Are Imperial Shih Tzus Healthy? 9 Conditions Every Owner Must Know

The short answer is: it depends entirely on the dog’s size, the breeding practices behind it, and how proactively its owner manages the health risks that come with the label.

Imperial Shih Tzus — dogs marketed under names including Imperial, Teacup, Miniature, or Chinese Imperial — share the standard Shih Tzu breed’s documented vulnerabilities. But many of those vulnerabilities are compounded by the deliberate size reduction that defines the Imperial label. The smaller the dog, the more concentrated and severe those risks become.

This article is a clinical companion to our overview guide: The Imperial Shih Tzu: Cute or Complex? Where that article explains what the Imperial label means, this one goes deeper — examining each documented health condition with its causes, clinical signs, diagnostic approach, treatment options, and prevention protocols. Every owner of an Imperial Shih Tzu, and every prospective buyer, should read and understand what follows before making decisions about purchase or care.

Why Imperial Shih Tzus Face Greater Health Risks

The American Shih Tzu Club sets the breed’s healthy size range at 9 to 16 lb (4.1 to 7.3 kg). The standard is not an aesthetic preference — it reflects the minimum structural requirements for the breed’s organ systems, bone density, airway, and cardiovascular function to work correctly.

When dogs are deliberately bred below this range — typically producing adults of 4 to 8 lb (1.8 to 3.6 kg) — the body is too small to house the systems required to sustain it. Organs do not shrink proportionally to the frame. Brachycephalic airway complications increase. Bone density decreases. The metabolic demands of a very small body exceed its capacity to meet them. This is the biological foundation of the health problems described below. Conditions shared with standard Shih Tzus are worsened by size reduction. Conditions specifically linked to extreme miniaturization are added on top.

Condition 1: Hypoglycemia

Hypoglycemia — dangerously low blood glucose — is the most immediate life-threatening risk in Imperial Shih Tzu puppies, and a recurrent concern throughout the dog’s life.

Cause

Very small dogs have minimal fat reserves. When blood glucose drops — due to missing a meal, stress, excessive activity, cold temperatures, or illness — the body cannot compensate rapidly enough. The American Shih Tzu Club cites Dr. Margret Casal of the University of Pennsylvania School of Veterinary Medicine on this directly: the brain can only use glucose for energy. When blood sugar falls rapidly, the brain is deprived of its fuel source.

Signs

Sudden lethargy or weakness, trembling or shivering, disorientation, glassy or unfocused eyes, loss of coordination, pale gums, collapse, or seizure. Onset can be rapid — a puppy that was playing normally may show collapse within minutes of a hypoglycemic episode beginning.

Emergency Response

Apply corn syrup, honey, or a concentrated glucose supplement such as Nutri-Cal directly to the gums for rapid absorption. Follow immediately with veterinary care. Do not wait for signs to resolve before contacting a veterinarian — glucose levels can continue to fall even after initial intervention.

Prevention

Feed three to four small meals per day rather than two. Never skip meals. Always have a glucose source on hand. Keep the dog warm — chilling suppresses appetite and accelerates glucose depletion. Monitor for signs of illness, as even minor infections can trigger hypoglycemic episodes in very small dogs.

Condition 2: Brachycephalic Obstructive Airway Syndrome (BOAS)

Every Shih Tzu carries a brachycephalic airway risk. In Imperial-sized dogs, the same anatomical abnormalities are present in a frame with even less space to accommodate them.

Cause

The Shih Tzu’s shortened skull reduces the space available for upper airway soft tissue without proportionally reducing the tissue volume. Stenotic nares (narrowed nostrils), an elongated soft palate, and a narrowed trachea each restrict airflow. In smaller dogs, these obstructions occupy a greater proportion of an already-compressed airway.

Signs

Noisy breathing at rest, snoring, exercise intolerance, labored breathing in heat or humidity, gagging, coughing, and in severe cases, cyanosis (blue-tinged gums) or collapse. Signs worsen with heat, excitement, obesity, and exertion.

