How to Talk to Children about Pet Loss and Grief

For many children, their first experience with the concept of death is with a family pet. Being able to openly discuss their feelings around the death and dying of their pet is a healthier way to encourage acceptance and healing. Children may go through all or a few stages of grief that adults feel: 

1. Denial

2. Crying

3. Bewilderment

4. Anger

5. Guilt

6. Depression

7. Attempts to rationalize loss

Additionally, children coping with grief can struggle with fear of abandonment, nightmares, insomnia, anger towards siblings/playmates, learning difficulties, and anxiety. We must remember that children’s cognition is not fully developed until the age of 25, thus their memory and perception are still maturing. Knowing the cognitive age of a child or teen can help adults know how to discuss this complicated subject. Encouraging open discussions and allowing a child to express their feelings can help them feel included and supported. 

The four stages of cognitive development:

Infants and toddlers (birth-2 years)

Infants and toddlers are in the early stages of developing their understanding of the world around them through body movement and their senses. They are not yet capable of rational thinking and understanding the concept of time, nor are they able to see things from another person’s perspective, however, they are highly responsive to their caregiver’s emotions and physical changes in their environment. Infants and toddlers do not understand the meaning of death, thus they do not need to be present during a palliative consultation or euthanasia unless their family prefers them to be.

Preschoolers (age 2-5 years)

While preschoolers are developing fine motor skills, magical/fantasy predominates their thinking. They tend to feel and express emotions deeply and may need extra grief support. They tend to interpret death as temporary or reversible, often confusing it with sleeping or being away. Sometimes preschoolers believe that death is a punishment for something they did or thought. 

Preschoolers sometimes want to be involved during end-of-life conversations, during which it is important to be direct and brief with terms like die or death instead of euphemisms like put to sleep. Lying to preschoolers about death is not recommended. It is common for children in this age group to be curious, asking the same questions repeatedly.

School-age (6-11 years)

Children in this age group begin to understand logic and start to see things from another person’s perspective. They begin to understand the permanence of death. Giving school-age children the opportunity to participate in their pet’s final days can help them understand what the animal is going through and can strengthen their human-animal and child-parent bonds. Presenting school-age children with the choice to be present during palliative discussions or euthanasia is recommended. Encourage questions around the process of dying of their pet, particularly in children older than 8 years. 

Tweens and teens (12-18 years)

Children in this age group are further developing logical thinking and abstract reasoning skills. They understand both the physical aspects of death and the emotional impact of the loss. Tweens and teens should be given the option to participate in palliative discussions and caregiving tasks for their pet. Teens don’t always express emotions like younger children, and tend to test boundaries and independence. They are often very attached to their pet, having grown up with them. Adults should be aware of mental health issues and suicide ideation symptoms, and be prepared to engage with professional mental health services if needed. 

Further support books:

Ages 2-6

• I’ll Always Love You by Hans Wilhelm

Ages 4-8

• Saying Goodbye to Lulu by Corinne Demas

Ages 6-9

• The Day Tiger Rose Said Goodbye by Jane Yolen

Teens

• Healing a Teen's Grieving Heart: 100 Practical Ideas for Families, Friends and Caregivers by Alan Wolfelt

Adults

• Goodbye, Friend: Healing Wisdom for Anyone Who Has Ever Lost a Pet by Gary Kowalski

• Losing My Best Friend: Thoughtful support for those affected by dog bereavement or pet loss by Jeannie Wycherley

• When Your Pet Dies: A Guide to Mourning, Remembering and Healing by Alan Wolfelt

• When Children Grieve: For Adults to Help Children Deal with Death, Divorce, Pet Loss, Moving, and Other Losses by John James, Russell Friedman, Leslie Mathews

5 tips for a successful veterinary experience

Since becoming a veterinarian over a decade ago, I have experienced a wide spectrum of client interactions. Many vet appointments unveil pure joys with the whiff of puppy breath, sneaky ear licks, or the honour of receiving a slow cat blink. Others can go south quickly with a fearfully aggressive patient or from the flusters of poor communication and a palpably untrusting client. 

Veterinary teams strive for excellent communication of their medical expertise to build a trusting relationship with pets and their owners. Sometimes this communication breaks down, resulting in a poor client/pet experience. 

Working in a veterinary hospital setting can be emotionally and physically exhausting. We are expected to shift tacks from emotionally draining euthanasias to bouncy new puppy/kitten exams within a span of minutes. We troubleshoot with uncooperative patients and work around time constraints of continuous appointments, hospitalized patients, emergency drop-ins, phone calls and prescription requests. We do our best, but in the end we are only human. 

I have compiled a list of tips for owners to help us help owners and their pets have a satisfactory veterinary experience:

1. Come prepared. 

Write down a list of questions, concerns and information about the pet (eg. the name brand and amount of food fed daily, including treats). This is especially helpful if owners need to send a close relative or friend to the vet’s office in their stead. If medications need refilling, it’s very helpful to order this in advance of the appointment so that we can have it ready. 

Nothing wrong

with a little nap-in-the-dish

2. Young children are better left at home. 

While it may seem that bringing young children to the vet would be an enriching learning experience for them, young children can be distracting and can interfere with communication between the veterinarian and the owner. Of course I understand that emergencies or circumstances may require children to be present, but if there is an option to leave them at home with a guardian, I find that is best. Believe me, I have my own young children - I know first hand the energy (and noises) that they bring!

From sweet

cuddles…

… to naughty chuckles

3. Managing a pet’s fear and anxiety. 

If a pet has moderate to severe anxiety and/or fearful behaviour at the vet’s office, please ask in advance how we can help make the visit less stressful. This might require a pet to be premedicated with an anti-anxiety medication and/or sedative. 

