TOPICS IN MEDICINE AND SURGERY

CRITICAL CARE NUTRITION FOR EXOTIC ANIMALS

Susan E. Orosz, PhD, DVM, Dip. ABVP (Avian), Dip. ECZM (Avian)

Abstract
Exotic animals presented to the veterinary hospital are often malnourished, particularly when ill.
Sufficient levels of energy and protein need to be provided for debilitated patients along with important
amino acids and vitamin supplementation. For raptor species, a clinical condition described as refeeding
syndrome also complicates medical and surgical success. It is important to understand malnutrition and
nutritional support to improve treatment outcome of weakened exotic animal patients that are presented
to veterinary hospitals. Many of the critical care principles described in this article are derived from
mammalian studies. Copyright 2013 Elsevier Inc. All rights reserved.
Key words: birds; exotic animals; malnutrition; nutritional assessment; parenteral nutrition; reptiles

M
alnutrition may be defined as any disorder with inadequate or unbalanced nutrition
associated with either nutritional deficiencies or nutritional excesses. These alterations
from normal lead to a nutritional deficit associated with an increased risk of adverse
clinical events, such as morbidity or death.1,2 Hospitalized exotic patients are often
malnourished from an initial imbalance of nutrients followed by decreased food
intake. Malnutrition has been treated clinically in hospitalized human and animal patients through both
enteral nutrition (EN) and total parenteral nutrition (TPN). A review of clinical trials, in human patients,
examined a number of factors comparing EN and TPN administration. The researchers concluded that EN
was associated with lower costs, improved nutritional outcomes, less mucosal permeability, and greater
wound healing.2 There also appeared to be a decrease in septic morbidity of patients that presented with
abdominal trauma but were enterally fed.

Review of these clinical trials led to several
important recommendations. Abdominal trauma
patients benefited from EN preferentially over
TPN. EN was the preferred method of supplying
the metabolic needs for all critically ill patient
types examined, except for head-injured patients.
In those patients, either TPN or EN was acceptable,
depending on the mental status of the patient. This
use of EN has led to a paradigm shift in human
intensive care units. Now nutritional therapy and,
in particular, EN is a primary component of the
therapeutic strategy for human intensive care unit
patients as it is capable of favorably altering the
patient’s recovery.3 The reason for this increased
success of EN is due to the fact that malnutrition
leads to a decrease in immunocompetence,
decreased tissue synthesis and repair, and altered
drug metabolism.
Although the relationship between poor
nutritional status and increased susceptibility to
disease has been clinically recognized for some
time, mechanisms that modulate the immune
system have been poorly understood, particularly
with veterinary patients. For example, impaired
immune surveillance has been proposed for the
increased incidence of cancer observed in
mammalian patients with micronutrient
deficiencies. Although research in the past has
focused on micronutrient deficiencies and their
role in an altered immune system, newer studies
are investigating the use of supraphysiologic levels
of micronutrients as immune modulators.
One area that has been investigated is the role of
energy in critically ill patients. These patients most
often have a decreased energy intake. However,
adequate levels are needed to provide the energy

From the Bird and Exotic Pet Wellness Center, Toledo, OH USA
Address correspondence to: Susan E. Orosz, PhD, DVM, Dip. ABVP (Avian), Dip. ECZM (Avian), Bird and Exotic Pet Wellness Center,
5166 Monroe Street, Suite 305, Toledo, OH 43623. E-mail: DrSusanOrosz@aol.com.
Ó 2013 Elsevier Inc. All rights reserved.
1557-5063/13/2101-$30.00
http://dx.doi.org/10.1053/j.jepm.2013.05.007

Journal of Exotic Pet Medicine 22 (2013), pp 163–177 1 6 3

 required for the patient that is often in a
hypermetabolic state. If sufficient energy is not
provided, the animal, whether it is a bird, reptile,
or mammal, undergoes gluconeogenesis and uses
up its dwindling protein mass to meet its
metabolic demands. Therefore, the clinician needs
to provide sufficient energy along with protein that
is balanced to meet the demands of malnutrition
and surgery for their malnourished patients.
Malnutrition commonly occurs in hospitalized
patients in part from altered metabolism as a
consequence of disease or surgery. There is a
variety of reasons a patient may present
malnourished, including decreased food intake
and/or a reduced ability to digest, absorb, or
metabolize nutrients. There are also a number of
disorders that may increase the risk of
malnutrition—those that alter the loss of protein
and electrolytes and those that alter nutrient
requirements. The first group (alteration of protein
and electrolyte loss) includes vomiting, draining
wounds, burns, ileus, diarrhea, abscesses, and
malassimilation. The second group (alteration of
nutrient requirements) includes trauma, blood
loss, liver disease, sepsis, drug-nutrient
interactions, burns, multiple surgical procedures,
chronic renal diseases, fever, and cancer.4
EN, when provided as soon as possible for the
malnourished patient, has a positive benefit for all
exotic animal patients. In a research investigation
where rats were studied, the loss in total body
water was less in the early-fed group compared
with the delayed group.5 This change in patient
management reduced catabolism and whereas
increased the rate of wound healing, reducing
recovery times of surgical patients and those with
traumatic injuries.
IMMUNOCOMPETENCE ______________________
It has long been known that there is a reciprocal
relationship between immunity and nutrition.
Nutrient deficiencies or imbalances suppress
immune function, and that in turn makes the
exotic animal patient more susceptible to
infections. Septic patients are typically anorexic,
which results in malnutrition, whereas certain
diseases alter some nutrient requirements.6
Decreased protein-calorie intake is the most
common case of secondary immunodeficiency in
people and can cause progressively poorer
responses of the immune system, including cell-
mediated responses, secretory IgA production,
phagocytosis, complement function, antibody
affinity, and cytokine production.7 In animal
1 6 4 Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
studies, there are reduced numbers of circulating T
lymphocytes, helper cells, and suppressor cells in
those patients that have protein deficiencies that
limit amino acids and nucleotide substrates
needed for cell proliferation.8
Malnutrition also decreases immune function of
existing cells as it affects complement secretion,
reduces kill capabilities of macrophages, and
decreases killer cell activity.9 However, the
numbers of T4 helper cells and T8 cytotoxic
suppressor cells in malnourished humans return to
normal quickly with nutritional supplementation.
