2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat

Abstract

Practical relevance: Inappetence may have many origins and, as a presenting sign or observation in the hospitalised patient, is common in feline practice. Nutritional assessment of every patient is encouraged, to identify the need for, and appropriate type of, intervention indicated. The impact of malnutrition may be significant on the feline patient, perpetuating illness, delaying recovery, slowing wound healing and negatively impacting gut health and immunity. Delayed intervention may result in the cat's deterioration; hence prompt control of contributing factors such as the underlying illness, pain, nausea, ileus and stress is vital to optimise voluntary food intake. Management is multimodal, comprising reduction of stress, medications and assisted nutrition in the form of tube feeding or parenteral nutrition. Use of antiemetic, analgesic, prokinetic and appetite stimulant medications may restore appetite, but placement of feeding tubes should not be delayed. Feeding tubes are generally well tolerated and allow provision of food, water and medication with minimal stress, although clinicians must be aware of complications such as stoma site infections and refeeding syndrome.

Clinical challenges: Cats are vulnerable to malnutrition owing to their unique metabolism and specific nutritional requirements. Moreover, their nature as a species means they are susceptible to stress in the hospital environment, which may result in reduced food intake; previous negative experiences may compound the problem. In particular, an inappropriate clinic environment and/or handling may cause or exacerbate inappetence in hospitalised patients, with negative impacts on recovery. Postponing interventions such as feeding tube placement to await improvement, owing to clinician or caregiver apprehension, may hinder recovery and worsen nutritional deficits.

Evidence base: The 2022 ISFM Consensus Guidelines on Management of the Inappetent Hospitalised Cat have been created by a panel of experts brought together by the International Society of Feline Medicine (ISFM). Information is based on the available literature, expert opinion and the panel members' experience.

Keywords: Feeding tubes; anorexia; appetite stimulants; gastrostomy; hyporexia; naso-oesophageal; nasogastric; nutritional assessment; nutritional support; oesophagostomy; refeeding syndrome.

Figure 1

Cats have higher protein requirements than dogs and humans, likely related to their evolution as hunters. Image courtesy of Sam Taylor

Figure 2

Factors commonly associated with inappetence in hospitalised cats. All must be managed to encourage voluntary food intake. (See also Figure 6 for causes of distress in hospitalised cats.) Image courtesy of Sam Taylor

Figure 3

Signs of nausea may include ptyalism or more subtle signs (inappetence, lip licking and turning away from food). Image courtesy of Serge Chalhoub

Figure 4

(a) Body condition score chart and (b) muscle condition score chart. Images from the Global Nutrition Committee Toolkit provided courtesy of the World Small Animal Veterinary Association (WSAVA). Available at the WSAVA Global Nutrition Committee Nutritional Toolkit website: http://www.wsava.org/nutrition-toolkit. Accessed 20 October 2021.© WSAVA (image a) and Tufts University, 2014 (image b)

Figure 5

Cats have highly attuned senses, including vision, hearing, olfaction and touch (pads and vibrissae), all of which should be considered when managing hospitalised patients. Image courtesy of Sam Taylor

Figure 6

The hospital environment contains multiple factors that can cause distress for cats. Image courtesy of Sam Taylor

Figure 7

All hospitalised cats should have somewhere to hide, and also perch, within their cage. Even something as simple as a cardboard box will reduce stress and encourage voluntary food intake. (a) A Cat’s Protection ‘Cat Castle’; (b) a cat’s own carrier used as a bed and perch in the hospital cage; (c) a simple cardboard box; (d) the front of the cage can be partially covered with a towel or blanket. Images courtesy of Sam Taylor (a and c), Nicki Reed (b) and Lumbry Park Veterinary Specialists, UK (d)

Figure 8

Cage layout can be optimised to reduce stress and encourage voluntary food intake, ideally by providing somewhere to hide and perch, and allowing food and water to be positioned away from litter trays and each other. Additionally, the front of the cage can be covered to offer more privacy. Image courtesy of Lumbry Park Veterinary Specialists, UK

