strong positive correlation was observed between concentration in fresh feces and concentration in fecal dry matter. 75.6% of the puppies were found to be infected by at ≥1 of the enteropathogens evaluated. Fecal calprotectin concentration was significantly influenced by age (*P* = .001), with higher concentrations in younger puppies, but not by viral (*P* = .863) or parasitic infection (*P* = .791). Fecal IgA concentration was significantly influenced by enteropathogen shedding (*P* = .01), with a lower fecal IgA concentration in puppies shedding at ≥1 enteropathogen compared to puppies without any enteropathogen shedding, but not by age.

**Conclusions:** Fecal calprotectin and IgA are of no diagnostic value to detect presence of enteropathogens in clinically healthy puppies or puppies with abnormal feces, but could help to better understand the maturation of digestive tract.

**Key words:** Age; Calprotectin; Digestive; Dog; Enteropathogens; Immunoglobulin A.

In dogs, gastrointestinal and hepatic diseases are the third most frequent problem reported by owners in United States and Australia.¹ In the United Kingdom, a survey based on client questionnaires reported that

**Abbreviations:**

CCECAI canine chronic enteropathy clinical activity index

IgA immunoglobulin A

From the Royal Canin, Aimargues, France (Grellet, Feugier); the Small Animal Clinic, College of Veterinary Medicine, University of Leipzig, Leipzig, Germany (Heilmann); the Ecole Nationale Vétérinaire d'Alfort, Université Paris-Est, Maisons-Alfort Cedex, France Polack, (Grandjean); the Scanelis, Colomiers, France (Boucraut-Baralon); the Clinic for Swine, Department of Clinical Veterinary Medicine, Vetsuisse Faculty Berne, Berne, Switzerland (Grützner); the Gastrointestinal Laboratory, Department of Small Animal Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Texas A&M University, College Station, TX (Suchodolski, Steiner); and the NeoCare, IHAP, IHAP, Université de Toulouse, INRA, ENVT, Toulouse Cedex 03, France (Chastant-Maillard);

Present address: Dr Grellet – NeoCare, IHAP, Université de Toulouse, INRA, ENVT, 23 chemin des Capelles, BP 87614, 31076, Toulouse Cedex 03, France.

The work was done in various French breeding kennels.

This material was presented in part at the 2014 European Congress of Veterinary Internal Medicine (ECVIM-CA) in Mainz, Germany.

Corresponding author: A. Grellet, 23 chemin des Capelles, BP 87614, 31076, Toulouse Cedex 03, France; e-mail: a.grellet@envt.fr.

Submitted September 16, 2015; Revised April 25, 2016; Accepted May 9, 2016.

Copyright © 2016 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

DOI: 10.1111/jvim.14255

up to 15% of dogs experienced mild diarrhea over a 2-week period.² Another study observed that, among sick animals presented for veterinary consultation, 7% of visits were related to diarrhea.³ Diarrhea is even more frequent in young dogs <6 months of age than in adult dogs, with 25% of puppies having abnormal feces during the weaning period.⁴,⁵ Diarrhea during this period is a major problem as it can decrease daily weight gain and increase the risk of death.⁶ As in other species, diarrhea is multifactorial, involving factors intrinsic to the dog (eg, breed size and age), nutritional factors (eg, diet change without transition, food type and quality), infectious diseases, and also lifestyle and environmental stressors.⁵⁻¹¹ Major enteropathogens associated with diarrhea in weanling puppies are canine parvovirus type 2 (CPV2),¹² the *Cystoisospora ohioensis*-complex, *Cystoisospora canis*,¹³ and *Giardia duodenalis*.¹⁴ Co-infections by these enteropathogens are frequently reported in puppies.⁴,⁵ Several diagnostic tests (such as PCR, antigen testing by ELISA, and fecal examination) must be combined for accurate diagnosis in cases of diarrhea in weanling puppies. However, the use of such routine testing can be difficult and expensive.