The combination of curbside care and the puppy/kitten covid-boom has resulted in many under-socialized pets that require extra patience and fear-free strategies at the vet hospital. Thankfully, veterinary medicine has evolved over the past decade such that fear-free practices are becoming standard of care. If a pet is too anxious or scared to tolerate a safe physical exam, we may abort the examination and discuss additional fear-free strategies to facilitate future examinations or medical procedures. This can be a dynamic process, requiring several attempts and drug cocktail trials. Often a pet’s anxiety and fears will escalate with each vet visit, unless these behaviours are managed appropriately.

Although many pets do best with their owners present, we encourage veterinary staff to hold pets during physical exams and procedures. Veterinary technicians and assistants are trained to read animal behaviours that can seem very subtle to the average person. This reduces the risk of bite/scratch injuries to all involved. 

If we advise premedication or even a muzzle, we do not mean any offense! Our goal is to help your pet while creating a safe work space. Pets that require a muzzle for examinations or procedures are not “bad”. They are often really scared and have the potential to fight back, causing great injury to veterinary staff and/or their owners. Training a reactive or fearful dog to be comfortable wearing a basket muzzle is a very important responsibility as an owner. https://muzzleupproject.com/ is a great resource for this!

4. Be open to veterinary recommendations. 

Sometimes veterinarians and owners may disagree. Veterinarians value the information that owners provide because owners observe and interact daily with their animals. Listening to and trusting veterinary assessments/advice is imperative to a positive veterinary-owner relationship. 

Unfortunately, the Information Age has provided the average person with an ocean of online “facts” to filter. Not knowing where or how to identify credible information can lead to ill-informed preconceptions. Veterinarians dedicate at least six (in my case ten) years of postsecondary education prior to becoming newly minted graduates. To retain a licence to practice vet medicine, we must complete many hours of continuing education every year. Additionally, we learn through daily practice, exposure to regular peer-reviewed research, and from vet-to-vet collaboration how to best serve the needs of our patients. There are no hidden agendas or kickbacks that drive our medical recommendations. We are here to help…and of course to cuddle some pretty cute critters.

5. Be kind. 

There are many scenarios that can lead to heightened emotional states as a pet owner. I know how it feels to worry about a pet’s illness that isn’t responding to treatment, to be overwhelmed managing a sick pet while also working full time or caring for young children, to face the anger and grief of euthanizing a beloved pet, to not be able to afford the gold standard care that a pet needs to survive. 

This guy lived for 5 weeks in a “cone of shame” while I administered constant eye drops to help heal a stubborn corneal ulcer…all while being heavily pregnant in my third trimester of pregnancy with my second child and working full time. Not fun!

Veterinarians and our staff are pet owners too. We often absorb raw emotions that our clients express and take them home, sometimes buried deep inside, waiting to be released. We accept this as do all healthcare professionals. If these emotions are not released with careful intent to cultivate resilience, this daily exposure to grief and anger leads to compassion fatigue and other mental health challenges. Kindness and grace truly can fuel the endurance of a veterinary team.

Quality of Life and When to Say Goodbye

As a veterinarian, I often encounter friends or clients who remark, “I could never do it” (the “it” refers to euthanasia). Although I don’t know any veterinarian who enjoys this particular duty, it is one of the most important services we provide for a suffering animal and its owner(s).  

As a dedicated vet student, I spent four years learning normal and abnormal anatomy and physiology, how to diagnose and treat numerous diseases and injuries, and even how to humanely end an animal’s life. There was never any formal training on how to council overwhelmed owners through the decision of when to euthanize their beloved pet, nor any discussions about how I would feel about it.  

My first year in practice was a steep learning curve in many ways and it didn’t take long before I was reeling from the effects of compassion fatigue. I spent many shifts sobbing in the staff bathroom, trying to pull myself together between appointments. I had been absorbing my clients’ grief and adding in some of my own, for having failed to save another patient. After a particularly devastating patient loss, I finally realized that I needed to make some professional and personal changes. I reduced my working hours, and eventually relocated back to my hometown to surround myself with a greater support system. I had a baby, and eventually another. These intermittent breaks from my profession forced me to pause, reflect, and gain a new perspective on life and death.  

Over the years, I have learned that death is not the worst outcome. Allowing for a peaceful and painless death can be the most beautiful last act of love that a pet owner can give to their companion. Knowing when to let go is not easy and it is such a personal decision. Although I hope that this article arms owners with some insights into understanding quality of life and acceptable end-points when making such a heavy decision, nothing can replace an honest conversation about your pet’s quality of life with your veterinarian. 

What is quality of life? 

Most veterinarians and pet owners I talk to agree that an animal’s quality of life is more important than its quantity of life. Although we all have a broad idea of what quality of life means, I find it helpful to break the concept down into more quantifiable factors that summarize an animal's physical and mental well-being. The following is a scoring scale for quality of life that pet owners can use regularly to help visualize the general well-being of their pet. 

Quality of Life Scale: The HHHHHMM Scale 

Score patients using a scale of 1 to 10 for each catagory. 

HURT - Adequate pain control, including breathing ability. Is the pet's pain successfully managed? Is he/she running/playing as often and vigorously as usual? Does he/she pant or groom excessively?  

Pain control can be improved with oral, injectable or transdermal medications.

HUNGER - Is the pet eating enough? Is the pet willing to eat his/her normal dog food, or is only enticed to eat “treats” or “junk food?” Does hand-feeding help? 

