Household Cleaning Products: A Pet Danger

X-ray of a cat that has eaten a metal mesh scouring pad

It’s spring cleaning time, but if you have pets please clean cautiously since some of the most common cleaning agents can be toxic to your pet. Birds are especially sensitive to the fumes from household cleaning agents.

Chlorine bleach has an extremely wide spectrum of activity against common bacteria and viruses. Its low cost makes bleach an attractive disinfectant and laundry additive. Bleach disinfects by oxidizing cell membranes, rupturing and killing cells. Bleach has the same effect on the gastrointestinal tract if your pet drinks undiluted bleach or chews on the bleach container. A splash of bleach into the eye of a curious pet can cause tearing, irritation and even an ulcer.

Some websites recommend the use of phenol-containing pine scented cleaners as a deterrent for cats who urinate outside their litter boxes. If you use these products, you may no longer have a healthy cat and the litter box issues will seem insignificant. When walking across your freshly mopped kitchen floor, your cats get phenol on their feet. Phenol is caustic to the delicate paw pads. Then, when cats groom, they ingest the cleaner which damages their liver and kidneys. When compared to dogs, cats are extremely susceptible to phenol toxicity since their liver lacks an important enzyme for metabolism of phenol.

Although not technically toxic, steel wool and metal mesh scouring pads can cause intestinal obstruction if consumed by your pet. At first glance these products do not have much culinary appeal, but when encrusted with steak bits from the grill or some scrambled eggs from the frying pan, a scouring pad becomes a tasty treat for your dog or cat. As you can see in the x-ray, the scouring pad unravels and prevents food from normally passing though the intestine. The sharp strands can also slice into the intestinal wall. Emergency surgery is required for removal.

Quaternary ammonium compounds are disinfectants with a broad spectrum of antimicrobial activity against bacteria, viruses and fungus. These compounds are popular cleaning agents colloquially called “quats.” Serious injury can result to both pets and people if they inadvertently come in contact with quats. Caustic burns, convulsions, low blood pressure and even death occur following ingestion or contact with the skin.

The AMC Emergency and Critical Care staff recently teamed up to save the life of a young Yorkshire Terrier with severe oral swelling and respiratory distress from ingestion of quaternary ammonium. Read his story: Yorkie Ingests Deadly Poison and Survives.

Not sure if a product is pet-safe? Download the material safety data sheet for any product you might purchase to prevent bringing a dangerous product home.

Resolve to Be a Responsible Pet Owner

It’s that time of year again; the time when we make New Year’s resolutions. I seem to make the same ones every year: eat healthier, exercise more, be kinder. My suggestion for 2013 is for every pet owner to be a responsible one. To achieve that goal, the American Veterinary Medical Association has developed a list of guidelines for responsible pet ownership.

Fur the Love of Pets believes this is a good list for pet owners to review before making their 2013 list of resolutions:

Commit

As the holidays approached, I received several tweets discouraging pets as holiday gifts since a pet is a lifetime commitment and acquiring one should not be an impulsive decision. You must choose the right pet for your lifestyle and should have as many pets you can comfortably care for, both physically and financially.

Good pet care involves more than food and water. A successful pet parent provides exercise, a stimulating environment and training.

Invest

Having a pet requires an investment of both time and money. Preventive healthcare saves money in the long run and helps prevent costly emergency visits.

Although vaccinations are part of a preventive healthcare program, the rabies vaccine protects human health as well.

Identify

Every pet should have both permanent and temporary identification. Permanent identification should preferably be a microchip, but a tattoo is a viable alternative. A collar with tags is a good temporary and immediate method of letting people know where your pet belongs if he should become lost.

Limit

Help decrease the nation’s pet overpopulation problem by spaying or neutering your pet. Preventing unwanted litters limits the number of animals entering shelters each year.

Prepare

Prepare for your pet’s future like you prepare for your family’s future. Assemble a “go bag” for your pet. Include your pet in estate planning; don’t assume your family is prepared to add your pet to their household and make provisions for your pet in case you can no longer be the primary caretaker.

What’s On the Mind of Pet Owners?

A recent survey of both pet owners and veterinarians interrogated the pet health issues each group thought were most important. In last week’s post, I discussed the issues from the veterinarian’s point of view. In this blog I will write from the pet owner’s point of view.

Pet owners said they were primarily concerned with vaccinations, fleas and ticks, heartworms, intestinal parasites, and spending money on medications. This list appears to overlap with the veterinary list on the topic of intestinal parasites, and both owners and vets are squarely focused on preventive healthcare; care to keep their favorite furry, feathery, or scaly companion healthy.

Vaccinations

Vaccinations float to the top of most pet owners’ lists because they save pets’ lives. Before vaccinations were available for common diseases like canine distemper and feline panleukopenia, these diseases spread through neighborhoods like wildfire, often resulting in the deaths of many pets. Decreases in the recommended frequency of some vaccines, coupled with the association between injections and tumors, has raised many questions in pet owners’ minds.

Intestinal parasites

Both pet owners and veterinarians agreed intestinal parasite control was an important issue for pets. How could it not be? Intestinal parasites are high in yuck factor, high in pet discomfort, and on the list of diseases people and pets can share.

Fleas and ticks

These critters are very similar to intestinal parasites with regard to yuck factor and pet discomfort. A pet with a flea infestation may mean you also have a house or apartment with a flea infestation since fleas spend more time off your pet than on. Pet owners want to avoid an expensive exterminator bill by preventing fleas on their pet. Pet owners also want to prevent fleas and ticks to protect their pet against diseases like Lyme disease and blood parasites.

Heartworms

Because heartworms are a serious health concern in both dogs and cats, they are an important medical issue for most pet owners. Nearly every state in the United States reports cases of heartworm in resident dogs and cats. This map shows heartworm cases by state.

Year-round heartworm preventative is a “two-fer” since most prevent both heartworms and some intestinal parasites.

Pet medications

Pet owners want the best for their pet. In my mind, the best are veterinary-specific products. I prefer to prescribe medications developed specifically for veterinary patients rather than human or compounded medications. Veterinary-specific medications assure you, the pet owner, the product has been tested in dogs or cats and will be absorbed, metabolized, and effective in your pet. But, because most pets do not have insurance and medications are paid for “out of pocket,” many times pet owners can be surprised at the cost. As a pet owner myself, I believe that these veterinary-specific medications are worth paying for.