In young children with gastroenteritis, several fecal markers are used to assess shedding of enteropathogens excreted, and to evaluate intestinal inflammation or local immunity.¹⁵ Calprotectin and immunoglobulin A
(IgA) are 2 of these markers. Calprotectin is a heterodimeric protein complex mainly present in neutrophils, monocytes, and reactive macrophages. In humans, fecal calprotectin concentrations were reported to be increased in patients with Crohn's disease or ulcerative colitis compared to healthy controls.¹⁶,¹⁷ Moreover, they also correlated with disease severity as quantified by endoscopy and histologic examination of biopsy specimens.¹⁸ In adult dogs with chronic diarrhea, significantly higher serum and fecal calprotectin concentrations have been reported compared to healthy dogs.¹⁹,²⁰ Sensitivity and specificity of fecal calprotectin for discriminating adult dogs with severe chronic diarrhea (Canine Chronic Enteropathy Clinical Activity Index [CCECAI] ≥ 12) from dogs with mild to moderate clinical signs (CCECAI < 12) were 53 and 92%, respectively, when a cut-off value of 49 µg/g was used.¹⁹ Secretory IgA is the predominant immunoglobulin subtype present in secretions, protecting mucosal surfaces from infectious agents. Therefore, fecal IgA concentration may serve as a marker of mucosal immunity.²¹ In dogs, fecal secretory IgA concentrations previously have been used to evaluate intestinal immunity.²²,²³

For interpretation of fecal IgA and calprotectin concentrations, how they are affected by physiological factors such as breed size or age must be taken into account. The canine species is characterized by large interbreed variations, primarily by stature. The digestive physiology of dogs is also known to differ slightly according to breed size. In large breed dogs, such as German shepherds or Great Danes, fecal moisture content is higher, soft stools are more frequent and the number of defecations is higher than in small breed dogs.⁷,¹⁰,¹¹,²⁴ This difference may be a result of lower mineral absorption, higher fermentative activity reflecting higher intestinal permeability and a longer transit time, or both.²⁵⁻³⁰ The same variation has been described in puppies, with large breed puppies having feces of lower consistency compared to small breed puppies.⁶ Age also affects concentrations of markers. Indeed, lower fecal IgA concentrations were described in puppies <6 months of age compared to adult dogs.³¹,³² In humans, an effect of age on fecal calprotectin concentration has been described with higher concentrations being observed in healthy children compared to healthy adults.³³ The same variation has been described between healthy puppies and healthy adults, but these results were obtained from dogs housed in the same breeding kennel.³² Therefore, the aims of our study were to determine if calprotectin and IgA are influenced by fecal moisture (Study 1) and to evaluate if these fecal markers can be useful to detect infection by an enteropathogen (virus, parasite, or both) in puppies, taking into account the effect of 2 potential biases, age and breed size (Study 2).

## Materials and Methods

The protocols of both studies were reviewed and approved by Royal Canin Internal Ethics Committee.

### Study 1: Relationship Among Fecal Moisture Content, Fecal Quality and Fecal IgA and Calprotectin Concentrations

A total of 70 purebred puppies from 18 litters from 10 different breeding kennels were included. Each puppy was identified by a colored collar and its age and breed were recorded. Depending on the mean adult body weight of their respective breed, puppies were categorized into 2 groups (small breed if the mean adult body weight was <25 kg; otherwise large breed). For each puppy, fecal consistency was evaluated by a single operator using a 13-point scale, based on the texture and shape of the feces (from liquid to hard and dry).⁶ Fresh feces were collected and weighed for each dog. If the stool volume defecated was sufficient (≥15 g), stools were separated into 3 aliquots, 1 for fecal moisture evaluation and 2 for measurement of fecal calprotectin and IgA concentrations. Water content of the stools was determined by weighing feces before and after lyophilization.³⁰ Calprotectin and IgA were quantified by in-house radioimmunoassays after extraction, as previously described.²²,³²,³⁴ All samples were analyzed using the same batch of tracer and reagents. To correct for fecal moisture, results for each marker were expressed as concentrations in fresh feces and also normalized to dry matter.

### Study 2: Relationship Between Fecal Markers and Enteropathogen Shedding

A total of 254 purebred puppies from 64 litters from 33 different French breeding kennels were included. Puppies vaccinated within the preceding 10 days before the visit and puppies with clinical signs of weakness, dehydration, or anorexia were not included in the study. However, puppies with an abnormal fecal quality were included in the study. Each puppy was identified by a colored collar and its age and breed were recorded. Depending on the mean adult body weight of their respective breed, puppies were categorized into small breed size or large breed size as described above. For each puppy, fecal consistency was evaluated by a single operator using a 13-point scale as previously described.⁶ Based on growth rate deterioration, thresholds for abnormal feces in puppies were previously validated and appeared to vary with breed stature and age.⁶ Briefly, feces with a score ≤5 were classified as abnormal for large breed puppies regardless of age. For small breed puppies, fecal scores ≤6 and ≤7 were classified as abnormal for 4–5 week old puppies and for older puppies between 6 and 8 weeks old respectively.

