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Veterinary Forum October 2007 (Vol 24, No 10)

A Helping Hand to a Healthy Life

by C. J. Ellis

    Pediatric wellness today means setting the stage for a lifelong commitment to health care, specialists say. "Do it early," emphasizes Richard B. Ford, DVM, MS, DACVIM, DACVPM, professor of medicine at North Carolina State University College of Veterinary Medicine, Raleigh.

    "It is like any investment program," he continues. "You need to start your IRA early and make regular contributions. If you don't start early, you likely will suffer the consequences." And raising a puppy or kitten means investing time and energy in establishing a strong foundation, adds Ford, who is a member of the Veterinary Forum Editorial Board.

    To achieve this, says C. A. Tony Buffington, DVM, MS, PhD, DACVN, professor of the department of veterinary clinical sciences at The Ohio State University, Columbus, "puppy and kitten visits have become complex. It means addressing behavior, vaccinations, ectoparasites, endoparasites, congenital disease, heartworm disease, dental health, diet and more."

    Ford agrees and believes pediatric wellness relies on four basic elements: infectious disease, diet, nutrition and behavior. "It means designing a strategy that works best for your patients, clients and clinic," Ford adds.

    But sometimes priming owners to pay attention to so many well care concerns can lead to information overload, explains Kersti Seksel, BVSc (Hons), MRCVS, MA (Hons), FACVSc (Animal Behaviour), DACVB, CMAVA, of Sydney Animal Behaviour Service in Australia, which is why she introduced puppy preschool and kitten kindergarten classes. "I found that owners would ask the exact same questions they had asked during the visit consultation," she says.

    How can veterinarians impart pertinent information that pet owners need to consider? "There are three forms of veterinarian"client interaction," offers Buffington, "intervention, education and collaboration." While all three are in­ter­twined, ultimately, he says, collaboration establishes the long-term relationship between a client and the practice.

    Teaching pets good manners

    Puppy preschool and kitten kin­dergarten are socialization and training sessions designed to educate owners about teaching their puppy or kitten good manners. "We know that the major reason a puppy is relinquished, for example, is because of house-training issues," Seksel says, "so we alert owners that many puppies do not have complete bladder control until they are about 16 weeks of age. Owners should not expect miracles before that time."

    But setting up puppy and kitten classes also means counseling owners about nutrition, preventive care, parasite control, oral hygiene, etc., which involve intervention, education and collaboration, says Seksel.

    "That's why I am a huge fan of these classes," Buffington says. "Parents never would expect to learn during a few 15-minute visits to the pediatrician everything they need to know about raising a newborn baby, but we seem to think we can disseminate everything a pet owner needs to know in that time." That's unrealistic, he adds.

    Ford finds the concept of puppy and kitten classes invaluable. Behavior, he says, plays a critical role in whether owners keep a pet. Is the pet going to be aggressive or docile? Is it going to soil the house? Is it going to be destructive?

    Seksel agrees: "Companion animals need outlets for what is normal behavior, such as teething and investigating their environment, to help avoid what owners may consider inappropriate behavior.

    "I also think owners often forget that puppies and kittens need to be taught how to behave just like kids need to be taught how to behave. Owners need to establish boundaries at an early age on what behavior is acceptable," she emphasizes.

    "In addition, often owners think a pet should automatically know what is right or wrong for that particular household." That is far from true, she adds. "Helping pet babies not to make mistakes and keeping them out of mischief are really important."

    Puppy and kitten classes are an ideal way to safely expose them to different scenarios. The important emphasis "is rewarding behavior the owner finds acceptable rather than punishing behavior the owner doesn't want," Seksel says.

    If the puppy is punished for soiling the carpet, for example, owners will not achieve their goal of housetraining. Instead, the owner needs to reward the puppy when it gets it right. "Owners need to understand that as social creatures, puppies really want to please them," Seksel says.

    A key to achieving acceptable behavior in puppies is teaching them "to do nothing," advises Seksel. "Learning how to be calm and quiet on cue sets the puppy up for being a lifelong companion and helps avoid fear reactions of the unknown." Puppies quickly realize that their assigned mat is not a play station, which helps them learn to be quiet on cue and to act properly around other animals.

    In contrast, Buffington offers, "it is important to remember that cats are not a pack species. So, owners need to approach kittens differently than they do puppies," although the reward basis is the same. "With cats," he continues, "the easiest thing to do is give them a food reward so they know they are engaging in a positive, acceptable behavior to the owner."

    Puppy preschool classes typically last 5 weeks, and the first class is attended by owners without the puppy. "If the puppy is present," Seksel explains, "owners will not listen any better than when the puppy is with them during the first well care visit." After providing some tips , owners go home and practice with the puppy before the subsequent classes, she adds.