The same occurs with immunoglobulins and
circulating antibodies as they transcend from
relatively low levels to normal ones with refeeding-
appropriate stimuli. In healthy beagles, a group fed
a monomeric diet immediately after surgery were
compared with a separate group of similar animals
administered an electrolyte solution. Beagles that
were fed the diet had twice the concentration of
globulins in 24 hours when compared with those
administered only the electrolyte solution.10 When
cats were fed only 25% of their resting energy
requirement (RER) for 7 days, they had a
significant decrease in their white blood cells,
lymphocytes, and monocytes, major
histocompatability complex class II expression,
phagocytic activity, lymphocyte proliferative
capacity, and delayed hypersensitivity response by
day 4 of this 7-day regimen. These significant
problems for the immune system outlined earlier
were reversed in these cats when fed their RER for 4
days. These data are just a sample of the evidence
that the immune system depends on and is
responsive to adequate nutrition. Nowhere is
adequate nutrition as important in veterinary
medicine as it is in exotic animal medicine. This is
due to the limited knowledge base of balanced
daily nutritional requirements for each species that
belong to large/diverse animal groups along with
the poor husbandry practices provided by many
owners. Adequate and balanced nutrition often is
the exception in these diverse species, which then
complicates treatment.
TISSUE SYNTHESIS AND REPAIR _____________
Appropriate nutrition is necessary for tissue
synthesis and wound healing whether those
wounds result from surgery, trauma, or infection.
The basic physiologic materials and collagen
essential for healing require adequate amounts of
amino acids and carbohydrates. Fibroblasts need
energy for the production of adenosine
triphosphate, deoxyribonucleic acid (DNA), and
ribonucleic acid (RNA) to synthesize the proteins
necessary for a number of repair activities.
Migration of these fibroblasts and epithelial and
endothelial cells also requires energy and protein.
In rats, there was a 91% increase in protein
synthesis with a corresponding 10% increase in
protein degradation with trauma.11 But in humans
who were fasted perioperatively, there was a 50%
increase in protein synthesis with a substantial
79% increase in protein degradation.12 These data
indicate that perioperative fasting should be very
limited, and that feeding the patient
postoperatively as soon as possible reduces
untoward effects and expedites patient healing.
DRUG METABOLISM _________________________
One common overlooked consequence of
malnutrition is altered drug metabolism. All
nutrients are essential to maintaining normal
cellular structure and function. Nutrient
deprivation alters the normal metabolic synergy
required for ion gradients, membrane potentials
and antioxidant defenses, and production of high-
energy phosphate compounds. Lipid supplements
are necessary for support of the cytochrome P-450
concentration and activity, and that significantly
affects drug metabolism. Protein-calorie
deficiencies may result in decreased hepatic
biotransformation of certain antibiotics and
antifungal drugs, decreased concentrations of
serum proteins that bind and transport drugs
through the body, and decreased renal blood flow,
which decreases drug elimination and elevates the
possibility of a drug overdose.13 Moreover, the
therapeutic effect may be altered even when given
at recommended dosages.
For that reason, the astute clinician monitors the
response to therapeutics and tries to provide
adequate protein and calories to reduce this
significantly important problem. With inadequate
nutritional support, there is a loss of mucosal
weight of the intestinal tract and this may lead to
inadequate absorption of oral therapeutic agents.
Diseased and debilitated patients require adequate
daily protein-calorie and other nutrients to
overcome immune and organ dysfunction to
provide tissue synthesis and repair for proper drug
metabolism.
STARVATION AND ILLNESS __________________
To comprehend the nutritional requirements of
animals during a metabolic crisis, it is important to
understand basic principles of energy metabolism.
The energy content of food is usually determined
Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
by a bomb calorimeter with the calculation for the
amount of energy in kcal/g of carbohydrates being
similar to that of protein. This is due to the fact
that protein is degraded in order for the dipeptides
and tripeptides and isoamino acids for
assimilation by the gut for absorption. When that
energy of assimilation (4.6 kJ/g) is subtracted from
the amount of energy produced by the bomb
calorimeter (22.59 kJ/g), then the energy provided
by protein (17.99 kJ/kg) is similar to that of
carbohydrates (17.15 kJ/g). However, fat yields
twice as much energy (38.91 kJ/g) as carbohydrates
and protein.14 For example, the energy of dry seeds
contains 6 times the energy content of fresh fruit in
the avian diet.
Although the values discussed earlier represent
the gross energy content of the building blocks of
food, digestible energy represents the energy of the
food that is absorbed from the gastrointestinal
(GI) tract. A small portion of the digestible energy
is excreted by the kidney along with the breakdown
of protein and other nitrogenous wastes as uric
acid in birds and reptiles and ammonia in
mammals. The energy within the products excreted
in the urine and feces is the excretory energy. The
energy retained in the body is the metabolizable
energy. When food stuffs are absorbed by the GI
tract, this causes an increase in the metabolic rate.
This calorigenic effect is the specific dynamic
action. The difference between the specific dynamic
action and the metabolizable energy is the
available energy for use by the animal. Associated
with this energy difference is the energy expended
to digest and transport nutrients across the
intestinal tract. Nutrients that are short chain or
elemental require less energy for this process than
complex or long chain nutrients. Consequently,
diets that are more elemental provide quicker
nutritional replenishment and have a greater
ability to improve those animals that are
malnourished.
The body temperature drops and metabolic rate
decreases when animals are deprived of food.
Glycogen reserves are usually depleted within 24
hours of a fast and gluconeogenesis begins within
several days. Gluconeogenesis is the metabolism of
protein for glucose to supply needed energy during
starvation or with increased metabolic demands
brought on by disease. Once glycogen stores are
exhausted, fat is preferentially metabolized as the
primary source for energy. Liver and muscle incur
the greatest losses in weight, after adipose tissue,
when the patient is not eating. Muscle mass, also
considered as a gauge to overall body condition, is
determined by palpation of the pectoral muscles in
1 6 5
 flighted birds and the epaxial and limb
musculature of mammals and reptiles.