After collection, fecal samples were separated into 3 aliquots: 5 g of fresh feces were stored at +4°C for fecal examination and the other 2 samples were frozen at –20°C for *Giardia intestinalis* antigen quantification and measurement of fecal calprotectin and IgA concentrations respectively.

A rectal swab (medical dry swab, cotton tip diameter 2 mmª) was collected from each puppy immediately after stool collection for detection of CPV2 and canine coronavirus (CCV). The swabs were stored at –20°C until DNA extraction.

Fecal examination was performed by the standard McMaster flotation technique using a saturated magnesium sulfate solution (density: 1.28 g/mL).³⁵ All eggs and oocysts were identified according to their morphological characteristics under light microscopy by a single operator.³⁶,³⁷ Copro-antigens of *G. intestinalis* were quantified by ELISAᵇ in 100 mg of feces.³⁸⁻⁴⁰ An optical density value >0.05 was considered positive according to the manufacturer's instructions.

Feces were evaluated for the presence of DNA and RNA from CPV2 and CCV by qPCR and qRT-PCR, respectively, as previously described.⁶ Results from duplicate PCR analyses from the
<figure><img src="image_2.png" /><figcaption>**Fig 1.** Fecal quality in puppies included in both studies.</figcaption></figure>

<figure><img src="image_3.png" /><figcaption>**Fig 2.** Correlation between fecal moisture and fecal score in 29 puppies. Scatter plot of the data overlaid with the regression line, and 95% confidence interval (gray zone). Each black point represents a dog ($r = -0.59$; $P = .001$).</figcaption></figure>

<figure><img src="image_4.png" /><figcaption>**Fig 3.** Correlation between fecal calprotectin concentration in fresh feces and fecal dry matter (n = 29). Scatter plot of the data overlaid with the regression line, and 95% confidence interval (grey zone). Each black point represents a dog ($r = 0.98$; $P < .001$).</figcaption></figure>

extracted DNA (ie, 2 PCR assay were performed for each fecal extract) were expressed semiquantitatively as virus loads. Puppies were defined as infected by CPV2 and CCV if viral loads were >$10^{10.3}$ and $10^{9.3}$ copies respectively.⁶

After extraction, calprotectin and IgA were quantified by in-house radioimmunoassays as previously described.²²,³²,³⁴ All samples were analyzed using the same batch of tracer and reagents.

## Data Management and Statistical Analysis

Data are shown as the median and range (min–max). Statistical analyses were performed using a commercial software package.⁵

Spearman's rho correlation coefficient was used to evaluate the correlation between fecal concentrations of each marker in fresh feces and fecal dry matter.

Number of puppies with positive and negative fecal test results for each enteropathogen was tabulated by age of the puppies. The significance of the univariate association between age and the shedding of each enteropathogen was determined using chi-squared-tests. A *P* value <.05 was considered statistically significant.

To assess the association between enteropathogens sheddings and fecal IgA and calprotectin concentrations in puppies, 4 statistical models were performed for each marker. In a first step, univariate analyses (Mann–Whitney and Kruskal–Wallis tests) were

performed to evaluate a possible association of each factor on either fecal marker. Variables examined included age of puppies (5–6/7–8/9–11 weeks of age), breed size (small/large), fecal quality (normal/abnormal), *G. inestinalis*, *C. Ohioensis* complex, *C. canis*, *Toxocara canis*, CPV2, and CCV shedding (yes/no), shedding of ≥1virus (yes/no), shedding of ≥1parasite (yes/no), and shedding of ≥1 enteropathogen (yes/no). In a second step, relationships between shedding of enteropathogens and fecal marker concentrations were evaluated in 3 different linear mixed models for each marker. In a first linear mixed model, effects of each pathogen (shedding of each pathogen [yes/no]) on either marker were evaluated. In a second linear mixed model, influence of the type of enteropathogens (shedding of ≥1 parasite [yes/no] and shedding of ≥1 virus [yes/no]) on either fecal marker was evaluated. In a last linear mixed model, global effect of enteropathogens (shedding of ≥1 enteropathogen [yes/no]) on both fecal markers was evaluated. In all of these mixed models, breed size and age of puppies were included as fixed effects and litter variable nested within breeding kennel was defined as a random term. For each model, the normality of residuals distribution was assessed using the Shapiro-Wilk test. According to residuals distribution for each of the multivariable models, the outcome was log transformed (fecal calprotectin concentration) or rank transformed
<figure><img src="image_5.png" /><figcaption>**Fig 4.** Correlation between fecal IgA concentration in fresh feces and fecal dry matter (n = 29). Scatter plot of the data overlaid with the regression line, and 95% confidence interval (grey zone). Each black point represents a dog (r = 0.97; *P* < .001).</figcaption></figure>

(fecal IgA concentration). Differences were considered significant for *P* values <.05. Quantitative data are presented as medians with ranges.