Blended/liquid diets and feeding tubes can be used to facilitate appropriate caloric intake. 

HYDRATION - Is the patient dehydrated? If you pull up a small “tent” of skin on the pet’s head, does it snap back into place as yours does? If you touch the pet’s gums, are they moist or dry/sticky? 

Subcutaneous fluids and electrolyte gel packs can supplement fluid intake for some pets. 

HYGIENE – What does the pet’s coat look like? Does he/she have the same luster and shine to the coat that was present as a younger animal? 

Frequent sponge baths can help keep a pet clean after elimination in addition to providing tactile stimulation. Barrier ointments (Vaseline) can reduce fecal/urine scald, and sometimes antibiotics are required to fight secondary infections. 

HAPPINESS - Does the pet express joy and mental stimulation? Is the pet responsive to things around him or her (family, toys, etc.)? Is the pet depressed, lonely, anxious, bored or afraid? 

Moving a pet’s bed closer to family members can reduce isolation and neglect. 

MOBILITY - Can the patient get up without assistance? Does the pet need human or mechanical help (e.g., difficulty rising on a tile floor)? Does the pet feel like going for a walk? Is the pet having seizures or stumbling? 

A harness or sling can facilitate a pet’s mobility, although cats and small dogs can still enjoy life with less mobility than their large dog counterparts. Providing soft and clean bedding, in addition to frequent repositioning of a larger pet is imperative in order to prevent bed sores. Mobility carts can help pets with paralyzed or extremely weak hind legs. Yoga mats and carpet runners provide traction, allowing weaker pets to get up and walk around a house with slippery flooring.

MORE GOOD DAYS THAN BAD - When bad days outnumber good days, quality of life might be compromised. The decision needs to be made if the pet is suffering. If death comes peacefully and painlessly, that is okay. 

*TOTAL *A total over 35 points represents acceptable life quality 

Perhaps the greatest burden of pet ownership is deciding when to let our companions go. We all wish that our pets could die peacefully in their sleep but in reality, this rarely happens. Most natural deaths involve slow, sustained periods of suffering. I truly believe that we should always aim to prevent suffering in our pets and if this is not possible, we must not allow the suffering to continue.  

This post is dedicated to my late loves: Ralphie (the best-worst Boxer there ever was), Buster (my favorite lapdog) and Luna (my crochety old kitty)

Sources:

Villalobos, Alice. The HHHHHMM quality of life scale.

Veterinary Anesthesia and Sedation 101

One of the most common worries that I discuss with clients is their concern for their pet who requires a general anesthesia. In this post, I will be discussing the difference between sedation and general anesthesia, and indications for each. I want pet owners to better understand the true risk/benefit of these procedures and all of the measures that a veterinary team takes to ensure the highest degree of safety for their patients.

I have noticed a common perception among clients that sedation is safer than general anesthesia. In reality, the sedative drugs (and doses required for heavy sedation) can have more profound depressive respiratory and cardiovascular side effects than those drugs used for general anesthesia. Animals that have underlying health concerns (eg. heart disease, respiratory pathology, kidney or liver dysfunction) can have higher rates of complications during heavy sedations. Secondly, monitoring a sedated patient is often not as comprehensive as during a general anesthesia. Thirdly, the patient’s airway is generally not secured under sedation compared to a fully anesthetized patient.

WHY THEN, DO WE SEDATE ANIMALS?

Sedation is often preferred for young, healthy pets that may require quick diagnostics (radiographs, ultrasound, CT scans, skin biopsies) or treatments (wound repair, placement of casts or bandage changes). The degree of sedation is chosen based on the expected duration and invasiveness of the procedure, as well as patient temperament. Sedation can also be preferred due to the lower cost to the client.

Sedative and opioid medications

An anesthetic machine delivers a combination of pure oxygen and an inhaled anesthetic into the patient

General anesthesia is preferred to safely perform longer and more invasive procedures. General anesthesia provides amnesia, analgesia (pain control) and muscle relaxation for the patient. Current anesthesia-related mortality rates are very low (0.05% dogs, 0.11% cats) for healthy pets. The anesthesia related mortality rates increase as the patient’s health status decreases. Each patient is given an ASA (American Society of Anesthesiologist) rating, which is a system for rating a patient’s anesthetic risk. This helps veterinarians to predict the risk of anesthetic morbidity and mortality and to create the safest individualized anesthetic plan.

ASA chart

In addition to a thorough pre-anesthetic history and exam, many older patients require additional diagnostic tests such as blood work, urinalysis, and sometimes, diagnostic imaging. Pre-anesthetic bloodwork and urinalysis are laboratory tests that allow us to detect otherwise hidden changes in organ function, red blood cell, white blood cell, and platelet parameters. Pre-anesthetic chest radiographs and sometimes heart ultrasounds can be required to diagnose and treat heart/respiratory diseases. An abnormality in any of these pre-operative tests warrants further consideration of ways to stabilize (and therefore to improve the ASA status of) the patient before anesthesia, and which anesthetic drugs to avoid.

In-house blood analysers

WHAT IS A GENERAL ANESTHESIA PROCEDURE?

There are three main steps to a general anesthesia:

1.      Premedication. This a combination of a sedative and an opioid pain medication that is injected into the patient. Combining these synergistic drugs in a premedication allows us to use lower doses of each drug with a greater effect and therefore less negative side effects on the patient. The sedative allows for reduced patient anxiety/stress and facilitates patient handling to place an intravenous catheter. The opioid provides analgesia (pain control) before the pain stimulus (surgical procedure) occurs.