Understanding that glycogenolysis occurs rapidly
and that the liver mass is quickly lost allows the
clinician to predict and treat liver failure more
effectively in patients with concurrent cachexia.
Simple starvation differs from critical illness by
various means.4,15 During starvation, the patient
attempts to maintain the normal blood glucose
level by increasing hepatic glycogenolysis,
increasing gluconeogenesis, and decreasing
glycogen stores. To maintain normal blood glucose
level, the animal decreases its insulin concentration
in the blood while increasing glucagon. In
omnivores, blood glucose level is maintained
through glycogenolysis and gluconeogenesis for
approximately 12 to 28 hours. At that time, the
liver is the net exporter of glucose in an attempt to
maintain the blood glucose at near-normal
levels.16 In omnivorous species, when the liver is
depleted of glucose, it switches to the production
of ketone bodies as its major energy source.
Ketone bodies are the oxidation products of long
chain fatty acids that are formed from trigylcerides.
Ketone bodies have an advantage over fatty acids as
they are water soluble; therefore, they can have a
wide distribution in the body and are able to
diffuse, with no active transport processes, into
cells to be used as an energy source. This has
important ramifications when the body is in severe
energy and protein loss. Conversely, fatty acids are
water insoluble and must be transported by
albumen in the blood stream. As lipolysis
increases, there is an increase in ketone bodies in
the blood stream that results in a mild acidosis.4,17
This is in contrast to carnivorous species that rely
solely on gluconeogenesis owing to their reduced
glycogen reserves relative to omnivores. The
decreased glycogen reserves in carnivores are due,
in part, to lower levels of glycogen synthase and
glucokinase concentrations.
Adipose tissue supplies glycerol for production
of glucose and fatty acids as a source of energy.
Once the hepatic glycogen stores are depleted,
amino acids become the energy source for
glucogenesis.4 Muscle catabolism releases
glucogenic amino acids, pyruvate, and lactic acid
for energy production in the liver. Amino acids are
obtained from the breakdown of skeletal muscle
proteins and visceral proteins.4,18 Eventually, the
liver uses immunoglobulins and lymphokines as a
protein source for energy, complicating immune
function. With the reduction of an animal’s
metabolic rate in simple starvation, there is a
1 6 6 Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
decreased conversion of T4 to T3 resulting in a
decrease in oxygen consumption.17
Another difference between critical illness and
simple starvation is that critically ill patients are in
a hypermetabolic state, due to local tissue injury or
changes in homeostasis.4 Therefore, patients
quickly become hypoglycemic and acidemic as a
consequence of neuroendocrine activity.4,15
Activation of the neuroendocrine system by critical
illness stimulates the sympathetic nervous system.
The level of neuroendocrine system activation is
associated with the degree of patient stress.18 The
activation of the neuroendocrine system causes
increasing levels of glucagon and cortisol in
mammals and presumably corticosterone in avian
species and reptiles. This can result in a rapid
depletion of nitrogen and potassium, complicating
healing and recovery from illness. The increased
adrenal steroids results in glucose intolerance in
tissues, despite hyperinsulinemia.4
This increased metabolic rate associated with
critical illness has been estimated to be between
15% and 30% with long bone fractures, up to 50%
with multiple injuries, and 100% with severe burns
in humans.4,15 Determining the metabolic energy
requirements have been based largely on clinical
impressions. However, scientific investigations
have looked at various components of
inflammation, such as interleukin-1 and tumor
necrosis factor, as more accurate predictors of
metabolic needs.
Clinically ill patients are often anorexic owing to
their disease process. Although these animals have
a decreased dependence on glucose for fuel with an
increased need for lipolysis as with simple
starvation, they have increased energy
requirements.19 This condition results in an
increased dependence on proteolysis compared
with those patients that are simply starved. The
response of the body to the critically ill state has
been divided into 2 phases—the acute phase
followed by an adaptive phase. The intensity and
duration of these phases is dependent on the
severity of the patient’s overall physical condition.
In general, the duration of the body response
phases is shorter with trauma or surgery compared
with infection.
Sepsis further complicates metabolic needs.
Oxygen consumption, cardiac index, and
metabolic rates increase in septic patients beyond
that of nonseptic patients. Septic patients also have
a tendency to utilize fat as the primary source of
energy. Sepsis in critically ill patients increases the
risk of multiple organ failure.1
 The acute phase of the diseased state is
characterized by catabolism and in mammals is
considered to last, on average, from 24 to 72
hours. During this phase, glucose is the preferred
fuel whereas muscles are insulin resistant. The
resultant hyperglycemia is maintained for net
immune and hepatic tissue anabolism. This is
important in order for underperfused tissues or
organs to have a source of energy. Membrane-
independent glucose can provide an efficient
energy source. During this hypermetabolic state,
there is an increased energy need while there is
decreased consumption of energy, which results in
a net negative energy balance. This is when there is
catabolism of protein and fat stores in an attempt
by the body to meet its increased energy demand.
This catabolic phase continues until the
neuroendocrine stimuli and cytokine mediators
are removed.20
Lean tissue and body weight are lost rapidly
during severe head trauma, multiple traumas, and
sepsis; conditions that are commonly observed in
companion exotic animals. The goal of the
clinician when patients present with these disease
conditions is to feed the catabolism with
exogenous sources—presumably by EN of
predominantly protein and fat. With the loss of
about 25% to 30% of the body protein stores,
there is a reduction of heart muscle mass and
function with secondary decreases in pulmonary
function and compromised immune function and
a subsequent increase in mortality.20
Clinicians often note a subjective definitive
turning point in their patients for the better,
which is associated with onset of the adaptive
phase. The adaptive phase is characterized by net
anabolism where there is an increased metabolic
rate with nitrogen gain and normal body
temperature. The adaptive phase is associated
with the rebuilding of damaged tissue, which
requires exogenous protein and energy sources.
Studies have shown that the respiratory quotient
in postoperative or severely traumatized dogs uses
fat as the preferred energy source and dietary
protein for anabolic processes.21 Therefore, the
clinician needs to provide fat and protein for the
patient during the adaptive phase. Dietary
carbohydrates need to be minimized in these
enteral refeeding formulas during the acute and
the catabolic phases of the diseased state.