Diagnosis and Treatment

Diagnosis is confirmed through physical examination of the airway, sometimes supplemented by endoscopy under sedation. Surgical correction — widening the nares, shortening the soft palate — is effective and significantly improves quality of life in moderate to severe cases. Mild cases are managed by weight control, avoiding heat, and minimizing excitement-driven exertion.

Prevention

Never use a collar on an Imperial Shih Tzu. A chest harness distributes all walking pressure across the ribcage rather than the trachea. Maintain a lean body weight — obesity narrows the airway further. Avoid outdoor activity in temperatures above 75°F (24°C). See: Shih Tzu Breathing Problems

Condition 3: Juvenile Renal Dysplasia (JRD)

Renal dysplasia is the single genetic disease most closely associated with the Shih Tzu breed specifically. The American Shih Tzu Club’s published guidance on Juvenile Renal Dysplasia states clearly that JRD is a developmental or genetic defect of the kidneys that has been best characterized in the Shih Tzu breed.

Cause

JRD is a congenital condition in which the kidneys fail to develop a normal nephron architecture during fetal development. Immature or fetal glomeruli remain present in the kidneys past six months of age. Research published at the WSAVA 2003 Congress describes JRD as the formation of abnormal nephrons with excessive mesenchymal stroma. Studies have found a correlation between mutant alleles of the COX-2 gene and clinical cases of renal dysplasia, with Shih Tzus among the breeds with the highest incidence. The MSPCA-Angell confirms the Shih Tzu as one of the breeds in which renal dysplasia has been best characterized and most frequently documented.

Signs

Increased thirst and urination beginning in young dogs (as early as two to five months of age in severe cases), weight loss, vomiting, reduced appetite, poor coat condition, and progressive deterioration over weeks to months. In mild cases, clinical signs may not appear until adulthood.

Diagnosis

Standard blood tests — BUN and creatinine — are not elevated until 70 to 75% of kidney function is lost, making them unreliable for early detection. Urine specific gravity, urinalysis, and imaging provide earlier indicators. Kidney biopsy provides a definitive diagnosis. The American Shih Tzu Club recommends that kidney tissue from dogs suspected of dying from JRD be sent to the University of Pennsylvania School of Veterinary Medicine for examination to support ongoing breed research.

Treatment

There is no cure for JRD. Treatment is supportive: phosphorus and protein-restricted diets, fluid therapy, and management of secondary symptoms. Mild to moderate cases may be managed for months to years with appropriate care. Severe cases in young puppies carry a poor prognosis.

Prevention

Request proof of parental renal health testing from any breeder. The American Shih Tzu Club Charitable Trust has funded research to locate a genetic marker for JRD. No definitive genetic test currently exists for routine screening, but breeders committed to reducing JRD incidence will have records of parental urinalysis and bloodwork. See: What to Know About Shih Tzu Urinary Problems

Condition 4: Congenital Cardiac Defects

Imperial Shih Tzus face an elevated risk of congenital heart defects relative to standard-sized dogs, due to the cardiovascular consequences of extreme size reduction.

Documented Cardiac Conditions

Pulmonic stenosis (PS): PS is the narrowing of the pulmonary valve, restricting blood flow from the right ventricle to the pulmonary artery. Research cited in the Veterinary Practice journal indicates that pulmonic stenosis accounts for approximately 31 to 34% of congenital heart diseases in dogs. Signs include exercise intolerance, fainting, and a heart murmur detected by a veterinarian during routine examination.

Patent ductus arteriosus (PDA): The ductus arteriosus is a blood vessel that connects the pulmonary artery and the aorta in fetal life, normally closing within days of birth. When it remains open, it creates abnormal blood flow between the two vessels. A published case report in the Journal of the American Veterinary Medical Association documented a PDA in a 3-year-old Shih Tzu, confirming the breed’s susceptibility to this defect.

Ventricular septal defect (VSD) and subaortic stenosis (SAS): Both conditions involve structural abnormalities affecting blood flow through the heart’s chambers and outflow tracts, placing additional workload on the cardiac muscle over time.

Signs

Heart murmur detected during routine auscultation, exercise intolerance, coughing, labored breathing, fainting, and, in severe cases, sudden collapse.