## Results

### Study 1

Seventy puppies (64 classified as belonging to a large breed) were included in the study (mean age, 8.8 weeks; range 6–14 weeks). Among these, 29 (41%) puppies defecated a sufficient volume of feces. These puppies consisted of large breed puppies between 6 and 10 weeks of age (mean age, 8.5 weeks). A median fecal score of 7 was obtained (range, 3–10; Fig 1) in the 29

puppies that defecated a sufficient volume of feces. Fecal moisture ranged from 50 to 77.2% (median, 66.7%), with a strong negative correlation with fecal scores (r, −0.59; *P* = .001; Fig 2).

Fecal calprotectin concentrations in fresh feces ranged from 2.9 to 59.5 µg/g (median, 10.5 µg/g), and from 5.8 to 200.8 µg/g (median, 32.2 µg/g) in fecal dry matter. A strong positive correlation was observed between fecal calprotectin concentration both in fresh feces and in fecal dry matter (r, 0.98; *P* < .001; Fig 3). A moderate negative correlation was observed between fecal scores and fecal calprotectin concentrations in fresh feces and in fecal dry matter (r, −0.38; *P* = .045; and r, −0.49; *P* = .007 respectively).

Fecal IgA concentrations in fresh feces ranged from 0.3 to 24.2 mg/g (median, 3.6 mg/g) and from 0.9 to 62.3 mg/g (median, 11.8 mg/g) in fecal dry matter. A strong positive correlation was observed between fecal IgA concentrations in fresh feces and in fecal dry matter (r, 0.97; *P* < .001; Fig 4). A moderate negative correlation was observed between fecal scores and fecal IgA concentrations in either fresh feces or fecal dry matter (r, −0.53; *P* = .003 and r, −0.64; *P* < .001 respectively).

### Study 2

Among the 254 puppies included in the study, 180 (71%) were large breed puppies. Puppies were between 5 and 11 weeks of age (mean, 7.7 weeks). The mean number of puppies included in each kennel was 8 (range, 1–18). A median fecal score of 8 was obtained (range, 1–12; Fig 1).

<table><caption>**Table 1.** Frequency of coshedding of enteropathogens in 254 puppies.</caption><thead><tr><th>CPV2</th><th>CCV</th><th>Toxocara canis</th><th>Cystoisospora Ohioensis Complex</th><th>Cystoisospora canis</th><th>Giardia Sp.</th></tr></thead><tbody><tr><td rowspan="5">CPV2</td><td>3.9 (10)</td><td>3.5 (9)</td><td>7.1 (18)</td><td>6.7 (17)</td><td>9.4 (24)</td></tr><tr><td rowspan="4">CCV</td><td>2.8 (7)</td><td>5.5 (14)</td><td>0.4 (1)</td><td>16.5 (42)</td></tr><tr><td rowspan="3">T. canis</td><td>11.4 (29)</td><td>3.1 (8)</td><td>3.1 (8)</td></tr><tr><td rowspan="2">C. Ohioensis complex</td><td>1.6 (4)</td><td>4.3 (11)</td></tr><tr><td>C. canis</td><td>8.7 (22)</td></tr><tr><td colspan="5">Giardia sp.</td></tr></tbody></table>

Data are shown as % (number) of puppies.