Increased carbohydrate fractions may lead to
electrolyte disturbances and hyperglycemia. This
rarely happens in omnivores but is more likely in
carnivores.19 Continued assessment of the patient
is required to meet the energy demands of the
Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
critically ill individual if they are in the
adapative phase.
REFEEDING SYNDROME _____________________
One of the most important complicating factors in
managing malnourished human patients is the
refeeding syndrome, which has been described in
raptors. However, this syndrome may be a
problem experienced in a variety of our veterinary
patients and is important to consider. Refeeding
syndrome occurs when previously malnourished
mammalian patients are initially provided
nutritional supplementation; the result is a rapid
fall in phosphate, magnesium, and potassium,
along with an increasing extracellular fluid volume,
leading to a variety of complications. The
complications include generalized muscle
weakness, tetany, myocardial dysfunction,
dysrhythmias, seizures, sodium and water
retention, and hemolytic anemia, leading to death
from cardiac or respiratory failure. Patients who are
malnourished develop a total body depletion of
phosphorous, whereas serum phosphorous levels
are maintained by redistribution from the
intracellular space. Although this definition defines
refeeding syndrome in humans, it is presumed to
occur in raptors as well, presumably because both
are meat eaters and insulin responds in a similar
manner in both.14
It is thought that the adverse physiologic effects
occur from initially refeeding the malnourished
patient carbohydrates. The delivery of glucose,
either enterally or parenterally as part of a feeding
strategy, results in increased circulating insulin
levels. This leads to a rapid uptake of glucose,
potassium, phosphate, and magnesium into the
cells resulting in a rapid reduction of these
electrolytes in the plasma. In addition, for an
unexplained reason, the body swiftly begins to
retain fluid, and the extracellular space expands.
The retention of fluids places an increased
workload on the heart. In humans, there is a
concomitant demand in the respiratory quotient,
as there is an increase in the O2 consumed and the
CO2 utilized. Most likely, raptors experience the
same metabolic anomalies. However, it is unclear
if malnourished frugivores undergo the same
problems.
Therefore, there are a number of
recommendations that can be followed to avoid
complications associated with the refeeding
syndrome. It is important to anticipate the
problem and refeed with formulations that contain
adequate levels of potassium, phosphate, and
1 6 7
 magnesium with lowered digestible carbohydrates
to all of the companion exotic species. Initial
refeeding rates should not exceed the patient’s
RERs; however, these can be very difficult to
determine in the common companion exotic
species. For example, there should be 5.5 to 7.5 g
protein/100 kcal in enteral nutritional
supplementation administered to critically ill dogs
and cats to meet their protein requirements. These
rates are increased slowly over subsequent days to
bring the patient into the anabolic phase. It is
recommended, in dogs and cats, to monitor serum
potassium, phosphate, and magnesium levels on a
daily basis. Although magnesium is difficult to
clinically monitor, and the blood supply of many
of the smaller patients is limited, electrolytes and
their balance need to be assessed if possible. Water-
soluble vitamins should be supplied, especially
thiamine, to facilitate energy metabolism. Patients
should be monitored daily for signs of fluid
overload and congestive heart failure. This is also
difficult in some of the companion exotic species
but clinicians should be closely monitoring their
patients for these untoward effects.
NUTRITIONAL FACTORS _____________________
Fluid and Electrolyte Therapy
The initial support of the critically ill patient
requires the management of fluid and electrolyte
imbalances and, if possible, acid-base disorders.
The water requirements in milliliters for normal
healthy animals has been approximated as equal to
their daily energy requirement (DER) in
kilocalories; for mammals 1 kcal (4.184 kJ) DER ¼
1 mL of water.19 Daily maintenance fluid
requirements in dogs and cats are approximated as
60 mL/kg/d. In a colony of blue-fronted Amazon
parrots (Amazona sp.), daily water needs were
approximately 100 mL/kg/d (unpublished data,
S. E. O., 1999). Each patient should be relatively
hydrated with a physiologic electrolyte balance, as
close to normal parameters as possible, prior to the
initiation of EN. Blood glucose levels and osmotic
imbalances are also a concern and should be
addressed. Although larger mammals (e.g., dogs
and cats) can withstand longer periods of delay
regarding enteral therapy, smaller exotic patients
cannot. Even in dogs and cats, the goal is to initiate
nutritional support within 24 hours of
hospitalization.
Osmolarity. Osmolarity is defined as the number of
solute particles per liter of solution. In dogs, serum
osmolarity 4310 mOsm/L and in cats a value
1 6 8 Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
4330 mOsm/L is considered hyperosmolar.22
Osmolality of the enteral formula affects GI
function and stool character. In enteral formulas,
the digestibility reflects the ability of the food to be
tolerated by the GI tract. As digestibility increases,
the osmolality decreases allowing for greater
absorption of nutrients. The decrease in osmolality
decreases the draw of water into the GI tract, further
complicating osmolality and hydration resulting in
potential shock to patient.
Energy. The primary problem for a clinician,
prior to initiating enteral nutritional
supplementation, is estimating the caloric needs
of the patient to match its energy requirements.
The proportion of fat and carbohydrates required
to meet those energy needs must be taken into
account for that particular patient based on its
underlying disease condition and physiologic
abnormalities. Improper calculations may result
in overfeeding, causing life-threatening
metabolic complications to a critically ill patient.
In humans, excessive carbohydrate feeding
results in hyperglycemia, hypercarbia, fatty liver,
and failure to wean from a ventilator.23
Overfeeding may also contribute to refeeding
syndrome. Moreover, excessive fat
administration may result in hyperlipidemia,
hypoxia, increased rate of infection, and higher
postoperative mortality.24 It has been suggested
that the proportion of fat and carbohydrates
supplying calories should be similar to estimates
used by the liver from body stores. At the
beginning of enteral nutritional
supplementation mammals tolerate the volume
of food to meet their RER at volumes of 1 kcal/
mL. This guide can also likely be used for exotic
species too. Chitty25 suggests that reptiles need
hypotonic formulas initially, but if hydration
precedes enteral feeding this may not be
necessary. Most enteral diets are adjusted so that
the energy density of the food used to address the
patient’s energy needs corresponds to their water
requirement. Usually the energy density is
adjusted to 1 to 2 kcal/mL.