Diagnosis

Echocardiography is the definitive diagnostic tool for congenital cardiac defects. Radiography and ECG provide supporting information. Annual cardiac auscultation from puppyhood allows early detection of murmurs requiring further investigation.

Treatment

Mild defects may be monitored without intervention. Moderate to severe PS can be treated by balloon valvuloplasty — a catheter-based procedure that dilates the narrowed valve. PDA correction depends on the direction of shunting; left-to-right shunting PDAs can be surgically ligated or closed via catheter. Medical management of pulmonary hypertension may be required for dogs with right-to-left shunting PDAs.

Condition 5: Dental Disease

Over 80% of standard Shih Tzus develop dental disease by age 3, according to data cited by veterinary researchers via Harvey (1998) in Veterinary Clinics of North America. In Imperial-sized dogs, the already-compressed brachycephalic jaw is further reduced, producing more severe tooth crowding and accelerating plaque accumulation and periodontal progression.

Cause

The Shih Tzu’s short jaw forces a standard complement of 42 adult teeth into a significantly smaller space than most breeds. Overlapping and rotated teeth create pockets where plaque accumulates faster and where standard brushing cannot reach as effectively. Periodontal disease — the bacterial infection of the gum tissue and supporting bone — is the predictable result without active daily intervention.

Signs

Bad breath, red or swollen gums, brown tartar deposits on teeth, difficulty eating, drooling, pawing at the mouth, and loose or missing teeth. Advanced periodontal disease causes significant pain that dogs often mask.

Treatment and Prevention

Daily brushing with a dog-safe enzymatic toothpaste beginning in puppyhood is the single most effective preventive measure. Annual professional dental cleanings under anesthesia beginning at age two — or earlier if tartar accumulates rapidly — are essential. The Veterinary Oral Health Council maintains a list of products with accepted claims for controlling plaque or tartar in dogs. See: Shih Tzu Teeth Care: Complete Guide

Condition 6: Eye Conditions

The Shih Tzu’s large, prominent eyes in shallow orbital sockets create multiple documented vulnerabilities. In Imperial-sized dogs, the orbital anatomy is even more compressed relative to eye size.

Documented Conditions

Keratoconjunctivitis sicca (KCS or dry eye) — insufficient tear production leading to chronic eye irritation and potential corneal damage. Corneal ulcers — surface wounds on the cornea that can progress rapidly to stromal melting and perforation in brachycephalic breeds due to reduced corneal sensitivity. Pigmentary keratitis — black pigment deposits on the cornea, found in over 90% of Shih Tzus with brachycephalic ocular syndrome, according to a study published in Veterinary Ophthalmology. Proptosis — displacement of the eyeball from the socket — is a genuine emergency risk for this breed, particularly if neck pressure is applied via a collar or during rough handling.

Prevention

Daily cleaning of the area around the eyes with a soft, damp cloth prevents tear staining and reduces facial fold dermatitis. Weekly eye checks identify any change in clarity, discharge color, or surface appearance that warrants veterinary assessment. A chest harness rather than a collar eliminates the primary trigger risk for proptosis. See: Shih Tzu Eye Care: Problems, Symptoms, and Treatments

Condition 7: Portosystemic Shunts and Hepatic Microvascular Dysplasia

Shih Tzus are specifically overrepresented in the population of dogs with portosystemic shunts and hepatic microvascular dysplasia — two related liver abnormalities documented in peer-reviewed veterinary literature.

Cause

A portosystemic shunt is an abnormal blood vessel that bypasses the liver, allowing portal blood to enter the systemic circulation without being detoxified. Research published in Veterinary Sciences via PMC identifies Shih Tzus alongside Maltese, Yorkshire Terriers, and Pugs as breeds overrepresented among dogs with extrahepatic congenital portosystemic shunts. Hepatic microvascular dysplasia (HMD) — an intrahepatic circulatory disorder causing portal blood to bypass normal liver tissue — has also been reported in Shih Tzus, as confirmed by the Merck Veterinary Manual.

Signs

Neurological disturbances (hepatic encephalopathy — disorientation, head pressing, circling, seizures), vomiting, diarrhea, poor weight gain, excessive thirst and urination, and urate urinary crystals or stones. Signs often wax and wane rather than being constant.