<table><caption>**Table 2.** Prevalence of enteropathogens shedding based on age (n = 254).</caption><thead><tr><th rowspan="2">Pathogens</th><th rowspan="2">Total Prevalence<br>(n = 254) % (n<sub>i</sub>)</th><th colspan="3">Age of Puppies</th><th rowspan="2">Global P-Value</th></tr><tr><th>5-6 weeks<br>(n = 40) % (n<sub>i</sub>)</th><th>7-8 weeks<br>(n = 141) % (n<sub>i</sub>)</th><th>9-11 weeks<br>(n = 73) % (n<sub>i</sub>)</th></tr></thead><tbody><tr><td>Coronavirus</td><td>22 (56)</td><td>10 (4)<sup>a</sup></td><td>19.1 (27)<sup>a</sup></td><td>34.2 (25)<sup>b</sup></td><td>.006</td></tr><tr><td>Parvovirus</td><td>18.9 (48)</td><td>22.5 (9)</td><td>19.9 (28)</td><td>15.1 (11)</td><td>.571</td></tr><tr><td>Giardia</td><td>37.8 (96)</td><td>25 (10)<sup>a</sup></td><td>29.8 (42)<sup>a</sup></td><td>60.3 (44)<sup>b</sup></td><td>&lt;.001</td></tr><tr><td>Toxocara canis</td><td>21.3 (54)</td><td>40 (16)<sup>a</sup></td><td>21.3 (30)<sup>b</sup></td><td>11 (8)<sup>b</sup></td><td>.001</td></tr><tr><td>Cystoisospora Ohioensis complex</td><td>30.3 (77)</td><td>32.5 (13)<sup>a</sup></td><td>36.9 (52)<sup>a</sup></td><td>16.4 (12)<sup>b</sup></td><td>.008</td></tr><tr><td>Cystoisospora canis</td><td>10.6 (27)</td><td>25 (10)<sup>a</sup></td><td>5 (7)<sup>b</sup></td><td>13.7 (10)<sup>a</sup></td><td>&lt;.001</td></tr></tbody></table>

n<sub>i</sub> = number of puppies infected for the category considered; n = total number of puppies in the category considered. For each line, categories with different letters (a, b) were significantly different (*P* < .05).
In general, 2 different enteric viruses and 4 parasites were identified (Table 1). At least 1 enteropathogen was identified in 75.6% (192/254) of the puppies. 71.7% (182/254) of puppies were infected by ≥1 parasite and 37% (94/254) by ≥1 of the 2 viruses tested. One-third (84/254) of the puppies were infected simultaneously with ≥1 virus and 1 parasite (Table 2). Puppies between 5 and 8 weeks of age had a significantly higher prevalence of *C. ohioensis* complex and a lower prevalence of CCV and *G. duodenalis* than puppies between 9 and 11 weeks of age (Table 1).

Fecal calprotectin concentrations ranged from 2.9 to 421.4 µg/g feces (median, 15.2 µg/g feces). Of the 254 puppies included, 44 (17%) had a fecal concentration >49 µg/g feces (threshold of clinical interest).¹⁹ Fecal

calprotectin concentration was significantly affected by age (P = .001) but not by breed size (P = .217), viral infection (CPV2, CCV, or both; P = .863), or parasitic infection (*G. duodenalis*, *C. ohioensis* complex, *C. canis*, *T. canis*, or both; P = .791; Table 3). Fecal calprotectin concentration was not associated with fecal score (P = .851). The concentration of fecal calprotectin was higher and more variable in younger puppies between 5 and 8 weeks of age than in the older puppies (9–11 weeks of age; Fig 5). Twenty-two, 21, and 7% of puppies had fecal calprotectin concentrations >49 µg/g feces at, respectively, 5–6, 7–8, and 9–11 weeks of age.

Fecal IgA concentration ranged from 0.1 to 27.2 mg/g feces (median, 4.5 mg/g feces). In contrast with calprotectin, IgA concentration was significantly influenced