Another concern has been calculating and
adjusting protein calories. The conservative
approach is to meet the energy demand with fats
and carbohydrates—depending on the animal type
—while addressing the protein requirement with
easily absorbed dipeptide and tripeptide amino
acids. This allows the protein components to be
used for protein needs, not as an energy source, as
complex proteins would need to be simplified
using the limited energy reserves of the ill patient.
Protein Requirements
For the presurgical or malnourished patient, one
must first provide adequate levels of protein that
contain a balance of amino acids; thereby,
reducing the possibility of gluconeogenesis
associated with malnutrition and/or an increase
in postoperative metabolic demands. Proteins are
degraded to amino acids. The amino acids that are
deaminated to a ketoanalog can then be
converted to glucose or fat, whereas the amino
group can move through the urea cycle in the liver
to make uric acid in birds and reptiles or
converted to a nitrogenous product for excretion
in the urine. The amount of protein that supplies
the RER is about 15% in a mammalian patient.
The RER in mammals is obtained through the
oxidation of glucogenic amino acids, as described
earlier.
Although one should avoid excess dietary
protein in patients with liver or renal failure, birds
can tolerate high levels of protein.26 High dietary
protein intake by critically ill dogs and cats is well
tolerated as opposed to a nutritional
supplementation that contains elevated dietary
carbohydrates.19 Feeding excess protein requires
energy expenditures to rid the body of this
oversupplemented nutrient and has been
associated with encephalopathy in mammals.
However, insufficient protein is associated with
low albumen levels, poor wound healing, poor
immune response, and muscle wasting.27
Additionally, there are specific nutrients that are
important for immunocompetence as they act
directly on the lymphoid system and immune cell
function. Arginine, glutamine, and foods that are
enriched with nucleotides have been shown to
significantly reduce the time needed for wound
healing and the length of hospital stay in human
burn patients.19
Arginine. Pharmacologic doses of arginine have
been shown to promote wound healing at least by
increasing the accumulation of hydroxyproline.28
Arginine may be used as a precursor for proline in
the formation of collagen. Additionally, arginine
has been found to be immune stimulating by
preventing thymic atrophy and by increasing the
responsiveness of peripheral blood monocytes to
T-cell mitogens.29 There are a number of benefits
and functions of arginine. It is a precursor to nitric
oxide, which is required to kill microorganisms
after phagocytosis. Arginine has been shown to
stimulate the release of growth hormone, improve
immune function, reduce healing time of injuries
Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
(particularly bone), and reduce the time for the
repair of damaged tissue. In postsurgical patients,
arginine supplementation has been shown to
enhance T lymphocyte response and augment
T-helper cell function in postoperative human
patients.30 Similar findings have been observed in
animal studies as there has been improved
nitrogen retention and wound healing.19
Animal sources of arginine include dairy
products, beef, pork, poultry, and seafood.
Vegetable sources include oatmeal, nuts (e.g.,
coconut, pecans, cashews, walnuts, almonds, Brazil
nuts, hazelnuts, pine nuts, and peanuts), seeds
(e.g., pumpkin, sesame, and sunflower), chick
peas, and cooked soybeans.
Glutamine. Glutamine is an amino acid that is
involved in many cellular processes. Studies in
humans have shown that following injury or in
those patients that are catabolic, there is a
precipitous drop in glutamine levels in red blood
cells and skeletal muscles. This suggests that
glutamine is conditionally an essential amino acid
during serious injury or catabolic states.31 In brain-
injured patients, the addition of glutamine and
probiotics to their enteral formula decreased
infection rates and days required for ventilation.
Data indicated that these patients had increased
energy and protein demands and showed
improvement after glutamine supplementation.32
Glutamine is mobilized from muscle cells to
provide the preferred energy source for
lymphocytes, hepatocytes, and intestinal mucosal
cells.33 Based on research results, the postoperative
diet of patients should contain increased levels of
glutamine.
Dietary sources of L-glutamine include beef,
chicken, fish, eggs, milk, dairy products, wheat,
cabbage, beets, beans, spinach, and parsley. Enteral
formulas designed for critical care nutrition should
have increased levels of glutamine to meet an
animal’s amino acid needs.
Fats
Optimally, the bulk of a critically ill patient’s
caloric requirement should be provided in the
form of fats. Fats are calorie dense (8.5 kcal/g)
when compared with carbohydrates and protein.
Mammals that do not eat, and presumably some
companion exotic species, shift to fat metabolism
after 3 to 5 days of reduced feeding. The addition
of fat therefore reduces complications of liver
metabolism.
1 6 9
 Omega Fatty Acids
The polyunsaturated fatty acids (PUFAs) of the n-6
and n-3 series are also associated with the immune
system and its response to disease. The PUFAs are
thought to affect the immune function in 3 basic
ways: altering eicosanoid synthesis, changing cell
membranes that affect membrane-associated
protein and receptor functions, and changing fatty
acid pools that affect cytokine production. In
general, the omega-3 series tend to produce fewer
inflammatory cytokines. The n-6 PUFA arachidonic
acid is the precursor for prostaglandins,
leukotrienes, and other related compounds that
produce proinflammatory cytokines. A number of
studies examining the anti-inflammatory role of
the n-3 PUFA in fish oils, eicosapentaenoic acid,
and docosahexaenoic acid in cardiovascular and
inflammatory/autoimmune diseases suggest that
they have a beneficial effect.34 Data from clinical
and research studies suggest that the balance of n-6
to n-3 should be closer to 2:1 for parenteral
nutrition with a markedly reduced immune
system.35 Feeding high levels of omega-3 PUFAs in
mice for 4 weeks resulted in compromising their
immune system by reducing their resistance to
infection.