    It is important, Seksel advises, not to have classes any larger than six puppies. The entire family is urged to attend, so in addition to six puppies, the class may have as many as 24 family members. "Any larger can lead to failure," she says.

    While the puppy preschool classes tend to run 4 or 5 weeks, the kitten kindergarten classes run 2 to 3 weeks. "The socialization period of kittens ends much earlier than with puppies, so they have to come to class before they are 10 weeks of age. If they are older, ’play' fighting may occur, so they do not learn how to interact appropriately with other cats."

    Kitten classes are a lot quieter than puppy classes, and the kittens are less interested in interacting with each other. "What amazes owners," says Seksel, "is that kittens at a young age can be taught tricks, including 'give me five.'" Owners also are encouraged to provide cats with environmental enrichment, such as scratching posts on multiple levels and different housing options.

    Once a puppy or kitten reaches adolescence, Seksel emphasizes, changing unacceptable behavior can be problematic. And, she adds, spaying or neutering at any age may not resolve behavior issues. "In our referral service, most of the pets that present because of behavior problems already have been neutered or spayed and the procedure did not minimize the unacceptable behavior."

    Getting the right nutritional start

    Owners also need to consider normal puppy and kitten behavior when making nutritional recommendations, says Buffington.

    "Traditionally," he continues, "puppies and kittens were fed a given number of times a day for the first 12 weeks, then one less meal for the next 4 weeks and so on until they became 6 months of age. And, although those kinds of recommendations may sound prescriptive and authoritative, they are not realistic," he says, adding that "if humans were required to follow that type of strict feeding recommendation to survive, we would all be plants."

    Buffington says that veterinarians should rethink their nutritional strategies based on three components: feeding, stress and activity.

    "I recommend that all vets do a 30-second diet history. What exactly does the animal eat? How much? How often? The reason is that they will learn quickly what foods are associated with a good physical examination and a healthy animal," he says.

    Buffington believes that each vet's recommendation will be different, depending on clinic location and the socioeconomics of the clients. "Each vet's list will reflect what that vet feels comfortable recommending based on individual experience.

    "Look at it this way," he continues. "There are 20 different rabies vaccines available. Do you think all practices carry all 20? Of course not. They have two or three because they are comfortable with using them."

    The key to keeping the well puppy and kitten healthy, Buffington says, is feeding for a body condition score (BCS) of 2 out of 5 during the period of early rapid growth. "As far as we can tell," he continues, "this is the best recommendation to prevent nutrition-related developmental orthopedic disease and obesity."

    Once the vet decides on the best diet, he or she needs to consider how much to feed, he says, adding that the variation in the amount needed to sustain this score is probably plus or minus 50%. Some animals may need 2 cups, while others may need 1 cup or 3 cups.

    "The beauty of using the BCS is that it focuses the owner on the condition of the animal. Instead of feeding according to label directions, it means feeding according to the puppy's or kitten's metabolism, exercise regimen and stress levels.

    Buffington then focuses on what happens in the individual household. What is the owner's schedule? How is feeding going to fit into toilet training and socialization?

    "If I have an owner who works 10 or 12 hours, recommending feeding the pet three times a day obviously isn't going to work. So the vet needs to rethink feeding strategies based on the owner's ability to feed the pet."

    This can be done by changing the size of different meals, with, for example, a bigger meal in the evening when the owner gets home, a smaller meal before bedtime, and an even smaller meal in the morning. "Make sure," Buffington emphasizes, "that the owner understands the reason for this strategy," that is, the pet will tend to its toileting needs after it eats and following this program helps the pet avoid making a mistake.

    Then there is the subject of treats. "There are two types of treats," Buffington says, "Food treats and fun treats. If the animal lives on a farm and is really active, food treats may be fine. But if the animal is warming the carpet, the owner needs to focus on fun treats. Fun treats don't have calories and also serve as stress reducers." Examples are playing with toys, teaching a behavior, taking a walk outdoors or providing environmental enrichment.

    "All of these decisions," Buffington remarks, "are part of collaboration. In veterinary medicine, we are way over-trained in 'find it, fix it!' Unless we understand the entire environmental situation, it is difficult to make a good recommendation on nutrition in 15 minutes.

    "So I tell my clients, 'We are going to look at diet, activity and stress. I can't tell by looking at your pet where the proper balance should be, so we are going to review all the options and work it out together.'"

    Preventing pediatric disease

    Behavior also can be a key in diagnosing medical issues, says Ford. "For example, if a puppy has a shunt, the owner may not realize that by being so quiet, the puppy is not really exhibiting normal behavior."