Diagnosis

Serum bile acid testing before and after a meal is the most sensitive non-invasive screening test. Abdominal ultrasound can identify the shunting vessel in most cases. Definitive diagnosis may require contrast portography.

Treatment

Single extrahepatic shunts can be surgically corrected with a good prognosis when identified early. Multiple shunts or HMD are managed medically with dietary modification with a low-protein, high-quality protein diet, lactulose, and antibiotics to reduce ammonia production in the gut.

Condition 8: Orthopedic Conditions — Patellar Luxation, Hip Dysplasia, and IVDD

Patellar Luxation

Patellar luxation — the kneecap slipping out of its groove — is one of the most common orthopedic conditions in small-breed dogs and is particularly prevalent in undersized Shih Tzus. Signs include intermittent hindlimb lameness, a skipping gait, and occasional leg-kicking during walking. Grade 1 and 2 luxations are managed with weight control, exercise modification, and joint supplements. Grades 3 and 4 require surgical correction to deepen the patellar groove and stabilize the joint.

Hip Dysplasia

Although more commonly associated with large breeds, hip dysplasia — abnormal development of the hip joint — occurs in Shih Tzus and is worsened in undersized dogs whose bone structure may be compromised from deliberate size reduction. Maintaining a lean body weight and providing low-impact daily exercise significantly reduces the rate of arthritic progression.

Intervertebral Disc Disease (IVDD)

Research from the University of California, Davis identified that 25% of the Shih Tzu population carries the CDDY allele associated with abnormal disc degeneration and IVDD risk. Signs include sudden unwillingness to jump, hunched posture, neck or back pain, and in severe cases, hindlimb weakness or paralysis. Owners of Imperial Shih Tzus should prevent access to furniture jumps, use ramps where possible, and seek immediate veterinary evaluation at the first sign of back or neck pain.

Condition 9: Skin and Ear Conditions

Skin Allergies and Facial Fold Dermatitis

Shih Tzus are prone to both environmental and food allergies that manifest as skin irritation, paw licking, and recurring ear infections. The facial folds that define the breed’s expression create warm, moist skin creases where bacterial and yeast overgrowth occur without regular cleaning. Daily gentle wiping of the facial folds with a soft cloth or veterinarian-approved wipe is required to prevent dermatitis in these areas. See: Allergies in Shih Tzus: Signs, Causes, and Treatments

Ear Infections

The Shih Tzu’s heavily coated, drooping ears trap moisture and restrict airflow — ideal conditions for bacterial and yeast overgrowth. Hair growing inside the ear canal compounds the problem. Weekly ear checks and regular cleaning with a veterinarian-approved ear cleaner are the primary preventive measures. See: How to Properly Clean and Care for Your Shih Tzu’s Ears

Behavioral Health: The Connection to Physical Well-being

Behavioral problems in Imperial Shih Tzus — including separation anxiety, excessive barking, and destructive behavior — are not separate from physical health. They are frequent expressions of it. An Imperial Shih Tzu experiencing chronic pain from dental disease, a hypoglycemic episode, or early-stage IVDD will present behavioral changes before many owners recognize a physical cause is involved.

Separation anxiety deserves specific attention in undersized dogs. The breed’s companion heritage makes isolation genuinely distressing. Undersized dogs may have lower physiological stress thresholds, making anxiety responses more intense and more physiologically costly than in standard-sized individuals. For full guidance, see: Shih Tzu Anxiety: How to Deal With It

When behavioral changes appear — withdrawal, reduced appetite, increased vocalization, change in gait or posture — the first step should always be a veterinary examination to rule out physical causes before addressing behavior in isolation.

A Comprehensive Prevention Protocol for Imperial Shih Tzu Owners

The following practices, applied consistently from the dog’s first week in the home, reduce the risk and severity of the conditions described above.

Feeding: Three to four small meals daily. Measure all portions. Keep treats below 10% of daily caloric intake. Never miss a meal, or let the dog go without food for more than 4 hours in puppyhood.

Dental care: Daily brushing with an enzymatic dog toothpaste beginning in the first week of ownership. Annual professional cleanings begin at age two.