Vitamin Needs
Vitamin C. Vitamin C is considered important for
collagen synthesis, antioxidant functions, and as a
free-radical scavenger.36 Vitamin C deficiency in
mammals alters connective tissues and results in
capillary fragility, hemorrhage, and muscular
weakness.36 Low levels of vitamin C have been
observed in elderly humans, smokers, patients with
liver disease, acute injury, or cancer; and in
postsurgical patients. Supplemental vitamin C for
hospitalized human patients has been suggested to
improve recovery.37
A dietary source of vitamin C is not normally
required for many species of birds, as they are able
to manufacture ascorbic acid. Depending on the
species, ascorbic acid is synthesized from glucose
using the glucuronic acid pathway in the kidneys
and the liver. However, insectivorous and
frugivorous avian species require dietary sources of
vitamin C. Some Passeriformes can synthesize
vitamin C at a very slow rate. Chickens, ducks, and
Japanese quail do not have a dietary requirement
of vitamin C, as they endogenously produce
sufficient levels. However, in the avian species that
synthesize their own ascorbic acid, the rate of
vitamin C production may be insufficient during
various stresses, physical trauma, and infectious
1 7 0 Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
disease conditions, thus requiring additional
supplementation of this vitamin in the diet.
In chickens, when dietary ascorbic acid was
increased above maintenance, there was improved
resistance to a variety of infections and improved
wound healing. This would suggest that to enhance
postoperative wound healing in companion birds,
an increased level of vitamin C would be necessary.
Vitamin C supplementation is particularly
important in avian cases that involve liver and/or
kidney failure.
Increased vitamin C supplementation, over daily
requirements, for brief postoperative periods may
benefit guinea pigs. High levels of vitamin C
(250 mg/kg) appeared to cause toxicity in guinea
pigs that were fed diets deficient in casein
protein.38 Possible toxicity associated with high
dosages of vitamin C administered to guinea pigs
was not observed when the animals were fed a
balanced diet. In another study, guinea pigs fed
150 mg/kg for 8 months were found to be at
increased risk for osteoarthritis of the stifle.39
However, when guinea pigs are fed appropriate
diets with adequate levels of protein for short
periods of time following surgery, the risks appear
to be minimal.
Vitamins A, E, and K. Malnutrition has been
associated with an increased risk of wound-related
complications.37 In addition to T-cell impairment
and alteration of granulocyte function, wound
healing can also be delayed with malnutrition.
Additionally, in birds, increased levels of vitamin E
interfere with healing and fibrosis and antagonize
the promotion of wound healing with vitamin
A.36,37 High levels of vitamin E (41000 IU/kg)
administered to pelicans resulted in the
development of hemorrhagic disease because the
vitamin E levels caused a subsequent deficiency of
vitamin K. Vitamin E can also adversely affect the
levels of other fat-soluble vitamins (e.g., vitamin A)
in the body.
Vitamin A is important for maintaining the
healthy epithelial surfaces of the respiratory
system, GI tract, renal tubules, and ureters. Vitamin
A is thought to support immune function through
maintenance of epithelial surfaces of the body that
act as barriers to infectious organisms. An example
can be seen with avipoxvirus infections—infection
requires that the epithelial lining is compromised,
which is often a sequel to vitamin A deficiency.
B Vitamins. Folic acid, thiamine, riboflavin, niacin,
pantothenic acid, pyridoxine, and B12 are essential
for the metabolism of glucose, fat, and protein in
the liver. Most of the B vitamins are incorporated
into coenzymes within a number of metabolic
pathways. The important caveat is that although
these vitamins are required in small amounts, they
are required daily for these metabolic pathways to
properly function. Overall, enteral diets contain
sufficient levels of B complex vitamins, but if the
patient is anorexic the vitamins can be added to
crystalloid fluids at 1 mL/1000 mL fluid.
Microminerals
Zinc is very important in various metabolic
pathways within the body of both mammals and
birds. In avian species alone zinc has been found to
be an activator or cofactor in more than 200
enzymes. Zinc deficiencies result in impairment of
metabolic pathways, alteration of pigmentation of
feathers during their growth, impairment of gene
expression, and alteration of cell division. Zinc is
an important metalloenzyme, particularly for DNA
and RNA polymerases.40 Although the association
between zinc and immunocompentency has not
been fully elucidated, zinc deficiency caused
primarily or secondarily from increased
corticosterone release results in lymphopenia and
thymic atrophy in mammals. Zinc deficiency has
also been shown to reduce cell-mediated and
humoral immunity, reduce T-helper cell-mediated
and humoral immunity, reduce T-helper cell
function, and diminish delayed-type
hypersensitivity responses.36 Zinc has been shown
to alter immune competence in birds as well.
Nucleotides
Nucleotides are the precursors to DNA and RNA
and are involved in a number of metabolic
reactions that are important for cellular
metabolism. Nucleotides are necessary for the host
defense system against bacterial or fungal
infections. Studies show that nucleotides are
needed for lymphocyte function and are important
ingredient of critical care diets. As pet foods and
avian diets contain grains and cereal, they should
contain adequate levels of nucleotides for the
hospitalized patient.
Nutritional Assessment
Nutritional assessment should be performed as
soon as possible upon a patient’s admission to
enhance treatment success. The patient’s history
should include dietary information to help
understand potential nutritional deficiencies or
excesses, or to determine if the animal is
Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
malnourished. A variety of measures have also
been used to nutritionally assess mammalian
patients. Body weight has been determined to be
one of the best assessors of nutritional status in
companion exotic animals, as well as humans. In
humans, if the patient has lost more than 10%
body weight, nutritional support is indicated; even
if the patient is obese.4 These factors need to be
taken into account with exotic animal patients as
well. Obese animals that suddenly stop eating pose
a greater health risk, especially if they have
significant fat in their liver or have liver failure as
they switch to ketone body formation as their
energy source.
Anthropometry is used in 2 methods to assess
the nutritional status of the patient.1 The first
method compares the patient values against
standardized controls, whereas the second
compares serial measurements over time.
Anthropometry is most accurate when the same
patient is monitored for over 1 month.1
Subcutaneous fat accounts for approximately
50% of an animal’s body fat stores; therefore,
changes to this fat reserve reflect altered nutritional
status.1 The skinfold thickness over the triceps
muscle appears to be the most common and least
expensive means to judge subcutaneous fat in
humans. Although it has been considered a
predictor of patient outcome,1 other medical
researchers found clinical judgment to be more
accurate.1,41
Skeletal muscle represents the major source of
amino acids for energy. Skeletal muscle represent
approximately 60% of the total body protein
pool.1 However, tests to determine depletion of
muscle mass have not proven to be clinically useful
for determining a patient’s overall body condition.