After looking carefully at the two lists of pet healthcare issues, one from pet owners and the other from veterinarians, are they really so different? Both groups’ lists really have only one item and it’s the same one: healthy, happy pets.

What’s On Your Veterinarian’s Mind?

A recent survey of both pet owners and veterinarians interrogated the pet health issues each group thought were most important. In this blog, I will write from the veterinarian’s point of view and in next week’s post, the issues from the pet owner’s perspective.

Starting with an exam

In an exam room with a pet owner and a furry, feathery or scaly patient, veterinarians focus on performing a complete physical examination, a pet’s need for routine blood testing, intestinal parasite control and issues related to senior pets and pain management.

Physical examination detects abnormalities in your pet’s body that veterinarians can determine the cause of through blood tests, x-rays, and other specialized tests. For example, crusty eyes will be tested for tear production, or a brown discharge in the ears will provoke an ear swab and a microscopic examination of the discharge to determine the best medication to clear it up.

If your cat is losing weight or your dog has a bad haircoat, thyroid testing might be indicated.

Blood tests

A complete physical examination is just one component of assessing a pet’s health. Veterinarians use blood tests to monitor organ function, monitor drug therapy and discover disease. Without them, we can only guess about your pet’s health. You shouldn’t be surprised that blood tests are high on our list.

Intestinal parasite control

The Companion Animal Parasite Council, a group of parasite experts, recommend all pets be treated with monthly anti-parasite agents. The recommendation stems from the need to keep your pet healthy and also protect humans against infection. Tummy upset is a common reason for urgent visits to veterinarians. Parasite control helps keep these visits less frequent and keep you and your pet happier.

Senior pets

A pet lifetime is compressed into 10-15 years. Once your pet reaches 8-10 years of age, she is considered a senior pet where one year of life represents multiple years of aging. To detect age related conditions, experts have recently increased the recommended frequency of visits for senior pets to a minimum of twice a year. When we see your senior pet, we will consider age related changes such as pain from arthritis.

Pain management

Veterinarians know pain from arthritis is an important issue for their patients and their families, but families and veterinarians alike struggle with how best to diagnose pain and measure response to treatment in pets who cannot talk. Watching them engage or not engage in their normal daily activities provides the best clue. Sometimes a hunch leads us to try pain medications and when we see a positive response, know we have made the correct diagnosis.

Now that you know what’s on your veterinarian’s mind you will be better able to understand how we can collaborate to keep your pet in perfect health. Be sure to take a list of what’s on your mind when you visit your pet’s veterinarian to promote this collaboration.

National Pet Cancer Awareness Month

November is a busy month. Not only is it National Diabetes Month, but it is also National Pet Cancer Awareness Month.

Cancer and diabetes are two important diseases the veterinarians at The Animal Medical Center treat every day.

According to VPI, a pet insurance company, their top ten insurance claims for pet cancer treatment include tumors we veterinary oncologists commonly treat.

1. Lymphoma or lymphosarcoma
2. Malignant skin cancer
3. Splenic cancer
4. Bone or joint cancer
5. Liver caner
6. Chest cancer
7. Bladder cancer
8. Brain of spinal cord cancer
9. Mouth cancer
10. Cancer of the cells lining the inside of the chest and abdomen

Surgery and cancer

Surgery is often the first procedure for a cancer patient and is commonly performed to get a biopsy of a lump which leads to the diagnosis of cancer. For one or two of the tumors on the top ten list, surgical excision might be the only treatment needed to control the tumor. If surgical excision isn’t enough to control the tumor, we often recommend chemotherapy.

Chemotherapy concerns

The tumors listed in the top ten insurance claims also include tumors veterinary oncologists manage with chemotherapy treatments. Chemotherapy helps us control the spread of some tumors and shrink others, improving both the length and quality of a pet’s life.

Many pet owners express concern over the potential side effects of chemotherapy treatment on their pet. Scientific research has proven their concerns unfounded. Carboplatin, a chemotherapy drug used to treat bone tumors called osteosarcoma and other tumors in dogs and cats, receives high marks for improving quality of life.

A combination of chemotherapy drugs for the treatment of feline lymphoma also improved the quality of life of cats suffering from this common tumor.

Setting expectations

Veterinary oncologists successfully give chemotherapy to dogs and cats on a daily basis. Because we have been treating pets with cancer for decades, we know what doses are safe and what additional therapies to administer to limit adverse reactions. In my experience, dogs tolerate chemotherapy better than people and cats tolerate it even better than dogs. I think psychology plays a role in chemotherapy reactions. Humans know what chemotherapy can do. My patients, smart as they are, have no clue about chemotherapy. The typical pet receiving chemotherapy has one or two off days following treatment and then their appetite and energy rebound. We obsess over every patient’s white blood cell count and send them home without treatment if the count is too low for safe administration. Every one of our patients has at least two people helping with chemotherapy administration: someone who holds the pet on a soft, comfortable mat, and a nurse specially trained in administration of chemotherapy drugs.

What can a pet owner do about cancer?

Take an active role in screening your pet for cancer using the Veterinary Cancer Society’s Ten Common Signs of Cancer in Pets.

Investigate pet insurance to see if it is right for your family. If you already have a policy, find out if cancer treatment is covered.

Animals Were Affected by the Hurricane Too

Hurricane Sandy created hardships for people living up and down the East Coast. Residents were displaced from their homes and sent to evacuation shelters or lived in flooded apartments, and life in general was disrupted. Sandy spared few. Animals, too, suffered as a result of the high winds and flood waters inflicted by the storm. The concept of zoobiquity springs from the fact that animals and humans share many of the same diseases. In the aftermath of Hurricane Sandy, I would argue we share much, much more.

Animal homes flooded

The ponies of Chincoteague Island have always held a special allure for me, and after visiting this barrier island last summer, I was concerned for the ponies’ safety as the storm surge rose. Before the storm, the pony caretakers opened the gates on the fences around the pony habitat, allowing the ponies to go to higher ground and have free range of the entire island. All the ponies safely weathered the storm, as you can see on this video of their hurricane experience.

The New York Aquarium sits right on the famous boardwalk of Coney Island and is at the epicenter of New York City hurricane damage. Although the aquarium was without power for several days, generators ran filters and staff members pumped oxygen into tanks, keeping the fish, invertebrates, and mammals well cared for in their watery homes.

One of the newest aquarium residents, Mitik, an orphan baby walrus, seemed to enjoy the storm, not unlike many other New York City youngsters who rejoiced when school was cancelled for a full week.