<table><caption>**Table 3.** Evaluation of factors influencing fecal calprotectin concentrations in 254 puppies (univariate and multivariate analyses).</caption><thead><tr><th rowspan="2">Variables</th><th rowspan="2">Fecal Calprotectin<br>Concentration<br>Median [range]</th><th rowspan="2">Initial Unadjusted<br>Analysis (P-Value)</th><th colspan="3">Linear Mixed Model</th></tr><tr><th>Each Pathogen<br>Evaluated<br>Individually<br>(P-Value)</th><th>Shedding of at<br>Least One<br>Parasite<br>or One Virus<br>(P-Value)</th><th>Shedding<br>of at Least One<br>Pathogen (P-Value)</th></tr></thead><tbody><tr><td><strong>Age</strong></td><td></td><td><strong>.001</strong></td><td></td><td></td><td></td></tr><tr><td>5–6 weeks</td><td>17.8 [2.9–352.9]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>7–8 weeks</td><td>18.8 [2.9–421.4]</td><td>—</td><td>.202</td><td>.203</td><td>.177</td></tr><tr><td>9–11 weeks</td><td>5.5 [2.9–69.3]</td><td>—</td><td><strong>.004</strong></td><td><strong>.002</strong></td><td><strong>.002</strong></td></tr><tr><td><strong>Breed size</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Small</td><td>19.8 [2.9–222.5]</td><td>.096</td><td>.139</td><td>.218</td><td>.217</td></tr><tr><td>Large</td><td>11.9 [2.9–421.4]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td><strong>Fecal score</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Normal</td><td>14.6 [2.9–421.4]</td><td>.851</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Abnormal</td><td>18.1 [2.9–127.3]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td><strong>Giardia</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>19.6 [2.9–421.4]</td><td><strong>.007</strong></td><td>.602</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>6.5 [2.9–222.5]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td><strong>Cystoisospora ohioensis</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>9.9 [2.9–352.9]</td><td>.104</td><td>.056</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>2.5 [2.9–421.4]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td><strong>Cystoisospora canis</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>15 [2.9–421.4]</td><td>.348</td><td>.73</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>15.3 [2.9–352.9]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td><strong>Toxocara canis</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Not shedding</td><td>11.9 [2.9–352.9]</td><td><strong>.005</strong></td><td>.87</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>3.4 [2.9–421.4]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td><strong>CPV2</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>14.2 [2.9–421.4]</td><td>.692</td><td>.65</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>18 [2.9–352.9]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td><strong>CCV</strong></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>17 [2.9–421.4]</td><td>.127</td><td>.67</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>6.5 [2.9–123.8]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Infection by at least one virus</td><td></td><td>.502</td><td>—</td><td>.863</td><td>—</td></tr><tr><td>No shedding</td><td>16.7 [2.9–421.4]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>1.9 [2.9–352.9]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Shedding of at least one parasite</td><td></td><td>.788</td><td>—</td><td>.791</td><td>—</td></tr><tr><td>No shedding</td><td>16.5 [2.9–93]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>13.9 [2.9–421.4]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Shedding of at least one enteropathogen</td><td></td><td>.92</td><td>—</td><td>—</td><td>.695</td></tr><tr><td>No shedding</td><td>16.5 [2.9–93]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>13.9 [2.9–421.4]</td><td>—</td><td>—</td><td>—</td><td>—</td></tr></tbody></table>

Bolded numbers are numbers with a *P*-value ≤.05.
<figure><img src="image_6.png" /><figcaption>**Fig 5.** Box-and-whisker plots of fecal calprotectin concentrations in 254 puppies. Each box represents the first to the third quartiles (25th to 75th percentiles), the bar in each box represents the median, and the whiskers represent the first to ninth decile (10th to 90th percentiles). Values with different letters (a,b) differ significantly (*P* < .05).</figcaption></figure>

by enteropathogen shedding (P = .01) but by none of the other factors tested (Table 4). Fecal IgA concentrations were 1.4 times lower in puppies that were shedding at least 1 enteropathogen (median, 4.1 mg/g feces; range, 0.1–22.7 mg/g feces) than in puppies without enteropathogen shedding (median, 5.7 mg/g feces; range, 0.5–27.2 mg/g feces; Fig 6). Fecal IgA concentration was not found to be associated with fecal score (P = .891).

## Discussion

Diarrhea is common in puppies around the time of weaning, and may be accompanied by slowed growth of the puppies.⁶ Viral and parasitic infections are very common in young puppies and are involved in weanling diarrhea.⁵,⁶,¹⁴,⁴¹⁻⁴³ The early detection of such infections would avoid growth retardation and could decrease the development of more severe forms of the disease. Thus, noninvasive markers of digestive health, the concentrations of which might be modified by the presence of enteropathogens, would be of great utility in these patients. Thus, our study investigated 2 fecal markers, calprotectin and IgA, used in human pediatric gastroenterology for their utility in weanling puppies. In our study, puppies that shed $\ge$1 enteropathogen had significantly lower fecal IgA concentrations than did puppies without any enteropathogen shedding identified. This lower fecal IgA concentration may be a cause or a consequence of the enteropathogen shedding. Immunoglobulin A can actively bind microrganisms, enterotoxins, and other antigens, and prevent adherence and subsequent penetration of the intestinal wall. Thus, a lower fecal IgA concentration could be caused by IgA being utilized in antigen binding or by enterohepatic recirculation of IgA. After IgA binds an antigen in the intestinal lumen, it is either excreted in the feces or is actively reabsorbed for destruction of the microorganism or virus by hepatic Kuppfer cells. Reabsorption of IgA could have been increased by an infection with an enteropathogen, which could result in decreased fecal

concentrations of IgA. Conversely, the lower fecal IgA concentration also could indicate the presence of altered local immunity and thus serve as evidence for a higher risk of infection with an enteropathogen. A positive impact of fecal IgA on protection against infectious diseases already has been described in other species. Mice lacking secretory IgA exhibit a significant delay in clearance of rotavirus infection compared with mice that have secretory IgA.⁴⁴ In children, fecal IgA concentrations also were shown to have an influence on protection against rotavirus infection and resulting disease.⁴⁵

