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taste, and consistency. Confirm that the cat is able to hide when they feel the need and has a safe, private places to eat. Feline facial pheromone may be beneficial to reduce stress.20 Verify that inadequate food intake isn’t due to other factors, such as dysphagia, pain (e.g., oral, dental, gastrointestinal, multisystemic, etc.), dislike of the diet (e.g., boredom, altered palatability, spoilage), aversion, fear (e.g., environmental changes including those in the social demographics). Palatability may be improved by bringing the temperature of moist food to body temperature and by changing the consistency of the diet.
Rehydration and correction of electrolyte imbalances
is important but may have been overlooked or the
need may have changed. Anti-emetics (e.g., maropitant, mirtazapine, dolasetron, ondansetron) have a place if the cat is vomiting.
Appetite stimulants including cyproheptadine (1 mg/cat PO BID), mirtazapine (1-2mg/cat PO q48h)21 may help to jump-start a cat’s appetite, but it is important to keep track of total calories consumed. A cat eating small amounts of baby food will not meet their caloric needs: they need 2-3 jars/day. Meat baby food is not balanced, but is sufficient for several weeks. If a cat is eating,
but not enough, supportive feeding (assisted syringe feeding or tube feeding) must be considered. There
are several diets specifically designed for the assisted feeding of cats (e.g., Purina ® Pro Plan® Veterinary Diets CN Critical NutritionTM), liquid balanced enteral diets for cats. Additionally, we can make a slurry from any canned food; blend with a liquid feline diet rather than water
to minimize loss of calories. If the weight is improving, but MCS is not, supplementing with 1oz (28g) of cooked chicken/day may be a low phosphorus protein option.
If the cat is reluctant to eat the renal diet or the MCS is not improving, consider feeding the diet that cat prefers and utilizing intestinal phosphate binders. Aluminum hydroxide dry gel powder (USP) is well accepted by most cats and can be mixed directly into moist food or added to dry. (Put the AlOH dry gel powder and dry food together in a plastic bag, shake.) (www.zzcat.com/CRF/ supplies/binders.htm)
Step 6: Supportive feeding
There are several options for assisted feeding each
with advantages and disadvantages. Syringe feeding, nasogastric (NG), esophagostomy or gastrotomy tubes are the most common choices. In general, the author starts with syringe assisted feeding until the cat is stable enough to allow the brief anaesthetic required for the placement of an esophageal tube. Syringe feeding can be very successful bearing a few things in mind. Because the oral capacity of a cat is only 1⁄2-1 ml, small volume syringes should be used being sure to provide the entire caloric dose. Like an NG tube, syringe feeding is suitable
only for the short term. A large bore feeding tube should be considered early and as a temporary measure to improve the nutritional plane (BCS, MCS) of the patient with kidney disease.
In cats with concurrent liver disease, three doses of Vitamin K1 (1.0 mg/kg q12h SC) should be given prior to tube placement, biopsies or any other procedure that might result in bleeding. Placement of esophageal tubes is not complicated and details are discussed elsewhere. (An example is listed in Resource below.) Instrumentation is very basic requiring only the following: 14-16 Fr red rubber feeding tube/urinary catheter, long curved forceps, a scalpel blade, suture and bandaging materials (or a KittyKollarTM) and a multiple use injection port (“prn adaptor”).
Calculating how much to feed requires that you know the calories they need to maintain their ideal, healthy weight as well as the caloric densities (kcal/ml) of the diet you are intending to use (see Table 2). Start by feeding 1/3 of the calories needed, on day two, feed 2/3, and on day three, feed the full calories needed for the ideal weight.
Table 2: Caloric densities of convalescent diets, for calculating feeding volumes:
ClinicareTM: 1 kcal/ml
Royal Canin/MediCal RecoveryTM: 1.04 kcal/ml
Hill’s a/dTM: 1.17 kcal/ml
Purina PPVD CNTM: 1.33 kcal/ml
Blending a renal (or any other) diet with a liquid diet will provide a higher caloric density than if water is used.
EXAMPLE:
4.0kg sick cat BCS 3/9, healthy weight 4.5kg BCS 5/9 Using the calculator, 216 kcal by day 3
315kcal = 302 ml of Royal Canin Recovery TM;
269 ml of Hill’s a/d TM;
236 ml of Purina PPVD CN TM
Example, using PPVD CN, the most calorically dense: Day 1 feed 80 ml
Day 2 feed 160 ml
Day 3 feed 236 ml
With surgically placed tubes there is a delay in how quickly one can start to use them; with an esophageal tube only a 2-3 hour delay is required to ensure full recovery from anaesthesia. Cats can eat with the tube in place although it is recommended to avoid offering food for the first week to reduce the likelihood of them developing an aversion to the food offered. Once a cat is eating well with tube in place the question becomes when one can remove the tube. Weigh the cat and,
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