Animals displaced

Aquarium residents were not evacuated from their home, but many New York City pets were. All New York City evacuation shelters accepted pets and Mayor Bloomberg encouraged residents to take their pets with them as they evacuated. The New York Veterinary Emergency Response Team has monitored the census of pets in evacuation shelters in the New York area. As of Veteran’s Day, 141 pets still remained in the city’s shelters.

Other animal displacements were a pair of brown pelicans. Brown pelicans are normally southern birds and are neighbors of the Chincoteague ponies. Wildlife rehabilitators reported two displaced brown pelicans blown off course by Hurricane Sandy and found in Rhode Island.

This time of year, Rhode Island is much colder than the birds’ normal southern habitat and these fellows are currently resting and recovering from their harrowing hurricane experience while awaiting transport home.

Families, animals included, reunited

Despite the upset and havoc Hurricane Sandy caused, there are happy stories too. Neighbors helping neighbors, runners of the cancelled New York City Marathon helping in relief efforts and families reunited. Patches the cat was rescued from the rubble of his home by a dump truck operator and Sandy the dog is back with his family.

My fellow animal lover, Jill Rappaport of NBC News, made this touching video about pet families and the hurricane.

What you can do

Microchips are a large part of the reason why happy post-hurricane stories can be told. If your pet is not microchipped, don’t wait until the next big storm. Now it the best time to get one.

The Animal Medical Center’s friend, Amy Sacks at The Daily News, has posted great information about how you can help pets affected by Hurricane Sandy.

Do you know anyone who had their lives or those of their pets disrupted by the storm? Share your stories in the comments below.

Photo: Matt Stanton

Your Child and Animals: Advice to Parents

As parents, we want to raise children who have a reverence for all living things, and what better way to educate them about animals than to spend a day at a petting zoo, a country fair, or a natural science museum featuring live animal displays? Animal events are fun and educational for the entire family, but before you attend an animal event, your children need a bit of advance preparation to protect themselves. Animals in public setting have been associated with some preventable health issues such as infection, injury, and allergic reactions.

Infection connection

Rodents, reptiles, livestock, pocket pets, and even wild mammals visit schools and are displayed at county fairs and science museums. The potential dangers vary from animal to animal. Livestock can carry the bacteria E. coli, which causes gastrointestinal upset in humans. Just last week I read a report of an E. coli outbreak linked to a fair in North Carolina.

Reptiles commonly shed another bacterium causing gastrointestinal upset: Salmonella. This organism is the reason turtles less than 4 inches in size have been banned from sale. Most experts consider turtles appropriate pets for children over five years of age.

Approach animals cautiously

Parents take their children to visit animal displays because they want their children to be comfortable around animals and to appreciate the natural world. Before you go, make sure your child understands if the animals can be touched and, if so, how to approach one safely. If your child is bitten during one of these events, you risk dampening your child’s enthusiasm for animals and simultaneously exposing him to a serious injury or infection.

Even iguanas can cause allergies

If you have a child with animal allergies, check with her allergist about how best to handle an animal visitation. Most children allergic to dogs and cats are likely to be allergic to other furry critters such as guinea pigs, chinchillas, and rodents. Some people even have allergies to iguana scales.

Take home messages

1. Teach children how to safely interact with an animal before visiting a petting zoo, county fair, or school event featuring animals.
2. Wash hands after every animal interaction or use hand sanitizer.
3. Children should not kiss animals or put their hands in their mouth after handling an animal.
4. Children too young to follow directions about hand washing and keeping their hands out of their mouths should not handle animals in public displays.
5. Because of the risk of transmitting an infection, hands should be washed after petting animals and before snack time.
6. Wild animals do not make good pets.

If you are an early childhood educator, guidelines for animals in schools have been developed by the Centers for Disease Control.

National Veterinary Technician Week 2012

AMC LVT, Monika Wright

October 14- 20, is a celebration of the contributions to the healthcare of animals made by veterinary technicians. Often called “nurses,” these licensed professionals practice under the supervision of a licensed veterinarian. In New York State, veterinary technicians prepare and give medications as ordered by the veterinarian, take x-rays, induce and maintain anesthesia, and assist with medical and surgical procedures. Most importantly, they are critical members of the team caring for your pet. Last year, in honor of Veterinary Technician week, I wrote about the care received by Jack Black the Cat.

Just as in human healthcare, nurses for animals are in great demand. Not only are career opportunities available for veterinary technicians to work in general veterinary offices, but specialization in various disciplines such as oncology or anesthesia, participation in biomedical research, enlistment in the military and even working as a technician in zoo and wildlife medicine are also widely available.

Like all professionals, there is a backstory about the day-to-day life of veterinary technicians. If you are considering a career as a veterinary technician or just know someone whose job it is to be a technician, you may be unaware of what a typical day entails. Hopefully this blog will give you a bit of the inside scoop and provide a greater appreciation for the labors of love they each perform every day for our pets.

Fashionistas need not apply

Looking for a job where you look great and wear fabulous clothes? Unless your skin tone becomes more ravishing when you wear scrub-suit green, being a veterinary technician is probably not for you. However, if you like to change clothes frequently, we can accommodate your needs. A shake of the head can send ear drops flying right onto your freshly laundered ensemble or a pooch with a bloody nose can change you plain shirt into a polka dot one!

Adoption options

Seeing cute animals all day, every day brings a smile to every technician’s face, since like veterinarians, they love being around animals. But loving animals occasionally has a darker side. Every animal hospital provides its employees with plenty of options to adopt a new pet: a basket of kittens left on the doorstep or a dog tied to the lamppost, but every family, even those with a member skilled in providing pet care, has a limit to the number of pets they can handle, both emotionally and financially.

Compassionate technicians may run the risk of trying to help too many of the animals in need that they encounter. Reliable resources for helping these animals are at the tip of the fingertips of the best technicians who know or have learned the limits of their care.

Injury report

Like many businesses, The AMC tracks statistics on workplace injuries. No surprises here: topping the list are bites and scratches, followed by back injuries. Fortunately, licks and kisses are not considered injuries, just part of the fun of being a tech.

A heartfelt thanks to all veterinary technicians

During National Veterinary Technician Week 2012, the veterinarians of The AMC would like to recognize our nearly 80 technicians – and every technician nationwide – for their commitment to their profession and the support of ours.

If you are thinking of a career as a veterinary technician, visit http://www.veterinarytechnician.com.