An intramuscular injection of acepromazine and hydromorphone is administered as a “premed”

*Sometimes a highly reactive and anxious patient requires an oral “pre-pre-medication” at home the night before and morning of with an anti-anxiety medication.

** Intravenous catheters are always placed to ensure venous access in the event that emergency drugs are needed, as well as to provide continuous intravenous fluids to maintain blood pressure.

An induction agent

2.      Induction. This is an intravenous injection of a short-acting injectable anesthetic drug that allows for the smooth transition from an awake state to an anesthetized state. Once anesthetized, the patient is intubated with an endotracheal tube to achieve a secure airway. Oxygen flows continuously into the tube and patient for the duration of the anesthesia.

Intravenous injection of the induction agent

Intubation immediately following induction

3.      Maintenance. An inhaled anesthetic flows (in addition to Oxygen) into the tube and patient at the lowest effective flow rate to create a steady state of anesthesia. The inhaled anesthetic is metabolized primarily in the lungs, allowing for a rapid recovery to an awake state once the anesthetic flow is stopped.

*All anesthetized patients are kept warm with specialized full body warming devices

Keeping our anesthetized patient warm with a forced-air warming unit

Side note: most anesthetic patients are required to fast for 12 hours before a general anesthesia. This practice is to reduce the risk of regurgitation and subsequent esophageal stricture.

MONITORING:

All general anesthesia (and to a lesser degree sedation) procedures are closely monitored and adjusted by trained veterinary personnel (in most cases a certified animal health technologist). Careful monitoring and adjusting of perioperative drugs (anesthetic agents, pain control and intravenous fluids) is imperative to ensure a safe and stable general anesthesia. In addition to patient monitoring of anesthetic depth, mucous membrane color, and respiratory rate, sophisticated monitoring machines are used to continuously measure:

1.      Blood pressure

This monitor displays oxygen saturation, heart rate, respiratory rate, blood pressure, and temperature

2.      Heart rate

3.      Heart electrical activity/rhythm (ECG)

4.      Oxygen saturation

5.      Expired CO2 levels

6.      Temperature

7.      Intravenous fluid rate

RECOVERY:

Patient care and monitoring doesn’t end when the gas is turned off. The post-operative recovery period is a critical period of time where the most anesthetic deaths can occur. Pure Oxygen is administered once the gas anesthetic is turned off, and the patient’s vitals and anesthetic depth are closely monitored until it is ready for extubation. Once extubated, any breakthrough pain and disorientation is addressed as needed, and continual warmth provided. Intravenous catheters are left in place for several hours until the patient is up and alert. Some higher risk patients are kept on intravenous fluids for some time post-operatively.

When your veterinarian recommends a general anesthesia or sedation procedure, please know that this recommendation is not made lightly and that a lot of training, planning and careful consideration is involved. Each anesthesia is tailored to the individual patient’s unique temperament and health needs.

SOURCES:

Mathews et al. Factors associated with anesthetic-related death in dogs and cats in primary care veterinary hospitals. Journal of the American Veterinary Medical Association. March 15, 2017, Vol. 250, No. 6, Pages 655-665. https://doi.org/10.2460/javma.250.6.655

Debunking common pet food myths - Part 1: The ingredients list

On any given day as a veterinarian, I am confronted with recurring questions and often determined (but scientifically questionable) statements from well-meaning pet owners. The vast majority of these discussions center around pet nutrition. Pet nutrition is such a heated subject that I will admit to sometimes avoiding engaging in further nutritional discussions and education with clients because I may not have the time or because I am easily discouraged. It can be overwhelming trying (and often failing) to constantly compete with opinions and poorly-sourced information found on the World Wide Web. Pet owners love their furry companions and one way to express their love is through food. Naturally, most owners want to feed their pets the “best” and many have strong opinions about which brands and ingredients are “best”. My goal for this series of nutrition articles is to address the most common myths and misconceptions regarding pet nutrition.

Before launching into these myths, I feel the need to provide some basic information about nutrition. All animals require essential nutrients from their diet in order to sustain long and healthy lives. Macronutrients (proteins, carbohydrates and fats that provide calories) and micronutrients (vitamins and minerals) must be present in the correct amounts and proportions to create a complete and balanced diet. Proteins are made up of amino acid building blocks, and are provided by both plant and animal sources in pet foods. When additional protein is ingested beyond the nutritional needs of an animal, it is metabolized and excreted by the kidneys. Fats are made up of fatty acid building blocks, and are essential to health and energy storage within the body. Excess ingested fat remains stored within an animal’s body (contributing to obesity and other chronic diseases) and can cause gastrointestinal illnesses. Although carbohydrates are not essential sources of calories in cats and dogs, they are well tolerated and allow for lower fat, lower calorie, and higher fiber diets. Only small amounts of extra carbs can be stored in the liver during shorts periods of fasting.

The Association of American Feed Control Officials (AAFCO) provides guidelines for pet food composition, with the goal of minimizing the risk of malnutrition in pets. If pet food manufacturers choose to follow AAFCO recommendations, they can indicate so on the product label. Although AAFCO creates minimum standards for pet food labeling and feeding trials, many board-certified veterinary nutritionists recommend that pet food companies provide testing above and beyond these minimum AAFCO trials. AAFCO does not regulate pet food adequacy or safety. In fact, in Canada, the pet food industry remains unregulated. This means that in Canada, it is up to the pet food manufacturers, not the CFIA, to issue voluntary recalls.

December 7, 2018 Canada’s unregulated pet food industry

Armed with some basic pet nutrition knowledge, we are ready to dive into some common myths!