No significant effect of any viral (CCV or CPV2) or parasite shedding (*G. duodenalis*, *C. ohioensis* complex, *C. canis*, or *T. canis*) on fecal calprotectin concentration was observed. This lack of difference in calprotectin concentrations between dogs that showed enteropathogen shedding and those that did not could be explained by the population of dogs enrolled in our study (ie, healthy puppies or puppies presenting only with an abnormal fecal quality without any other clinical sign). In humans, the patient's clinical status influences the concentrations of this marker. In children who are clinically healthy but infected by *Giardia*, no effect on fecal calprotectin concentration was described.³³ However, in human patients with viral gastroenteritis, fecal calprotectin concentrations were reported to be associated with the severity of clinical signs.⁴⁶ In our study, 18.9% of puppies were found to be excreting a high load of CPV2 but without any of the typical clinical signs (eg, hemorrhagic diarrhea, vomiting, prostration, dehydration, anorexia). This healthy carrier state could explain the lack of association between shedding of this virus and fecal calprotectin concentrations. Another study comparing fecal calprotectin concentrations among healthy puppies, puppies with an abnormal fecal quality, and puppies with clinical parvovirus infection would be needed to further elucidate this relationship.

Fecal moisture in our study ranged from 50 to 77.2% (median, 66.7%), with a negative correlation with fecal scores, which is accordance with previous studies.¹⁰,³⁰ A negative correlation also was observed between fecal markers and fecal score. The higher IgA and calprotectin concentrations in puppies with liquid or soft feces in this study do not seem to be a direct consequence of stool consistency (dilution) because this negative correlation was observed for fresh feces as well as for concentrations based on fecal dry matter. The negative correlation between fecal score and fecal marker concentration could be explained by the effect of age acting as a confounding factor. Indeed age influence feces quality (lower fecal score in very young puppies)⁶ and, at the same time, age influences fecal concentrations of both markers (higher fecal concentrations in very young puppies).⁴⁷

Our study indicates that fecal calprotectin concentrations decrease and stabilize with age. This result is in accordance with our longitudinal study performed in young dogs around the age of weaning.⁴⁷ In humans, considerably higher fecal calprotectin concentrations also have been observed in infants around the time of
<table><caption>**Table 4.** Evaluation of factors influencing fecal IgA concentrations in 254 puppies (univariate and multivariate analyses).</caption><thead><tr><th rowspan="2">Variables</th><th rowspan="2">Fecal IgA<br>Concentration<br>Median [Range]</th><th rowspan="2">Initial Unadjusted<br>Analysis (P-Value)</th><th colspan="3">Linear Mixed Model</th></tr><tr><th>Each Pathogen<br>Evaluated<br>Individually<br>(P-Value)</th><th>Shedding of at<br>Least One Parasite<br>or One Virus<br>(P-Value)</th><th>Shedding of at<br>Least One<br>Pathogen<br>(P-Value)</th></tr></thead><tbody><tr><td>Age</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>5-6 weeks</td><td>2.3 [0.3-22.7]</td><td>.003</td><td>—</td><td>—</td><td>—</td></tr><tr><td>7-8 weeks</td><td>5.5 [0.1-24.2]</td><td></td><td>.971</td><td>.506</td><td>.489</td></tr><tr><td>9-11 weeks</td><td>4.1 [0.2-27.2]</td><td></td><td>.375</td><td>.193</td><td>.176</td></tr><tr><td>Breed size</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Small</td><td>5.7 [0.14-19.2]</td><td>.019</td><td>.091</td><td>.138</td><td>.197</td></tr><tr><td>Large</td><td>3.9 [0.1-27.2]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>Fecal score</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Normal</td><td>4.4 [0.1-27.2]</td><td>.891</td><td>—</td><td>—</td><td>—</td></tr><tr><td>Abnormal</td><td>5.4 [0.3-21.9]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>Giardia</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>4.9 [0.1-27.2]</td><td>.816</td><td>.127</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>4.3 [0.1-22.7]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>Cystoisospora<br>ohioensis</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>4.5 [0.1-27.2]</td><td>.126</td><td>.333</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>4.5 [0.1-20.8]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>Cystoisospora<br>canis</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>4.4 [0.1-27.2]</td><td>.048</td><td>.021</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>5.5 [0.2-22.7]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>Toxocara<br>canis</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>4.8 [0.1-27.2]</td><td>.165</td><td>.415</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>4 [0.1-20.8]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>CPV2</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>4.5 [0.1-27.2]</td><td>.535</td><td>.373</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>3.8 [0.3-21.9]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>CCV</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>4.8 [0.1-27.2]</td><td>.118</td><td>.802</td><td>—</td><td>—</td></tr><tr><td>Shedding</td><td>3.3 [0.1-20.8]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>Infection by at least one<br>virus</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>4.8 [0.1-27.2]</td><td>.743</td><td>—</td><td>.864</td><td>—</td></tr><tr><td>Shedding</td><td>3.7 [0.1-21.9]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>Infection by at least one<br>parasite</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>5.5 [0.5-27.2]</td><td>.062</td><td>—</td><td>.058</td><td>—</td></tr><tr><td>Shedding</td><td>4.2 [0.1-22.7]</td><td></td><td>—</td><td>—</td><td>—</td></tr><tr><td>Infection by at least one<br>enteropathogen</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>No shedding</td><td>5.7 [0.5-27.2]</td><td>.072</td><td>—</td><td>—</td><td>.01</td></tr><tr><td>Shedding</td><td>4.1 [0.1-22.7]</td><td></td><td>—</td><td>—</td><td>—</td></tr></tbody></table>