    Anthony P. Carr, Dr. med. vet, DACVIM, a member of the Forum Editorial Board and associate professor of small animal clinical sciences at Western College of Veterinary Medicine in Saskatoon, Canada, agrees: "Sometimes owners think they have a really well-behaved puppy because it is so docile and quiet when it really has a neurologic or cardiac problem." By asking a few questions about behavior during the initial visit, veterinarians can intervene early in detecting neurologic or heart disorders, he says.

    "During the well-care exam," he continues, "it is important that veterinarians perform a thorough auscultation on a puppy or kitten — not just listen to one spot on the chest but make sure they check all valves." In puppies and kittens, he says, it is necessary to listen "up and underneath the elbow area. Otherwise, you might miss an abnormality, such as a PDA."

    Addressing parasitic prevention, however, can be more difficult, Carr advises, especially when it comes to intervention. "With puppies, parasite prevention should start as early as possible by deworming the mother just before birth to prevent shedding of eggs into the environment." Puppies ideally should be on a deworming program at 2 weeks of age, then dewormed every 2 weeks until they are at least 12 weeks of age.

    Unfortunately, many new owners don't have access to the puppy's deworming history.

    With kittens, "worm transmission occurs through fecal and oral routes or through the mother's milk," Carr says, "so it takes longer for kittens to become patent and for eggs to be shed into the environ­ment." Kittens should, therefore, be placed on a deworming program at about 4 to 6 weeks of age and dewormed every 2 weeks until they are about 14 to 16 weeks of age.

    It is important to educate clients about breaking the cycle of transmission, Carr emphasizes, especially with roundworms and hookworms, which can cause human illness, especially among young children who might be exposed to feces in outdoor dirt. These parasites also can cause significant illness in puppies and kittens.

    Published findings, Carr adds, indicate that many veterinarians in North America are not following recommended CAPC deworming procedures. Depending on how heavy the worm load is, he says, puppies and kittens can become quite debilitated. "We also know that internal parasites can increase the risk for puppies to do poorly if they contract parvovirus."

    In the management of clinical disease in puppies and kittens, Ford believes that veterinarians are primarily focusing on administering conventional puppy and kitten vaccines and treating for intestinal and heartworm disease. "What is appropriate for each individual puppy or kitten should be based on the clinician's assessment of the risk and [educating and collaborating] with the owner to reach a decision."

    For example, Ford continues, the need for heartworm prevention in dogs is known, while in cats it depends on individual risk for HARD (heartworm-associated respiratory disease). Cats have about a 10% risk of that of dogs in developing heartworm disease, which makes the decision even more difficult. "HARD can be fatal," Ford says, "but it isn't more prevalent than heartworm disease in dogs."

    Veterinarians should consider the geographic area and not just whether the cat stays indoors when making decisions on feline heartworm prevention. "Just because a cat is indoors only," Ford continues, "does not mean that a preventative is inappropriate." For example, he says, a cat in Mobile, Ala., may be at high risk because that is the heart of heartworm country and mosquitoes have easy access to the home.

    "With dog owners in high-risk areas," Ford stresses, "I believe we need to take a firm stance on heartworm prevention by telling owners that any dog seen at the clinic must be on a heartworm preventative and that heartworm prevention is a lifelong problem. If the owner went to a malaria-endemic country, wouldn't he or she insist on taking a malaria preventative?"

    There is a proliferation of combination preventatives, Ford continues, with heartworm preventatives being used as a parasitic preventative against intestinal parasites. "The molecules that work against heartworm also are working against certain intestinal parasites, and each product has a different claim," he says. The products are continuing to change, he adds, with some new products including prevention against ectoparasites.

    On the vaccine side, Ford stresses that all puppies and kittens need to receive the core vaccines — panleukopenia, herpesvirus and calicivirus for cats and distemper, parvovirus and adenovirus for dogs, plus of course rabies vaccine.

    The reasons for giving noncore vaccinations should be a medical decision made by the veterinarian based on the reasonable acceptance of risk, he adds.

    "The new vaccine protocols have not changed the importance of vaccinations in puppies and kittens," Carr says. "The new protocols have more to do with the adult animal and vaccination intervals. If puppies and kittens are not properly immunized, they inevitably will become sick."

    Respiratory infections in cats are highly contagious, Carr adds, and can be fatal. Vaccination is, therefore, essential. "When you vaccinate cats for herpesvirus and calicivirus, however, vaccination alone does not prevent infection. It only prevents serious clinical disease. A vaccinated cat can be exposed and still develop mild clinical self-resolving signs."