The ingredients list on my cat’s Hill’s TD diet

Pet Nutrition Myth #1: Using the ingredients list to choose a pet food

The majority of pet owners choose a pet food based on the ingredient list. According to board-certified veterinary nutritionists, here are some reasons why this is one of the worst ways to judge the quality of a pet food!

• ingredients are listed in order by weight from heaviest to lightest. Ingredients high in water content (meat and vegetables) will be listed before other dry ingredients despite potentially contributing fewer nutrients to the diet. For example, a diet with chicken (over 70% water content) listed as the first ingredient may have less actual chicken than a diet made with chicken-meal (less than 10% water content) that is listed as the second or thirst ingredient.

• some manufacturers add ingredients to the diet purely as a marketing strategy. Such ingredients have unfounded benefits and may be found in tiny amounts. A perfect example is a diet advertising a whole food such as blueberries, where the blueberries are listed after the vitamins and minerals (this would mean that there are less than a few grams of blueberries per pound of food).

• some manufacturers describe individual ingredients as “human grade”. First of all, there is no evidence to suggest that human grade ingredients are always more nutritious or safe than those destined for pet food. Secondly, once an ingredient is going into a pet food, it is automatically no longer “human grade” (unless the pet food is manufactured in a human food processing plant - which doesn’t happen - and unless the ingredient never leaves the human food chain - by going into pet food, it will leave the human food chain). So, the unregulated term, “human grade”, as it relates to pet food ingredients, is another marketing strategy.

• the ingredients list does not provide any information about the quality of the ingredients or the nutritional composition of the diet. I will explore this idea in subsequent nutrition articles, using specific ingredients as examples.

While the ingredients list doesn’t give us information to judge the quality of a pet food, it can provide some important insights:

• some commercial diets don’t contain enough ingredients to be truly complete and balanced. For example, a diet listing various meats, animal organs, and carbohydrates (ie. no supplemental vitamins and minerals) is not sufficient. Be ware of diets that do not list vitamins and minerals in addition to other essential nutrients.

• the term, “100% natural” on a food label should be a red flag. Most vitamins and minerals are synthetic, so if a diet is truly “100% natural”, it is most certainly not complete and balanced.

If scanning the ingredients list isn’t helpful in gauging the quality of a pet food, how should owners be choosing the best food for their beloved pets? The World Small Animal Veterinary Association (WSAVA) has created several recommendations for gathering useful information to select pet foods.

The first piece of information is provided on the pet food label:

All pet foods sold in Canada and the US must have a nutritional adequacy statement written on the label, which provides the following information:

1. Whether the diet is complete and balanced according to AFFCO guidelines

2. How the company determined that the food is complete and balanced (by formulation and/or by feeding trials)

3. The life stage that the diet is appropriate for

Nutritional Adequacy Statement

A reputable pet food company should also provide the following information to its customers, upon request:

• employment of a full time qualified nutritionist (PhD in animal nutrition or board-certified veterinary nutritionist)

• who formulates the diets and a list of their credentials

• location of food production and manufacturing

• whether the diets are tested with AAFCO feedings trials or by formulation to meet AAFCO nutrient profiles. If the formulation method is used, is the finished product analysed?

• details of quality control measures used to ensure consistency and quality of ingredients and of the end product

• a complete nutrient analysis of the diet (not just the guaranteed analysis, which only indicates minimums and maximums). Each nutrient should be accounted for in grams per 100 kilocalories or grams per 1000 kilocalories rather than on an “as fed” or “dry matter” basis, which doesn’t account for different energy densities of different foods

• calorie content per gram, can, or cup of the diet

• product research with results published in peer-reviewed scientific journals

If the above information cannot be obtained from the pet food company, owners should be cautious about purchasing the brand. Choosing the right pet food can be an overwhelming experience for owners. In addition to the infinite options of commercial diets found at pet stores, supermarkets and veterinary clinics, owners are exposed to a constant barrage of unfounded opinions, myths, dietary fads and marketing ploys. Stay tuned for future articles that will continue to probe and debunk pet nutrition myths so that owners can base their pet food choices on facts not fluff.

Sources:

Association of American Feed Control Officials website: https://www.aafco.org/Consumers

Cummings Veterinary Medical Center at Tufts: Clinical Nutrition Service and Petfoodology website: https://www.vetnutrition.tufts.edu/petfoodology/

World Small Animal Veterinary Association Nutrition Toolkit: https://www.wsava.org/nutrition-toolkit

Rabies, crazies!

I had a rare child-free morning today, so naturally I got my blood drawn to check my rabies titre. This little task was nudged closer to the top of my to-do-list on the heals of several unsettling Canadian news stories this month: a young Parksville, B.C. man tragically died from rabies, then a few days later, a four year old boy in Hearland, N.B. was bitten by a rabid bat in his room while sleeping.

July 16, 2019 Young man dies from rabid bat encounter

July 20, 2019 Four year old bitten by rabid bat

Although rabies is incredibly rare in Canada, these stories rekindled widespread fear and interest in the disease. Of all the zoonotic diseases (infectious diseases that are transmitted between animals and humans), rabies takes the cake for the worst symptoms and mortality rate (once clinical signs appear). My goals for this article are to explain what rabies is and how it is transmitted, what we can do to prevent it from infecting ourselves and our pets, and what to do if we are exposed to a potential rabies threat.