You will find lots of useful information and even job opportunities in your area.

The Compounding Pharmacy Problem: What Pet Owners Should Know

A rare form of human meningitis has recently been in the news. The outbreak, believed to stem from fungal contamination of a medication compounded to treat back pain, has resulted in several fatalities. The manufacturer of the implicated medication is not a big pharma or an overseas company; the medication was produced by a compounding pharmacy in Massachusetts. The Food and Drug administration has identified fungal organisms in a sealed vial of methylprednisone acetate produced by the compounding pharmacy.

Pets not affected

This outbreak is unusual since the fungi involved, aspergillus and exserohilum, live in soil and water. Exactly how they came to contaminate the medication is under intense investigation. Since veterinarians don’t treat back pain in dogs and cats with steroids like methlyprednisone acetate injected around the spinal cord, there are no reports of fungal meningitis in pets, but veterinarians do use compounded medications, and understanding their role in managing disease in your pet is important.

Compounding defined

Compounding is the alteration of the original drug dosage form for the purposes of ease of administration or because the original dosage form is unsuitable for the purpose intended. Translated for the pet owner, compounding is flavoring a medication to hide the bad taste, dissolving pills into a liquid to facilitate administration, or putting multiple medications into one capsule to help a pet owner comply with a multidrug treatment protocol. Without a good compounding pharmacy, my job would be impossible.

Compounding dangers

Compounding is not regulated by the FDA because it is a process initiated by prescription and on a case-by-case basis. In veterinary medicine, compounding rules have been stretched in an attempt to create cheaper medications. Some compounding pharmacies offer expensive medications at unbelievably low prices. I suspect these cheaper products are being produced by what is known as bulk compounding from raw materials. Just last week, I had to advise a pet owner against using the compounding pharmacy’s cheaper “house” brand of an expensive medication. That medication is not currently available as a less expensive generic. Although I am sympathetic to the financial burden of treating a pet with cancer, my overriding concern is for the patient and the efficacy and safety of the prescribed treatments. Prescribing an approved medication provides some assurance of efficacy and safety for my patients.

Medication safety

Listen to your veterinarian. If they believe a particular medication is better, ask why. If they are concerned about the safety and efficacy of a compounded medication, I recommend trying to make the standard formulation work for your pet.

Learn more about safely medicating your pet.

Plan, Prepare and Respond: Disaster Planning for Your Pet

September is Disaster Preparedness Month. Whether it is a hurricane, flood, or fire, disasters affect every member of the family, pets included. To help the furred and feathered members of your family weather a disaster safely, here are The Animal Medical Center’s suggestions for disaster planning.

Plan

Advanced planning is critical. Identify a safe place to take your pets in an emergency. New York City shelters will house animals in the event of emergency, but not all shelters will. Check NOW to see if your local emergency shelter plan includes pets. If not, find a boarding facility that will. Make a list of pet-friendly hotels in your area. Visit PetsWelcome.com for a state-by-state listing.

In case you and your pet are separated, be sure you pet is both microchipped and is wearing a collar with ID tags for quick identification.

Prepare

Create a Pet Go Bag for each pet in your household. The Pet Go Bag should contain information about your pet and necessary supplies. These include: your pet’s medical records and contact information for your veterinarian, proof of identification (including microchip number, photo of you and your pets), food, water, medications – enough for one week, pet first aid kit, leash, muzzle, toys, a sheet to use as bedding or to cover the carrier, towel, litter and pan, trash bags. Keep everything together with your pet’s carrier and consider storing your pet’s medical records in the “cloud” using a service like Microsoft Health Vault.

Respond

Remember first responders’ primary goal is helping people, but keep these following tips in mind once disaster strikes: Take your Pet Go Bag if you and your pet are evacuated. If your pet has sustained injuries administer first aid until veterinary help is available. Bathe your pet as soon as possible to clean wounds. Feed your pet only safe food such as that in your Pet Go Bag. Register your family and your pet as “Safe and Well” using the Red Cross website.

For more information about disaster planning for your pet, go to the Federal Emergency Management Agency website.

Demystifying General Anesthesia, Part I: Preanesthesia Protocols

Except for the dreaded cone, there is no medical procedure more feared by the families of my patients than general anesthesia. Their concern is well founded since there is always a risk of death, but the risk is very small – about 0.1%, meaning 1 in every 1000 procedures, result in an anesthetic death. This data comes from a large study of private clinics in England where routine procedures, such as neutering, were most commonly performed. The risk of death during general anesthesia rises with illness, advanced age and surprisingly, in the British study, mid-sized dogs.

While risk-free anesthesia does not exist, veterinary teams work hard to minimize the risk for every patient undergoing an anesthetic procedure. In November 2011, the American Animal Hospital Association published guidelines for small animal anesthetic procedures. In this blog, I will highlight how the guidelines help to minimize this risk in your pet.

Anesthesia is more than choosing the anesthetic agent; it is a team effort by a highly trained and skilled veterinary medical team. Anesthetic planning, induction, and recovery require multiple steps and multiple team members, beginning with an examination and testing.

Pre-anesthetic evaluation and examination

During this phase, your veterinarian is looking for risk factors – underlying disease or physical abnormalities which will impact the anesthetic procedure. Blood tests are used to identify problems which make anesthesia trickier, such as diabetes or liver disease. An echocardiogram may be recommended if your pet has a heart murmur. Brachycephalic (short nosed) dogs are prone to upper airway problems and are at greater anesthetic risk. The team will need to plan additional monitoring for your flat-faced friend. If the planned procedure carries a high risk of bleeding, a blood type or crossmatch will be ordered to facilitate a blood transfusion. The anesthesia team will also determine if the planned procedure requires only heavy sedation or, because the procedure is a major one, general anesthesia. Whatever your veterinarian’s recommendation, monitoring will be a part of the procedure.

Monitoring protocols and equipment

Immediately prior to the induction of anesthesia, an intravenous catheter is placed in your pet. The intravenous line provides a conduit for administration of fluids and other medications the pet will require. Multiple wires attached to beeping, tweeting boxes will be connected to your pet. These boxes measure blood pressure, blood oxygen levels, and an electrocardiogram before, during, and after anesthesia. An esophageal stethoscope can be inserted into the throat to facilitate constant monitoring of the heart instead of requiring the operating room staff to periodically place a stethoscope on the chest wall. Body temperature, measurement of blood sugar, and other blood parameters help the anesthesia team to determine if respirations are adequate and your pet remains stable.