Grooming: Brushing every two to three days. Bathing every three to four weeks. Weekly ear checks and cleaning. Daily eye and facial fold cleaning.

Veterinary schedule: Annual examinations from age one to seven. Biannual examinations from age seven onward. Bloodwork and urinalysis are performed annually from age 5 to screen for early renal and hepatic changes.

Exercise and environment: Two short daily walks in cool conditions. No outdoor activity above 75°F (24°C). Ramps instead of furniture jumps. No collar — a chest harness only.

Emergency preparedness: Always have a glucose supplement (Nutri-Cal or corn syrup) on hand for hypoglycemic emergencies. Know the location and hours of the nearest emergency veterinary clinic.

Recommended Health and Care Products

These products directly address the documented health vulnerabilities of Imperial Shih Tzus covered in this article.

Vet’s Best Enzymatic Dog Toothbrush and Toothpaste Kit

The most impactful single daily health habit for an Imperial Shih Tzu. Daily brushing from puppyhood is the primary prevention for the dental disease that affects more than 80% of this breed by age three. The Vet’s Best Enzymatic Kit includes a finger brush for initial training and a standard adult brush, using natural enzymes and baking soda to break down plaque.

Nutri-Cal High Calorie Nutritional Supplement

A mandatory emergency item for every Imperial Shih Tzu household. The Nutri-Cal supplement is a concentrated glucose paste applied directly to the gums during a hypoglycemic episode for rapid blood sugar restoration. It is also used daily for very small puppies with high caloric demands. Recommended by the American Shih Tzu Club as a standard first-response tool.

Puppia Soft Step-In Dog Harness (XS)

A collar applied to an Imperial Shih Tzu’s neck creates tracheal pressure that worsens BOAS and elevates proptosis risk. The Puppia Soft Step-In Harness distributes all pressure across the chest wall — eliminating the primary equipment-related risk factor for two of the most serious conditions in this breed. ASIN: B000VY5PEK

Zymox Ear Solution with Hydrocortisone

A veterinarian-recommended enzymatic ear cleaner that addresses bacterial and yeast overgrowth without requiring aggressive manual cleaning that can damage delicate ear tissue. The Zymox Ear Solution is highly rated among small-breed owners for recurring ear infections and is appropriate for routine preventive maintenance between veterinary visits.

Cosequin DS Plus MSM Joint Health Supplement

For Imperial Shih Tzus with confirmed patellar luxation, early-stage hip dysplasia, or IVDD risk, a daily glucosamine and chondroitin supplement supports joint cartilage and reduces inflammatory progression. Cosequin DS Plus MSM is one of the most extensively studied joint supplements in veterinary medicine and is consistently recommended by veterinary practitioners for small-breed dogs with orthopedic conditions.

Vetericyn Plus Antimicrobial Ophthalmic Gel

Daily eye cleaning is essential for Imperial Shih Tzus. The Vetericyn Plus Ophthalmic Gel is a veterinarian-formulated antimicrobial gel appropriate for daily periocular cleaning, removing discharge, reducing tear staining, and preventing the bacterial buildup that leads to eye irritation and infection in brachycephalic breeds.

FAQs

Conclusion

The question “are Imperial Shih Tzus healthy?” does not have a single yes or no answer — but it does have a clear, honest one. These dogs carry a concentrated version of the standard Shih Tzu’s documented health vulnerabilities, and in many cases, those vulnerabilities are worsened by the deliberate size reduction that defines the Imperial label. Renal dysplasia, congenital cardiac defects, portosystemic shunts, hypoglycemia, BOAS, dental disease, eye conditions, and orthopedic problems are not rare edge cases — they are the expected health landscape of this breed, more intense in smaller dogs. None of this means an Imperial Shih Tzu cannot live a long, good life. Many do, with dedicated owners who understand the risks, prepare for them, and address them proactively. The difference between a dog that thrives for 14 years and one that struggles from the start is almost entirely determined by the owner’s level of preparation and the quality of the daily care provided. Begin with our full overview guide — The Imperial Shih Tzu: Cute or Complex? — and then return to this article as the clinical reference you consult throughout the dog’s life.