RABIES DISEASE:

Rabies is the name of the disease that is caused by a group (or variants) of viruses in the genus Lyssavirus. There are different rabies variants within the same species of reservoir hosts that live in different geographical areas. Multiple variants of fox, skunk, raccoon, and bat rabies exist, with most human rabies cases in North America being caused by bat virus variants. In developing countries across the world, dogs (domestic, feral and wild dogs such as coyotes, jackals and wolves) are the most important reservoir host for the disease. Reservoir hosts are those species in which the virus is able to live and reproduce. Vector hosts are those species that transmit the virus to another host. All rabies reservoirs are also it’s vectors, however, not all rabies vectors are reservoirs. For example, cats are effective vectors of rabies, but there are no documented feline rabies variants to date.

Rabies is most often transmitted via the saliva following the bite of an infected animal. The virus is sometimes transmitted by saliva, salivary glands or brain tissue that contacts fresh wounds or mucous membranes. In the case of the young Parksville man, a rabid bat flew into his hand, exposing him though an unnoticeable bite or scratch. Although the vector is usually showing clinical signs of rabies at the time of transmission, some animals can shed the virus for up to 8 days prior onset of clinical signs.

The incubation period (time between catching an infection and clinical signs appearing) for rabies can be long and variable. Typical cases in domestic cats and dogs have an incubation period of two weeks to three months, however sometimes it can be much shorter or longer.

The virus travels up the peripheral nerves to the spinal cord and finally to the brain, causing encephalomyelitis. The virus then migrates down peripheral nerves to the salivary glands, where it is shed in the saliva. Once the virus has replicated sufficiently in the central nervous system, it is disseminated to all innervated organs in the body.

Once in the CNS, rabies causes major behavioural changes in its host, which can look like either the “furious form” or the “paralytic form”. Infected animals with the furious form are often irritable, hyperexcitable, and very aggressive towards other animals, people, and moving objects. They become more uncoordinated, can suffer from seizures, and eventually progressive paralysis leads to death. Wild rabid animals often lose their fear of people and normally nocturnal species can become active during the day. Rabid animals with the paralytic form are uncoordinated, with paralyzed throat and chewing muscles. These animals are unable to chew and swallow food, salivate profusely, and can have a dropped lower jaw. The paralysis progresses to the rest of their body, leading to coma and rapid death. Infected humans can experience spasms, periods of agitation, hallucinations, fear of water and fresh air, difficulty talking and swallowing, progressive paralysis, and coma.

It is important to note that rabies can infect any animal, including livestock such as cattle and horses, and of course bats. In British Columbia, bats are the only known reservoir host of rabies (0.5% of the bat population is infected with the virus). The BC Centre for Disease Control (BCCDC) reports that 13% of BC bats submitted for testing are positive for rabies. There is a higher prevalence of rabies in submitted bats because rabid bats exhibit abnormal behaviours that increase their contact with people and domestic animals.

RABIES PREVENTION:

There are an estimated 70, 000 human deaths worldwide per year from rabies. Although human cases in Canada are exceedingly rare (26 deaths since reporting began in 1924), Canada is not rabies free. Combined efforts from the public, veterinarians, public health and wildlife government departments, and the Canadian Food Inspection Agency (CFIA) are needed to mitigate the spread of rabies in Canada.

Dr. Lucy Kinninmonth and Rachel give Satti her rabies vaccine. Photo credit: Eleanor Stewart

Photo credit: Eleanor Stewart

Veterinarians and the public should work together to ensure that pets are vaccinated for rabies. The Canadian Veterinary Medical Association (CVMA) considers rabies to be a core vaccine for both dogs and cats. Cats in particular are the most commonly affected domestic species in the USA and Canada. Even indoor cats should be vaccinated, as they may escape or come into contact with a bat that enters a house. Rabies vaccines are available for the following additional domestic species: horses, ferrets, cattle, and sheep. Wildlife departments currently use oral vaccinations for mass immunization of wildlife such as raccoons in certain parts of Canada (Ontario) and the USA. Dogs and cats can be vaccinated for rabies as young as 12 weeks of age (in British Columbia, where I practice, most pets are vaccinated for rabies at 16 weeks of age). They receive their first rabies booster 1 year later. Further rabies immunizations are given every 1-3 years, depending on the type of vaccine used. A dog or cat is considered immune 28 days following it’s initial rabies immunization, and immediately immune following additional rabies boosters.

Cats that have a history of injection-site sarcomas believed to be associated with a rabies vaccine should not be re-vaccinated for rabies, if possible. Feline injection-site sarcomas are aggressive tumors that can very rarely result from the injection of any substance into the space under the skin. Although a specific cause has not yet been established, it is currently thought that the inflammation related to injectable products can lead to the formation of sarcomas. For most cats, however, the risk of contracting a deadly zoonotic disease such as rabies outweighs the possibility of an injection-site sarcoma (which is currently documented to occur at a rate of 1 case per 10, 000 to 30, 000 vaccinations). Many veterinarians take additional precautions by vaccinating pets in locations that would make tumor removal easier, should an injection-site sarcoma occur (eg. placement low on a leg or in the tail instead of the area between shoulder blades). A small, firm lump can develop under the skin following a vaccination. This lump should disappear several weeks after vaccination. If it persists beyond 3 weeks, owners are advised to contact their veterinarian.

Our old-lady, Luna

When I was in vet school, I adopted an old-lady cat during an external rotation at the Winnipeg Humane Society (WHS). Several weeks after her adoption, I discovered a persistent and firm nodule on her right shoulder (exactly where she was vaccinated for rabies at the WHS). One of my 4th year classmates surgically removed the nodule, which was biopsied and came back as non-specific inflammation. I’ve always wondered whether the nodule would have turned into a sarcoma, had I not addressed it early on. When in doubt, it is always better to be safe than sorry! This old gal lived on for another four years, when she finally succumbed to chronic kidney disease and end-stage osteoarthritis.