Creatinine-height index in humans is a ratio of
24-hour urine creatinine excretion in a patient,
compared with a height- and sex-matched control
expressed as a percentage. Depletion is defined
when the creatinine-height index is less than 80%
of normal and appears to have a limited predictive
power.1,42
The best nutritional test in humans for
predicting patient outcome appears to be serum
albumin. In humans, its half-life is approximately
18 days after its synthesis in the liver. Although the
length of the half-life inhibits predicting acute
outcomes, it shows a high degree of correlation to
30-day mortality in hospitalized patients.43
Albumin concentrations of 2.8 to 3.5 g/dL suggest
mild protein depletion, 2.2 to 2.7 g/dL moderate
depletion, and less than 2.2 g/dL severe
depletion.36 In humans, albumin o3.5 g/dL,
1 7 1
 transferrin o200 mg/dL, and a prealbumin
o15 mg/dL indicate depletion of serum proteins
and a substantial risk.1
FEEDING PLANS FOR BIRDS _________________
EN for birds can be divided into 2 groups:
omnivorous and carnivorous. Examples of
omnivorous birds treated in clinical practice
include psittacines, passerines, and poultry.
Psittacines, poultry, and columbiformes have a
crop that acts as a food storage site in the proximal
GI tract; this structure can be used to the clinician’s
advantage. Young birds often have a much larger
crop than adults, expanding up to 9% to 10% of
the body weight. However, adults have much
reduced crop volumes (e.g., 3% to 5%). This is
compounded by the fact that as birds become sick,
they tend to reduce the volume of food consumed,
with a subsequent loss of total crop volume.
Suggested amounts of food to tube feed different
avian species are listed in Table 1.
The goal of nutritional support is to provide the
metabolic needs of a debilitated patient in a highly
digestible food supplement. The diet should be
designed to suppress protein catabolism while
supplying enough calories to meet the metabolic
demands of the patient. Enteral nutritional support
using metal feeding “needles” or tubes or red
rubber catheters is the easiest and most practical
method to supplement patients that require this
treatment. The bird should be maintained in an
upright posture and the tube passed into the crop
(Fig. 1). The oropharynx should be observed for
overflow. Often, the volume fed needs to be
gradually increased as it becomes evident that the
bird can tolerate the amount of supplement
administered during the initial treatment period.
Enteral feeding should be the last procedure when
handling the patient before its return to the cage.
The enteral formula must be warmed uniformly
(i.e., warm water bath) to 391C to 40.5˚C (1031F
to 105oF) before feeding. It is important to avoid
TABLE 1. Suggested volumes and frequency for tube
feeding anorectic birds2
Volume (mL) Frequency
Finch 0.1 to 0.3 6 times/d
Parakeet 0.5 to 1.0 QID
Cockatiel 1.0 to 2.5 QID
Conure 2.5 to 5.0 QID
Amazon 5.0 to 8.0 TID
Cockatoo 8.0 to 12.0 BID
Macaw 10.0 to 20.0 BID
QID, 4 times daily; TID, 3 times daily; BID, 2 times daily.
1 7 2
hotspots within the formula that will be fed to the
patient, which can occur when using a microwave;
hotspots can result in crop burns. The patient
should be hydrated before being fed and be able to
maintain its head in an elevated position. One may
use very dilute formula for the first few feedings to
adjust the GI tract to the enteral supplement and to
provide partial rehydration.
Several key nutritional factors need to be
considered when choosing an enteral formula to
meet the demands of the cachexic patient. One
factor is the osmolality of the diet provided. The
osmolality of the enteral formula is often not
reported as it relates to digestibility of the product.
As the digestibility of the formula increases its
osmolality decreases, allowing for greater
absorption of nutrients. Osmolality also has an
effect on the quality and movement of the food
through the GI tract.
As discussed previously, the energy content of
the formula must be sufficient to meet the
metabolic needs of the patient (Table 2). As the
patient’s energy requirements escalate, food may
be provided more frequently; however, one may
reach a point where there is a mismatch, at which
time the animal’s condition will deteriorate. This is
an important consideration for avian patients, as
they often do not tolerate the stress of handling
and have a higher metabolic rate when compared
with carnivorous mammals. Stress is a particular
problem with wildlife species.
Raptors and other carnivorous species require
diets low in carbohydrates (2%) and high in
protein (17% to 20%) and fat (2% to 28%).
Emaciated raptors often need partial rehydration,
as they routinely present with anemia with low
plasma protein levels. These severely debilitated
birds of prey need enteral formulas that are at least
partially elemental, as their GI tracts cannot
tolerate whole “complex” foods. Additionally,
these birds do not have the energy reserves to
digest foods before preparing them for assimilation
along a compromised GI tract. Raptors that present
in critical condition can benefit from an enteric
diet with increased levels of arginine and
glutamine (e.g., Lafeber Emeraid Carnivore,
Cornell, IL USA).
FEEDING PLANS FOR SMALL MAMMALS _____
Ferrets
Ferrets are obligate carnivores that have a short
intestinal tract and colon, but do not have a cecum
or ileocolic valve. This suggests that healthy ferrets
require a highly digestible diet, especially in the
Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
FIGURE 1. (A) Placement of a stainless steel gavage feeding tube in a psittacine. (B) Anatomic representation of the
proximal esophagus and crop in the psittacine bird.
critically ill or debilitated patient. Although the
exact nutritional requirements have not been
determined, it is suggested that adult neutered
ferrets need about 30% to 40% protein, 18% to
20% fat, and 2% fiber.44 Carbohydrates should be
limited, and those provided in the normal animal
should be in the complex form. In ferrets
diagnosed with insulinoma, the amount of simple
carbohydrates must be limited, but should be
sufficient for the blood glucose to elevate into the
normal range. Feeding small amounts of protein
and fats throughout the day help limit wide
fluctuations in blood glucose noted in ferrets with
insulinomas.
Diets designed for cats provide nutrition close to
the requirements considered normal for ferrets.