My next blog will continue discussing anesthetic procedures, starting with premedication, anesthetic agents, and finally the role pet owners play in anesthetic procedures.

Pet Medications: 6 Tips to Keep Pets Safe

All of us want to give the best and safest medications to our pets. Here are my tips to make sure your pet gets the medications he needs.

1. Approved is easy

Some of the work of selecting safe medications for your pet has already been done for you. The United States Food and Drug Administration (FDA) approves medications for use in pets by a similar process used for human drugs. Animal vaccines receive approval from the United States Department of Agriculture and treatments to prevent ectoparasites, also known as flea and tick preventatives, by the Environmental Protection Agency. Approved medications help you ensure you are administering drugs that have met standards for both safety and efficacy.

2. Don’t play veterinarian and give your own medications to your pet.

Certain human medications can be lethal to pets. For example, acetaminophen (a common brand is Tylenol) in cats, ibuprofen (a common brand is Advil) in dogs. The leading phone call to animal poison control experts is about accidental or owner administered human medications.

3. Human pharmacies

Like nearly all veterinarians, I too prescribe human medications for my patients. I do this for convenience when the pet owner is far from The Animal Medical Center or because there is not a veterinary-approved version of the drug. Human medications are most often a solution for dogs over 40 or 50 pounds, since tablet and pill sizes are too big for cats and little dogs. So if it is Saturday night and your veterinarian tells you to come to the clinic to pick up medication, it is because nothing but a doggie drug or kitty capsule will do.

4. Legal drugs

The law requires all veterinarians to prescribe medications only in the context of a valid veterinarian-client-patient relationship. Translated from the legalese, the statement means I have to examine your pet in order to prescribe a medication. This is all about safety –Fluffy’s safety. Although you are sure she has the same skin condition as last year, I need to be sure you are correct in order to prescribe the medication with the best chance of fixing the problem with the least risk of an adverse reaction.

5. Custom compounding

Veterinarians rely on compounding pharmacies to convert pills and tablets into chicken-flavored liquids, to place multiple medications into a single capsule to simplify medicating the pet with bear trap-like jaws, or to scale down a large tablet for a tiny terrier. Regulations govern compounding like they do for any prescription. Prescriptions for compounded medications can only be written on a case-by-case basis and must be made specifically for an individual pet. Compounded medications may mean the difference between therapeutic success and failure, but because compounded products are not regulated, products may be of variable quality as demonstrated in a recent scientific study of compounded trilostane. Using a pharmacy certified by the Pharmacy Compounding Accreditation Board assures you of a compounding pharmacy that adheres to established principles, policies and standards.

6. Internet pharmacies

The challenge in using an internet pharmacy is finding the right one. Although the prices offered by electronic drug stores are attractive, high-quality service may be lacking. Red flags in online reviews include companies who fill email boxes with spam, distribute counterfeit products, or never ship product at all. I spoke with the CEO of PetCare Rx, Jonathan Shapiro, about how his company ensures the quality of medications they ship. “PetCare Rx purchases product directly from the manufacturer or veterinary purchasing groups to protect our customers from counterfeit products. Consumers should look for an internet pharmacy accredited by the Veterinary Verified Internet Pharmacy Practice Sites (Vet-VIPPS). This accreditation ensures the pharmacy complies with regulations and laws governing pharmacy practice.”

The AMC Goes Electronic

AMC staff members work on the new EMR system

This past week was a watershed week at The Animal Medical Center. With the flip of a switch, an electronic medical record (EMR) became a new part of practicing veterinary medicine.

What is an EMR?

The name, electronic medical record, does not do this system complete justice. It is definitely electronic. Consequently, we have computers in every nook and cranny of the hospital attached to three types of new printers – one for collar-style name tags, one for cage cards, and one for blood sample labels. A paper medical record includes notes about examinations, results of blood tests and x-rays, surgery descriptions, and diagnoses. Our EMR includes all those components, but it goes further.

But wait, there’s more

With this new system, I can order x-rays from my 8th floor clinic computer and the radiology team on the 2nd floor knows exactly what I want – faster than we can transport the pet to radiology. Previously, the patient and a paper request were transported to radiology. The same software that records patient information also orders blood tests from the laboratory or pills from the dispensary. For hospitalized patients, all medications administered by the nursing staff are now requested on an electronic whiteboard and recorded with the click of a mouse.

My personal favorite

Each patient has an electronic clipboard and on the top is a handy little box. Once I figured out how to use it, I went back into all my patients’ clipboard records from this week and loaded them up. I can write anything I want in the box. My plan is to use it like an electronic post-it note to remind me when certain infrequently performed tests are due. In Vivian’s box I put the date for her next iron injection, for Cleo the date her urine needs a follow-up culture, and I added the dates of scheduled chest x-rays for several more pets. One of the reasons both physicians and veterinarians are moving to EMRs is to help them become better doctors, and this will definitely help me.

New tools

The EMR allows importing of photograph files, a feature particularly useful for oncologists like me who want to monitor the response of a tumor to treatment. The photographs also help the ER doctors who might not know what the tumor looked like before, but now can click open a JPEG file and see the tumor for themselves. The EMR contains dog and cat diagrams ready for annotation to mark the location of abnormalities found on examination.

Improving the health of all animals

In addition to improving care for individual pets, the EMR will help improve care for all pets by facilitating research. Old style paper medical records cannot be searched for information. Our electronic medical record allows us to search and find all patients with a particular diagnosis or disease. Information gleaned from the records will help us to share information with other veterinarians about successful new treatments. Thus, the EMR will benefit not only AMC patients, but patients everywhere.

Transitioning to any new system is hard work and takes persistence, but with all these benefits, we have entered a new era.

If your veterinarian uses an EMR, some store records in “the cloud” allowing you to view your pet’s medical information anytime. Ask about this feature the next time you visit your veterinarian, as the information could be very valuable during an ER visit.

Zooeyia: The Positive Health Benefits of Animals in our Lives

Did you know a pet can improve your family’s health? Zooeyia (ZOO-ey-ah) is a recently invented word to describe the health benefits of pets.

This new word was coined from the Greek root words for animal (zoion) and health (from the Greek goddess of health, Hygeia). The inventors of the word consider it the opposite of zoonosis, which refers to diseases transmitted from animals to man or vice versa.

We all want our families to be healthy, but just how do pets improve our health and the health of our families?