Figure 9

Wide-brimmed ceramic bowls are preferred to avoid the cat’s whiskers touching the sides of the bowl; this is particularly important for brachycephalic cats. Image courtesy of Linda Ryan

Figure 10

Maximise positive experiences and interactions, if accepted by the cat. This cat particularly enjoyed being groomed and would often start to eat after being brushed in the cage. Image courtesy of Sam Taylor

Figure 11

Naso-oesophageal (NO) feeding tubes. (a) Cat with an NO feeding tube in place. Suitable for short-term feeding and easy to place, this tube is secured with tape and tissue glue. (b) This NO feeding tube is secured with sutures. Note the use of a softer fabric Elizabethan collar to prevent interference, while avoiding the stress associated with hard plastic collars and still allowing the cat to eat. Another method of securing NO tubes is the use of staples. With all methods, the aim should be to avoid patient distress/discomfort and interference with the whiskers or line of vision. Note that nasogastric tubes can be secured similarly. Images courtesy of Sam Taylor (a) and Lindsey Dodd (b)

Figure 12

Oesophagostomy (O) feeding tubes. (a) A polyurethane O tube coiled and kept in place with a purpose-made fabric collar (Kitty Collar). (b) An O tube with additional length removed (note this tube is secured with a finger trap suture to the periosteum of the wing of the atlas, as preferred by some clinicians). (c) A red rubber O tube covered with a dressing. Images courtesy of Sam Taylor (a), Danielle Gunn-Moore (b) and Serge Chalhoub (c)

Figure 13

Correct placement of an O tube confirmed with radiography. The tube should terminate in the distal third of the oesophagus. Image courtesy of Sam Taylor

Figure 14

Oesophagostomy tube site cellulitis (a) and abscess (b). Topical antibiotic therapy may be adequate to manage infection, along with increased cleaning of the site. However, infection may necessitate tube removal in some cases, as well as sedation or anaesthesia for surgical debridement/flush. Culture and sensitivity testing should be performed where possible to enable appropriate antibiotic selection. Antibiotic-impregnated discs (c) can be placed around the stoma site. Images courtesy of Sam Taylor (a and c) and Carolyn O’Brien (b)

Figure 15

Gastrostomy feeding tubes. (a) This cat was diagnosed with oesophagitis and was in poor body condition and benefited from placement of a gastrostomy feeding tube at the time of surgery for intestinal biopsy. Dressing of gastrostomy tubes can be challenging as dressings tend to ‘bunch’ cranially to the hindlimbs. Body suits may be tolerated by some cats, but care must be taken to avoid chronic stress associated with dressings/ clothing while the tube is in place. (b) Cat with idiopathic megaoesophagus and a low-profile PEG tube. This cat was fed via the tube for 7 years. Images courtesy of Sam Taylor (a) and Elise Robertson (b)

Figure 16

When patients have both feeding tubes and IV lines, particularly central venous catheters, ensure they are appropriately labelled. Image courtesy of Dan Chan

Figure 17

Some patients with severe vomiting or regurgitation, for example, may benefit from being fed via a constant rate infusion, which can be facilitated with standard syringe drivers. Image courtesy of Dan Chan

Figure 18

Example feeding record for a hospitalised patient with a feeding tube. This record sheet is available to download from the supplementary material (see page 636)

Figure 19

Cats should be allowed to adopt a comfortable position when being tube fed, avoiding stress and heavy restraint. This cat is relaxed, accepting being stroked and shows no sign of nausea or pain while receiving an O tube feed. A bed has been placed under the cat’s head to raise it slightly to avoid reflux of food proximally. Image courtesy of Sam Taylor

Figure 20

Severely debilitated cats and those that have been starved (typically after going missing) are at risk of refeeding syndrome. This cat had a body condition score of 1/5 after going missing for several weeks. Image courtesy of Sam Taylor