In the last decade, I have noticed an increasing trend of adopting pets (mostly dogs) that have been imported from developing countries. It is so important that prospective adopters ensure that their newly acquired pets are vaccinated for rabies prior to being imported. Most of these developing countries have a higher prevalence of rabies in domestic cats and dogs. Although the CFIA and Canada Border Service Agency require imported dogs and cats to have their rabies vaccinations, sometimes these pets arrive with fraudulent documents. Despite importation laws in both Canada and the USA, there has been a rise in illegally imported underage puppies from high-risk countries. In addition to posing a public health threat from rabies, these puppies can carry other zoonotic diseases (eg. parasites, MRSA, Brucellosis) that are especially harmful to children, elderly people, and to other immunocompromised individuals. See the following articles for more details on these importation concerns:

Canada not doing enough to prevent disease from imported dogs

Illegal puppy imports

If your pet has been exposed to a potentially rabid animal (any wild animal or domestic animal showing clinical signs of rabies), take your pet to a veterinarian promptly. Your vet will most likely update your pet’s rabies vaccine, regardless of your pet’s vaccination status. Further actions will depend on the exposed pet’s vaccination status at the time of exposure and whether there has been concurrent human exposure. Detailed guidelines for veterinarians can be found on the BCCDC website BC rabies guidelines for veterinarians and by logging into the CVBC website.

If you find a wild animal which may be rabid, do not touch the animal. Contact a the BC Wildlife Veterinarian at 250-953-4285

If someone has been bitten or scratched by a bat in BC, the bat should be tested for rabies. If the bat is alive and can be captured, please contact the Community Bat Programs of BC at 1-855-9BC-BATS (1-855-922-2287) and your local public health unit Immunize BC for assistance. Further instructions can be found at BCCDC. Immediately following a potential rabid animal exposure, it is important to:

1. Wash the wound with soap and running water for 15 minutes, followed by further flushing with water.

2. Call you doctor or local public health unit Immunize BC

It is imperative to receive post-exposure rabies treatment within 7 days of exposure.

All seriousness aside, today my 4 year old came home with a bite mark from one of his daycare “friends” (apparently this is a common behaviour among small children at daycares!). Bless his little soul, he asked me very seriously, “Mommy, will I get rabies now?”.

SOURCES:

American Veterinary Medical Association. https://www.avma.org/Pages/home.aspx

BC Centre for Disease Control. http://www.bccdc.ca/health-info/diseases-conditions/rabies

Canadian Veterinary Medical Association. https://www.canadianveterinarians.net/

Journal of Feline Medicine and Surgery (2013) 15, Supplementary File: Rabies, Disease Information Fact Sheet

Merck Veterinary Manual. https://www.merckvetmanual.com/

Where’s the beef?? Are grain-free diets causing heart disease in dogs and cats?

Last month’s hot-button media headline was no doubt the report from the FDA investigation into the potential link between grain-free diets and dilated cardiomyopathy (DCM) in dogs and cats. The following link is the latest report on the FDA’s findings since they launched their investigation in 2018:

June 27, 2019: FDA investigates possible grain-free diet and DCM link

The FDA investigation began after a large group of veterinary cardiologists had alerted the FDA to an increase in cases of DCM in dog breeds not genetically predisposed. The common thread in these cases was that the affected patients were eating boutique, exotic protein and grain-free (BEG) diets. The FDA investigation updates have stirred up a frenzy of online discussions and outrage from BEG diet supporters. Unsurprisingly, an onslaught of social media comments was unleashed, directing disdain at and mistrust of veterinary diets and veterinary nutrition knowledge. In light of this latest surge in online misinformation and confusion, I decided to write an article summarizing what we know as a veterinary/scientific community about the issue.

First, a word about dilated cardiomyopathy (DCM). DCM is a type of heart disease where the heart muscle cells become progressively destroyed or lose their function. This causes the heart's pumping chambers (ventricles and subsequently atria) to become thin and dilated and progressively weaker. There are multiple known causes and types of DCM: taurine deficiency in cats and dogs, genetic mutations within some breeds (Dobermans, Boxers, Irish Wolfhounds, Great Danes), drug related (chemotherapy drug doxorubicin), and viral induced (parvovirus).

A diagnosis of DCM is devastating for any pet owner. It can lead to abnormal heart rhythms, congestive heart failure, and even sudden death. My own Boxer, Ralphie, (also know as Ralphageddon, Ralphalfa-sprout, Ralphie-Roo, Poo-face) was recently diagnosed with arrhythmogenic right ventricular cardiomyopathy ("Boxer Cardiomyopathy"). He will need regular cardiac ultrasounds to see if he is among the small percentage of Boxers who will go on to develop DCM.

Ralphie in Tofino, BC

Let’s go back to the importance of taurine. Taurine is an amino acid that is crucial to myocardial health. In 1987, it was discovered that DCM in cats was associated with insufficient taurine in diets, and that the disease could be reversed if affected cats were supplemented with taurine. After that landmark study was published, taurine was required to be added to feline diet formulations. It is now rare to see taurine-deficiency DCM in cats, except those fed home-made preparations or commercial diets that are based on inadequate nutritional expertise or poor quality control.