In his recent book, Spontaneous Happiness, Dr. Andrew Weil includes a chapter entitled “Relate to companion animals,” where he writes about the gift of spontaneous happiness and emotional health that comes from relationships with pets. Two recent news stories have suggested dog ownership improves physical health as well. Dog ownership decreases the risk of developing a cold or asthma, and having a pet in the home results in healthier kids.

But there are other important health issues recently identified by the Institute of Medicine of the National Academies. Here are four of the twelve leading health indicators that pets can contribute to:

1. Pets increase exercise 

American families have become couch potatoes, resulting in an epidemic of obesity and diabetes in both children and adults. One of the goals of the Institute of Medicine is to increase healthy behaviors, such as exercise. Dog owners exercise more than non-dog owners due to the dog’s requirement for exercise, and children in dog-owning families exercise more as well.

2. Pets lessen the impact of chronic disease 

The occurrence of chronic diseases, such as cancer and cardiovascular disease, places a heavy financial and emotional burden on the family. Another of the Institute of Medicine’s goals is to decrease the impact of chronic diseases on the population, including cardiovascular disease and cancer. Cats have been shown to decrease the risk of cardiovascular disease in their owners, and the presence of a pet in the life of a cancer patient has been shown to provide great comfort and support during cancer treatment.

3. Pets promote community 

In our increasingly urbanized society, loneliness and isolation can occur, especially among elderly family members who live alone. Pets also help promote a healthy social environment within their community, not just for their owner, but for all members.

Communities with pets benefit from more civic engagement, neighborliness, and community spirit, contributing to a decreased sense of loneliness within the community.

4. Pets facilitate smoking cessation 

Smoking-related illnesses rob smokers of their health. Family members who do not smoke should be coached not to pick up this habit and those who do should be encouraged to stop. Pets living in a home with a smoker suffer from the effects of secondhand smoke just like children do. If smoking pet owners are made aware of the risks to their pet, research has shown it can motivate some smokers to quit, due to the risks to their pet.

One small furry pet can give your family all these benefits and a good deal of fun and love as well.

Share Your Thoughts: How have your pets benefited your or your family’s health? Share your experiences in the comments section below.

Prebiotic or Probiotic: Good for What Ails You and Your Pet?

Babs is available for adoption in CT (details below)

The yogurt aisle in the grocery store has become intimidating. Although I have my favorites, most of the little cartons now seem to be claiming health benefits beyond providing nutrition. Labels and advertising campaigns extol the benefits of probiotics and prebiotics in our diets. But what are they and how do they help aid in our health? And, could these aids be beneficial to our pets?

To start, pre- and probiotics are classified as functional foods since the food has a function other than a nutritional one.

Prebiotics are food for beneficial bacteria and these compounds are not digested, they are fermented and enhance growth of good bacteria. Prebiotics consist of fiber, which serves as nutrition for the millions of bacteria residents in our (and our pet’s) intestinal tract, promoting the growth of good bacteria, which in turn promotes intestinal health. Reports indicate prebiotics improve colitis symptoms, strengthen the immune system, and prevent colon cancer. Common foods such as whole grains, bananas, onions, garlic, and artichokes are considered prebiotics. Food may also have a prebiotic fiber as an additive.

Probiotics are the good bacteria themselves and they may occur naturally in some foods or be used to fortify others. Probiotic yogurts contain live cultures of good bacteria designed to repopulate the intestinal flora to generally promote digestive health or to be used after a disease or medication has disrupted the normal balance of intestinal bacteria. For example, Bifidobacterium lactis is a component of a very popular yogurt promoted to improve digestive health. Lactobacillus is another common probiotic bacteria.

Prebiotic pets

You may not know it, but your pet may already be receiving prebiotics in your pet’s food as treatment of gastrointestinal upset. At least two pet food companies, Iams and Purina, add prebiotics to both dog and cat foods. Iams uses fructooligosaccharides derived from beet pulp in some of its tummy-friendly foods and Purina adds aleurone derived from wheat.

Probiotic pets

In addition to recommending my patients’ owners visit the yogurt aisle to help combat tummy upset from antibiotic administration, I can also prescribe probiotics specifically designed for pets. One such product contains two probiotic bacteria: Streptococcus thermophilus and Lactobacillus bulgaricus in a tasty powdered form. The other contains a different organism, Bifidobacterium animalis in a chewable tablet. Both have helped to resolve diarrhea in patients of mine.

Veterinary use of probiotics is not limited to just dogs and cats. The intestinal bacteria of Guinea pigs and rabbits are uniquely sensitive to antibiotics. Following antibiotic treatment, overgrowth of a bad bacteria known as Clostridium occurs. The AMC’s exotic pet specialists commonly prescribe a probiotic containing yeast from tropical fruits, Saccharomyces boulardii, to combat this problem.

If you have a pet with recurrent stomach problems, ask your veterinarian about pre- and probiotics.

Babs is available for adoption through Petfinder.

Tips for Using the Internet Wisely: Pet Healthcare

I can spot an internet-savvy client a mile away. They usually have a ream of computer printer paper poking out of their handbag or stuffed in the storage pocket of their cat carrier. If the pet owner has consulted a good website, my job is easy. We can have an informed discussion of their pet’s medical problem and I can build on their self-taught knowledge base. If they visited an inaccurate website, my job becomes more difficult, as I have to undo myths and misconceptions. Since 30-40% of pet owners with a sick pet visit a website before they visit their veterinarian, I have created three guidelines for wise internet use in the pet healthcare field.

1. Use reputable websites.

When I am searching for health information for myself, I go to the websites of well-respected institutions and organizations: National Institutes of Health, Mayo Clinic, or Johns Hopkins University, for example. The same holds true when you search for pet health information – visit websites of well-respected institutions like The American Veterinary Medical Association and the Food and Drug Administration Veterinary Page. Visit the WebMD Healthy Pets Community to see more reputable websites for pet health information.

2. Know the author.

When deciding whether or not to believe the information you find on the internet, check the author’s credentials. Each WebMD Expert has a biography page where you can read about them and learn their areas of expertise. Some websites just list the author as “ACME website staff.” This gives you no opportunity to determine how qualified the author is to write on the particular topic. Recently, I found a website where medical information was being dispensed by a dog walker. While this person is knowledgeable about dogs, I would look elsewhere for information on medical care for my dog.