    According to Ford, he often is asked, "Are there breeds at risk of vaccine-induced injury? And the answer," he emphasizes, "is that both the AAHA task force and AAFP vaccine panel identified no breed-specific risk to a vaccine. There is no track record and thus no specific breed-related risk vaccine policy."

    Another issue of zoonotic concern is the raw food diet. "It is a major zoo­notic risk for people," Carr says. "Having uncooked meat in a household introduces the risk of exposing people to Salmonella and Campylobacter."

    A recent study published in the Canadian Veterinary Journal unsuccessfully tried to sterilize food bowls. "The researchers took a thimbleful of meat and placed it into a food bowl, then washed it in a dishwasher. They still were able to culture the organisms," Carr says.

    A healthy adult might only experience a bout of diarrhea, but immunosuppressed people, such as the elderly and young children or infants, could become severely ill, he adds.

    "If I know that one of my patients is on a raw food diet and needs to be held overnight in the clinic, I will segregate the animal because it could be shedding Salmonella. The other patients being held overnight are stressed animals that could easily pick up the organisms."

    Ford agrees: "There is no place for a raw food diet because there is no way to protect puppies from potentially fatal disease. True, their ancestors lived on a raw food diet, but what owners do not understand is that these wild animals also died at a young age while on these diets. Puppies and kittens are not adapted to eating raw food." Plus, unlike with pet foods, which are highly scrutinized for safety, there is no control over a raw food diet or any way to check the source, he says.

    Keeping a healthy mouth

    Raw food diets also can be detrimental to oral health, says Jan Bellows, DVM, DAVDC, DABVP, of All Pets Dental Clinic and Hometown Animal Hospital in Weston, Fla. "These diets advocate feeding bones, and bones can break teeth. We always inform owners never to feed anything that is harder than the tooth itself."

    Dogs chewing butcher bones and hard nylon chews represent half of his patients that present with fractured teeth, says Bellows, who also is a member of the Forum Editorial Board. In addition, studies have found that many wild animals die from periodontal disease or from being unable to protect themselves because of fractured teeth.

    Like good nutrition, dental care is necessary to provide optimal health and quality of life, Bellows stresses. "Diseases of the oral cavity, if left untreated, are often painful and can contribute to local or systemic diseases that are life-threatening or critical in scope."

    At the first well-care visit, veterinarians should mention the importance of good oral health, he advises. "It is necessary to take baby steps when talking with owners about their 'baby.'"

    At each subsequent wellness visit, Bellows recommends that vets mention one aspect of oral care. "Don't just explain the importance of brushing," he continues, adding that actual toothbrushing may be difficult to do.

    "Whether a puppy or kitten allows its teeth to be brushed depends a lot on its personality and whether the owner can achieve success," Bellows says, so promoting toothbrushing is not essential.

    Instead, he continues, owners can achieve plaque control by using Dentacetic wipes (DermaPet), OraVet (Merial) and Green­ies for puppies and a daily Q-tip rub at the gingival margin and Greenies oral treats for kittens. "Vets and owners together need to address plaque control by using a multi-product approach and rotating products to achieve different strategies."

    When oral health goes unaddressed in a puppy, it can lead to periodontal disease and significant lesions in the kidneys, heart, liver and brain, according to one study by DeBowes and colleagues, Bellows explains. Cats are not as prone to periodontal disease, but it still can occur.

    "We need to educate owners about the problems that can surface before and during eruption of the permanent teeth," Bellows emphasizes. He recommends showing owners pictures of problems that may surface, such as retained deciduous canine teeth, missing first premolars, misdirected teeth and supernumerary teeth.

    When veterinarians see the puppy or kitten for the first time at 7 or 8 weeks of age, occlusion can often be estimated based on the appearance of the deciduous teeth and positioning of the upper and lower jaws.

    In addition to working with puppy owners on how to keep the pet's mouth clean and watching for improper eruption patterns, "another arrow in our quiver for controlling periodontal disease in dogs is the relatively new dental vaccine. Initially I only recommended vaccine for small breeds that typically are predisposed to early periodontal disease," Bellows explains, "but I eventually decided that this approach is unfair. Large breeds also get periodontal disease."

    Bellows makes sure that clients are not given a false sense of security, however. "Owners need to understand that plaque control is still essential in maintaining a healthy mouth. The vaccine may prevent progression of periodontal disease by controlling one of the major oral pathogens, but owner cooperation is equally important."

    the veterinarian can provide a helping hand to guide the owner on the right

    Adopting a new puppy or kitten can mean the start of a wonderful relationship, but only if way to "parent" the new pet.

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