The leading cause of death for Pekingese, as for many other Toy breeds, is trauma. Top leading causes of organ systems include neurologic and cardiovascular, e.g., congestive heart failure. When diagnosed early and successfully treated with medication, a Pekingese with this problem can expect to live many years. A heart murmur is a potential sign of a problem, and must be evaluated by a veterinary cardiologist. Very often, the problem does not surface until the dog is 6 or more years old, so it is very difficult to screen the problem in a pup.
The other main problems of the breed are eye issues and breathing problems, resulting from its tiny skull and flattened face, and skin allergies (and hotspots). An especially common problem is eye ulcers, which may develop spontaneously. Pekingese may also develop keratoconjunctivitis sicca (dry eye) and progressive retinal atrophy.
The Pekingese should not be kept outside, as having flattened faces and noses can cause them to develop breathing problems, making it difficult for them to regulate their body temperature in overly hot or cold weather. Their long backs, relative to their legs, make them vulnerable to back injuries. Care should be taken when picking them up to give adequate support to the back: one hand under the chest, the other under the abdomen. Short legs give some Pekingese difficulty with stairs; older dogs may not be able to go up or down stairs alone.
In an effort to address the breathing difficulties caused by the breed's flat face, the Kennel Club (UK) significantly changed the breed standard in October 2008, removing the clause that the "profile flat with nose well up between eyes" and adding instead that the "muzzle must be evident". This was in response to public opinion following the BBC programme, Pedigree Dogs Exposed. The breed standards of two other flat-faced breeds, the Pug and English Bulldog, were soon also changed.