3. Understand the website’s editorial policy.

Once an article has been written for a website, ask how that article has been “vetted.” You might find that information in the “About Us” section of the website.

I checked with Susan Segrest, executive editor of Vetstreet.com. She says, “For all of our medical content, not only are many pieces written by veterinarians, the articles go through an additional veterinary review. During this stage, veterinarians who are also editors will assess facts and advice and send questions back to writers for more information. They may also discuss the articles with other members of the Vetstreet medical team or request that we send the article on to a veterinary specialist for additional review.”

While you are clicking and printing, keep in mind the internet can only provide information; those of us who write for websites cannot diagnose and treat your pet’s medical condition by bits and bytes, only your veterinarian can do that.

Lost in Translation

Veterinarians request a lot of information from pet owners. We interrogate them: What does his cough sound like? We dictate to them: Give these pills three times a day. And we expect them to understand a foreign language — doctor talk. Mistranslated doctor talk results in communication gaps between veterinarians and pet owners. Here are some examples from last week’s patient visits at The Animal Medical Center.

Barfy is regurgitating twice a day.

This “lost in translation” example comes from the innocent misuse of the word regurgitate. Medically speaking, regurgitate is similar to vomiting, but there is an important difference. When a dog regurgitates, a forceful heave-ho and wretch are missing. The food or liquid comes back up without an increase in abdominal pressure. Picky, I know, but, as a veterinarian, this information is diagnostically critical. Dogs and cats that regurgitate have an esophageal problem, and those that vomit typically have a problem further down the digestive tract. This picky distinction directs my diagnostic evaluation, so I have to get it right or I bark up the wrong diagnostic tree, so to speak.

Is Fluffy urinating more than usual?

This translation gap was my fault. The poor cat owner didn’t know how to answer. Was I asking more in frequency or more in volume? I tried to avoid using doctor talk to ask what was really on my mind; was Fluffy pollakiuric or polyuric, the special words for increased frequency of urination or increased volume of urination. Increased volume of urination suggests diseases like diabetes, kidney failure or a kidney infection. Increased frequency of urination suggests a bladder infection, bladder stones or possibly a bladder tumor. Once again picky, but critical.

My cat, Peter, gets dialysis at home every other day.

This comment was made by a patient new to The AMC and it caught me off guard. The AMC is the only center for dialysis between Boston and Philadelphia and this cat was a local from 89th Street in Manhattan. Dialysis happens in the hospital and not at home. What really happened was the owner had been trained by her regular veterinarian to give fluids subcutaneously to her cat to help combat the effects of failing kidneys. Cats with kidney disease often become dehydrated as their failing kidneys waste water by producing excessive amounts of urine. Supplementing feline fluid intake with subcutaneous fluids keeps cats feeling and eating better because they are not dehydrated. Dialysis, also used to treat failing kidneys, filters the blood through a machine to remove waste product since the kidneys no longer perform this function. Same disease, different treatment.

If you are not sure what your pet’s veterinarian just told you or can’t understand the question you were just asked, don’t hesitate to ask for clarification. Don’t let your pet’s diagnosis get lost in translation.

Salmonella in Pets and Humans

On April 6, 2012, the United States Food and Drug Administration announced a voluntary recall of Diamond Naturals Lamb Meal and Rice dry dog food. Since the initial recall, several other brands of food manufactured in a South Carolina plant have been voluntarily recalled for possible Salmonella contamination. Voluntary recalls of pet food are not uncommon, but this recall is unusual. Illness in humans, not dogs, prompted the recall.

Outbreak investigation

Scientists at the Centers for Disease Control checked the genetic fingerprint of the Salmonella found in the dog food against a national database of foodborne infections and found people infected with an identical bacterium. Because the Salmonella isolated from the dog food and the people is a rare type, the humans were interviewed to determine if there was a common source of infection. These interviews revealed many of the infected people had been exposed to dogs and the brand of dog food included in the initial recall. Subsequent recalls have all involved food manufactured in the same facility.

Why did people get sick?

This medical mystery seemed backwards to me. I could understand if my dog and I both got sick from some food I slipped her at the table, but I would suspect hardly any of us grab a handful of tan nuggets from our dog’s bowl as a quick snack.

So to help me understand, I called my sister, Mary Hohenhaus, MD, FACP, who is also a board certified internist (but for people) with Brigham and Women’s Physicians Organization in Boston.

The other Dr. Hohenhaus says:

Salmonella bacteria are a leading cause of infectious gastroenteritis in humans – more than a million cases in the U.S. each year. Symptoms include diarrhea, cramping, and fever starting anywhere from 12 to 72 hours after exposure.

Catching Salmonella is easy only if the bacteria can find their way into your mouth. I use a scoop to measure out dry food for my cat, but I could just as easily grab a handful of kibble for Sam’s bowl – and if the next thing I did was grab a handful of grapes for my breakfast, I could be in trouble.

Food and water contaminated with animal feces are a common source of Salmonella infection. Outbreaks have been associated with meat, eggs, dairy products, and fresh produce, as well as processed foods. Pet birds and reptiles can carry Salmonella without appearing ill. Feces from infected humans are another source.

Many infections are mild and don’t come to medical attention. Most people get better within a week just with extra fluids and rest. Children, the elderly, and people whose immune systems don’t work well are more likely to have severe cases of Salmonella, where the bacteria enter the bloodstream. These people need intravenous fluids, antibiotics and close monitoring in a hospital.

This current outbreak is a good reminder that Salmonella can show up in some surprising and unexpected places. It also reminds us that contaminated foods look, smell, and taste perfectly normal. The best protection against Salmonella and many other infections is common sense: keep your hands clean (and out of your mouth) and practice food safety.

When should you wash? After using the toilet, before preparing food, and any time your hands are visibly soiled are a must. Don’t forget to wash after playing with pets, not just after poop-scooping. A pocket-sized bottle of hand sanitizer is a great addition to your daily walk with Fido.

In the kitchen, wash utensils and work surfaces thoroughly after handling raw meat and eggs and before preparing produce – especially important if fruits and vegetables will be served raw. Thoroughly cook meat and eggs, and be sure to serve hot foods hot and cold foods cold. For more information click here.

This Dr. Hohenhaus is worried about dogs

Although the Salmonella cases making the news are human, dogs can also contract Salmonella after eating tainted food. Veterinarians in New York City are required to report certain diseases to the Department of Health and Mental Hygiene just like physicians are. We report zoonotic diseases, diseases transmitted between animal and humans, which include: Salmonellosis, tuberculosis, Rocky Mountain spotted fever, and leptospirosis.