Veterinary research suggests that although Golden Retrievers and Cocker Spaniels are not genetically predisposed to DCM like their Doberman counterparts, they may be genetically predisposed to taurine-deficiency. An additional dietary factor (grain-free and legume-containing diets) was recently discovered in Golden Retrievers diagnosed with DCM and low taurine blood levels. These dogs showed significant improvement in their cardiac ultrasound results and blood taurine levels after a change in diet and taurine supplementation. Most of the patients improved clinically and half of the patients were able to discontinue some medication. This means that unlike DCM in genetically predisposed dogs, the DCM in diet-associated cases can sometimes be reversed. What is puzzling to researchers and FDA investigators is that the blood taurine levels in other affected breeds (including mixed breeds) appear to be normal. In some of these dogs, a change in diet (with or without taurine supplementation) results in a reversal of the DCM. Possible causes for these non-taurine, diet-associated DCM cases are currently being investigated.

Tugger, Willow and Satti

The FDA document summarizes some interesting findings from the recently reported DCM cases:

1. Most products fed were classified as grain-free, or containing peas and/or lentils or potato/sweet potato. No one animal protein source was predominant.

2. Most reports were for dry dog food formulations, but other types (raw, semi-moist and wet foods) were also represented.

3. The report published a list of the most commonly reported pet food brands that were named in the DCM cases. The top three brands include: Acana, Zignature and Taste of the Wild.

4. The FDA is working closely with the pet food industry to determine if changes in diet formulations, ingredient sourcing, or processing may be contributing to the spike in reported cases of DCM.

So why have grain-free pet diets become all the rage in the past ten years? A question like this opens a nutritional can of worms that even I don't have the stomach for. Suffice to say, pet food fads often follow human diet fads and humans are easily influenced by suave marketing techniques. Clever marketing + Dunning-Kruger effect + social media access = massive shifts in consumer ideology. The Dunning-Kruger effect is alluded to nicely by Charles Darwin in The Descent of Man, where he writes, “Ignorance more frequently begets confidence than does knowledge”. The following link describes this psychological theory in detail:

What is the Dunning-Kruger effect?

Current veterinary nutritionists report that most dogs and cats are very good at digesting and extracting the nutrients from whole grains. Whole grains provide important sources of protein, minerals, vitamins, essential fatty acids and fiber in diets, while keeping the fat and calorie content low. There is no current scientific research demonstrating that grain-free diets are healthier than diets containing grains. Some dogs may be allergic to specific grains (eg. wheat), however, these specific grain allergies are less common than allergies to animal proteins such as chicken, beef, dairy, and egg. In fact, food allergies are much less common than other types of allergies such as environmental and flea allergies. Gluten allergies are very rare in dogs, and have only been documented in some Irish Setters and Border Terriers. There are no documented cases of gluten allergy in cats. The following article provides an in depth look at the grain-free pet food craze:

How Americans decided dogs can’t eat grains

Back to my original question. Do grain-free diets cause heart disease in dogs and cats? Despite the concerning associations between grain-free diets and DCM, we have not yet established a cause and effect relationship. The number of diet-associated DCM cases remains very small. Between January 2018 and April 2019, 524 new cases of DCM were reported to the FDA (515 canine, 9 feline), some of which involved more than one animal per household. The American Veterinary Medical Association estimates that Americans own 77 million dogs and 58 million cats. As a veterinarian and pet owner, I stand by my belief that there is no one food type or even brand that is best for all pets. I can’t say that I ever jumped onto the grain-free bandwagon for myself (I don’t have celiac disease), and I don’t believe that owners need to be feeding grain-free diets to their cats and dogs. I will continue to support pet food brands that value quality control, thoroughly researched diet formulations, and knowledgeable technical support teams.

As the FDA continues its investigation, it is imperative that veterinarians obtain complete diet histories from their patients (cats and dogs) diagnosed with heart disease. If a patient is diagnosed with DCM and is on a BEG, vegetarian, vegan or home-prepared diet, veterinarians should be testing plasma and/or whole blood taurine levels. In addition, other dogs in the household that are eating the same diet should be screened for DCM. Possible diet-associated DCM cases should be reported to the FDA. If the patient is a Golden Retriever, the veterinarian or owner can also report the case to the Josh Stern Cardiac Genetics Laboratory. All dogs with possible diet-associated DCM should be supplemented with taurine, and a follow up cardiac ultrasound performed in 3-6 months.

Owners are advised to watch their pets carefully for clinical signs of heart disease: weakness, slowing down, exercise intolerance, rapid and shallow breathing, coughing, and fainting. Any of these symptoms warrant a prompt visit to a family veterinarian (where it is important to bring a list of everything the pet eats). Owners of possible diet-associated DCM pets are encouraged to save and submit all dietary components they are currently feeding (main food, treats, chews, supplements) and corresponding product labels. These owners are also advised to change their pet’s diet to one made by a well established manufacturer that contains standard ingredients (eg. chicken, beef, rice, corn wheat).

Sources:

Cherry K. What is the Dunning-Kruger effect? Verywellmind.com. June 14, 2019

Cummings Veterinary Medical Center at Tufts: Clinical Nutrition Service and Petfoodology website: www.vetnutrition.tufts.edu/petfoodology/

Freeman LM, Stern JA, Fries R, Adin DB, Rush JE. Diet-associated dilated cardiomyopathy in dogs: what do we know? Journal of the American Veterinary Medical Association
December 1, 2018, Vol. 253, No. 11, Pages 1390-1394

Kaplan JL, Stern JA, Fascetti AJ, Larsen JA, Skolnik H, et al. (2018) Taurine deficiency and dilated cardiomyopathy in golden retrievers fed commercial diets. PLOS ONE. December 31, 2018, 13(12): e0210233

Mull A. How Americans decided dogs can't eat grains. The Atlantic. July 2, 2019

U.S. Food and Drug Administration website: www.fda.gov