Bolded numbers are numbers with a *P*-value ≤.05

birth compared with those in healthy older children and adults.33,48–50 In our study, 17% of puppies had high fecal calprotectin concentrations (>49 µg/g) similar to those observed in adult dogs with inflammatory bowel disease, with large interindividual variations.19 These high concentrations do not appear to be linked to viral or parasite shedding because this effect of age on fecal calprotectin concentrations was still observed when both variables (age and enteropathogen shedding) were taken into consideration within the same statistical model. Moreover, we previously observed a spontaneous normalization of fecal calprotectin concentrations in healthy puppies during the weaning period.47 The type of food (eg, natural milk, industrial milk, dry food) may have influenced fecal calprotectin

concentrations. Human infants who are exclusively breastfed show significantly higher fecal calprotectin concentrations compared to those receiving a mixed diet.49,51 The effect of natural milk may depend on several factors such as hormones (eg, ghrelin, leptin), cytokines and other immunostimulants and growth factors (eg, epidermal growth factor, granulocyte colony-stimulating factor), which all contribute to the development of the gastrointestinal immune system.51 Milk ingestion was not controlled in our study, with puppies having free access to maternal milk. However, from 5 to 8 weeks of age, the proportion of natural maternal milk decreases continuously in a puppie’s diet because of physiologic progressive weaning. Developmental processes occurring in the digestive tract during this period
<figure><img src="image_7.png" /><figcaption>**Fig 6.** Box-and-whisker plots of fecal IgA concentrations in 254 puppies. Each box represents the first to the third quartiles (25th to 75th percentiles), the bar in each box represents the median, and the whiskers represent the first to ninth decile (10th–90th percentiles). Values with different letters (a,b) differ significantly (*P* = .01).</figcaption></figure>

of life also could explain the higher fecal calprotectin concentrations. During the first weeks of life, intestinal permeability is higher⁵², which may lead to transepithelial migration of neutrophils, as observed in adults with inflammatory bowel disease.⁵³ The physiological establishment and stabilization of the gut microbiota also may have an effect on calprotectin release as has been suggested in humans.⁵⁴,⁵⁵ The higher calprotectin concentrations observed also could be linked to bacterial gastrointestinal infections as described in children.¹⁵,⁵⁶

## Conclusion

Our study indicates that fecal calprotectin and IgA are of no diagnostic value to detect the presence of an enteropathogen in clinically healthy puppies or puppies with abnormal feces. However, these markers might be useful to better understand the maturation of the digestive tract, the development of systemic and local immunity, and the establishment and stabilization of the gut microbiota. The development of noninvasive fecal biomarkers that may prove to be useful to evaluate gastrointestinal health in puppies remains a challenge.

## Footnotes

## Acknowledgments

This study was partially funded by Royal Canin SAS (Aimargues, France). Royal Canin SAS participated in the study design, sample collection, and statistical analyses. We thank owners of the kennels for their contribution to this work.

*Conflict of Interest Declaration:* No product branded by Royal Canin was tested in the experiment and authors belonging to the Royal Canin staff have no conflict of interest to declare. Other authors also declare no conflict of interest.

*Off-label Antimicrobial Declaration:* Authors declare no off-label use of antimicrobials.

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