I contacted one of my colleagues at the New York City Department of Health and Mental Hygiene, Dr. Sally Slavinski, Assistant Director Zoonotic, Influenza and Vector-borne Disease Unit, and she says no canine cases associated with this recall have been reported to the DHMH. I do have veterinary colleagues out of state who have seen a smattering of dogs they believe contracted Salmonellosis from the recalled foods.

Prevention in pets

For tips on preventing foodborne infections in your pets, click here.

Healthy Pets Make Happy Homes: National Pet Week 2012

May 6-12, 2012 is National Pet Week and the theme chosen by the Auxiliary to the American Veterinary Medical Association is “Healthy Pets Make Happy Homes.”

Each year the Auxiliary sponsors a poster contest around the year’s theme. This year’s winner, Stephanie Jensen, depicts a whimsical home filled with children and happy family pets. While the painting is charming and deserving of accolades, the scene made me think hard about pets and families.

Just the right number of pets makes a happy home

Ms. Jensen’s painting shows a home containing every imaginable pet, but when adding pets to your family, each addition requires careful consideration. For those of us who love pets, it is difficult to resist adding another foundling to our brood. But if we continually increase our home’s pet population, at some point, the number of pets we have will exceed the resources we have to care for them. By resources I am not talking just about financial resources, but space, time, and energy as well. My current feline foster family of seven makes me very happy every morning when I peek in and see all those little cats snoozing in their fur bed. Since the family will be adopted once the kittens are self-sufficient, I can handle caring for seven cats for several weeks, but I could not do this on a forever basis and still work full time!

Children and pets, happy together

In addition to showing many different pets, Ms. Jensen’s painting shows children and their pets. The benefits of pets for children were recently the topic of a New York Times blog by pediatrician Perri Klass.

As a pediatrician, she reports commonly asked questions about children and pets, because of the widely held belief that pets are good for children’s social and emotional health. She also says that, until now, there has been little good scientific research on the benefits of pets for children. Some recent studies suggest a variety of positive outcomes associated with children and pets:

• Young children living in a household with a dog may be less likely to become overweight.
• Animal assisted therapy has a positive influence on children’s development.
• Animal assisted therapy alleviates acute pain in children.

Pets can also pose health risks to young children, and parents should take steps to protect their children from pet-related illness, especially bites.

Keep your pet healthy and keep your home happy

The pets depicted in Ms. Jensen’s painting look very healthy. To keep your pet healthy and your home happy, provide your cat and dog with a good preventive healthcare program and visit their veterinarian annually.

How do you keep your family and pets happy and healthy? Share your stories in the comments section below.

Photo: Stockbyte

Your Child and the Loss of a Pet: Answers to Tough Questions

In my last blog I wrote about children and pet loss based on a presentation given at The Animal Medical Center by Dr. David Schonfeld, a developmental-behavioral pediatrician. I recently posed some frequently asked questions about pet loss to him; here’s what he had to say.

Q: I just found out our 15-year-old family cat has a serious medical problem. What should I tell my children?

Begin by telling your children that your cat has a serious illness. In simple terms, appropriate to the children’s developmental level(s), help them understand what is wrong with the cat’s health (e.g., the heart is weak and may not be able to beat for much longer; the cat’s kidney isn’t working, which means he can’t make urine like he needs to in order to keep from getting very sick, etc.). Explain that you are doing what you can to take care of the cat and keep it comfortable, but unfortunately, the veterinarian does not feel she will be able to cure the illness; you are concerned that the cat may die from the sickness.

Remember, very young children have a short time perspective – dying “soon” may mean some time that day. If the illness is such that it will likely limit the lifespan of the cat, but death is not likely to occur within days, weeks, or even months, it’s probably better to say that the cat is seriously ill and may not be able to get over the illness (without suggesting it will likely die from the illness, unless the child asks a question about whether death is possible from the illness).

Some additional points to keep in mind: Children may worry that the illness can spread to them or others in the family – you may wish to reassure them that it isn’t contagious. Children often worry that they did, didn’t do, or should have done something to prevent the illness – explain that there is nothing they did to cause the illness and nothing that they or anyone else can do now to make it get better. They can, though, help to keep the cat comfortable. Share with your children how this news makes you feel (e.g., sad, worried about the cat, etc.) and what you are doing to help cope with those feelings. Once you have provided this information, stop and let your children ask additional questions and react to the information. Take your lead from your children about how to continue the conversation.

Q: Some parents want to replace a dead pet without telling their child the old one has died by substituting a similar pet without the child’s knowledge. Why is this problematic?

Children begin to understand death at a very young age – well before most parents think they do. Replacing a pet without acknowledging the pet’s death may suggest to children that you don’t think they can handle the reality or you are not able or willing to address difficult or sensitive topics with them. Certainly, that’s not a good message for children to hear from their parents. Some children may also become insulted because it suggests that you think their personal connection with their pet was so meaningless that it doesn’t even warrant acknowledgement. If you try to replace a pet too early, children may reject the new pet. They miss their pet – the one they knew and loved. They don’t just miss having any pet. Allow them to experience and express their grief and help them learn how to cope with the distress – it’s unfortunately not going to be the last time in their lives they experience loss or disappointment. But it may be one of the first times you can help them learn the skills to cope with such loss (thereby making them more resilient when faced with loss in the future) and it helps them see you as someone who is there for them when they really need you most. After all, that’s what makes parents really special in children’s lives.

Q: Our family dog died last week and my child seems very sad and is not talking very much about anything. What can I do to help?

Parents should explain what’s happened and what it means and invite children to ask questions and share their feelings. Model sharing some of your feelings and techniques that you have used to cope (e.g., talking with a family member or friend, remembering happy times you spent with the pet when it was alive, looking at pictures, etc.). But as with all invitations, you need to wait for children to accept – you shouldn’t try to force children to speak before they feel ready. Be physically and emotionally present and periodically inquire how the children are doing and make references to the pet in casual conversation. Children will take the opportunity to talk when they are ready, or they may express their thoughts indirectly through play, writing, or in other ways.

For parents coping with a death in the family, either of a pet or a human family member, a free guide (available in English, Spanish, Japanese and Chinese) is available for parents on how to support a grieving child and includes more discussion on how to explain death to a young children – it can be downloaded or you may order free, printed copies.

Photo: iStockphoto