Diets designed for dogs do not meet the normal
nutritional requirements of ferrets and would
further complicate the acute phase of critical illness
associated with catabolism. Ferrets are commonly
diagnosed with GI tract diseases that are often
chronic and associated with debilitation and
muscle wasting. Clinically, ferrets diagnosed with
TABLE 2. Formula for calculating the basal metabolic
rate (BMR)2
BMR ¼ K  weight (kg)0.75
Passerines K ¼ 129
Non-passerines K ¼ 78
Adjustments may be made for certain disease
conditions
Nutritional adjustments as multiples of MER
(maintenance energy requirements):
Starvation 0.5 to 0.7
Elective surgery 1.0 to 1.2
Mild trauma 1.0 to 1.2
Severe trauma 1.1 to 2.0
Growth 1.5 to 3.0
Sepsis 1.2 to 1.5
Burns 1.2 to 2.0
Head injuries 1.0 to 2.0
MER varies from 1.3 to 7.2 times the BMR depending upon
the energy required for an activity.
Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
chronic GI tract disease are often fed with a
supplemental diet to help build muscle mass.
Ferrets that are cachexic would benefit from a
semielemental diet (e.g., Emeraid Carnivore,
Lafeber Company). Once stabilized, other easily
digestible diets can be provided (Oxbow Carnivore
Care, Murdock, NE USA) or feline a/d (Prescription
Diets, a/d, Hills Pet Products, Topeka KS USA).
Ferrets are often fed at a rate of 10 to 25 mL per
feeding, even though they have a stomach that can
hold approximately 100 mL. The daily nutritional
requirement for ferrets would be comparable to
those needed for cats. Kitten milk replacers can be
used for kits.44
Rabbits
Rabbits are herbivores that are concentrate
selectors and hindgut fermenters of the colon and
cecum. Rabbits have microbes in their GI tract,
predominately Bacteroides spp., that breakdown
fiber in the hindgut. There is no evidence of
Lactobacillus being normally found in the GI tract of
the rabbit. Rabbits require 26% to 32% fiber and
about 2.2 kcal/g of diet.45 Rabbits have a high feed
intake of 65 to 80 g/kg of body weight and a
relatively fast GI transit time of 19 hours. These
figures should be taken into account when
calculating the quantity and type of enteral
nutritional support one feeds to a debilitated
rabbit. The most common presenting problem of
rabbits that require enteral feeding involves GI
disease, which is often associated with an
imbalance of the microflora of the gut. Imbalance
of microbial flora in a rabbit’s GI tract may be due
to insufficient fiber, too much carbohydrate, and/
or high levels of starches.
Dietary fiber is one of the most important
components of maintaining gut health, stimulating
gut motility with the insoluble fiber, and reducing
enteritis.45 Diets with less than 25% fiber result in
gut hypomotility, enteritis, reduced cecotrope
formation, and prolonged retention time in the
1 7 3
 hindgut, causing fermentation and further
dysbiosis.45 Cattle and other foregut fermenters
utilize digestion of their microbes to meet their
protein and amino acid requirements whereas
rabbits do not. Coprophagy meets the amino acid
needs of the sulfur-containing amino acids lysine
and threonine in the rabbit; however, this
microbial protein has been shown to meet only a
minor portion of a rabbit’s protein requirement.46
Instead, healthy rabbits digest protein directly from
their forages, which enables them to meet their
daily protein requirements. Cecotropes are often
ingested when the energy content of the diet is low.
However, rabbits that are ill often do not produce
or ingest their cecotropes. It is important not to
elevate protein levels greater than normal in critical
care diets, as this can increase cecal ammonia
levels, alter the cecal pH, and further complicate GI
health.
Enteral feeding should be instituted as early as
possible in rabbits and other hindgut fermenters.
This helps to reduce pain associated with colic
whereas the fiber helps to stimulate GI tract
motility and limit bacterial translocation across the
gut. Enteral feeding also helps to reduce the
consequences of hepatic lipidosis, a common
problem in rabbits. Enteral diets should be
evaluated carefully to match the needs of the
rabbit patient. Human replacement diets contain
low levels of fiber that are soluble and are not
suitable for the hindgut of a rabbit. Moreover,
human replacement diets provide energy
predominately as fat, which is not appropriate for
rabbits. Veterinary products developed for
carnivorous small animals are also not
appropriate.
There are several critical care dietary products
designed for hindgut fermenters that have
appropriate amounts of insoluble fiber. The more
elemental is Lafeber Emeraid Herbivore
(1.32 kcal/mL with 31% crude fiber). Three critical
care diet products are designed for rabbits in the
second stage of catabolism—the Oxbow Critical
Care, fine grind diet (1.9 kcal/mL with 21%
minimum and 26% maximum crude fiber);
Supreme Science Recovery (19% minimum crude
fiber); and Supreme Science Recovery Plus (25%
minimum crude fiber). These diets are
appropriately labeled as recovery foods for longer-
term nutritional support. The fine grind of Oxbow
Critical Care is designed to pass more easily
through a nasogastric tube. All of these diets can
be administered by syringe feeding small volumes
to avoid aspiration and monitor swallowing while
feeding.
1 7 4 Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
FEEDING PLANS FOR REPTILES ______________
Nutritional support of the anorexic or cachexic
reptile patient is an important component to the
treatment plan. However, diagnosing anorexia may
be difficult in reptile patients because of the
infrequent feeding schedules of certain groups of
these animals (e.g., snakes). Some reptiles will fast
when their body temperatures cool, thereby
lowering their metabolic rate, whereas others may
be overweight from overfeeding. To assess
potential problems associated with reptile
anorexia, a thorough history of what an animal has
been fed and eaten, its body condition, the
environmental temperatures it is maintained
under, and any species specific idiosyncrasies need
to be assessed. Reptiles that are cachexic have
muscle wasting over the vertebral column, with
atrophy of the epaxial muscles and prominent
spinal processes (e.g., snakes); have more
prominent long bones in those with legs; and the
disappearance of fat pads in the base of the tail in
lizards. Reptile patient’s that are obese often have
fat over the vertebral column, making it hard to
locate the spinous processes, and a distended
coelom, which needs to be distinguished from
other causes of GI distension (e.g., gas within GI
tract). Changes in the biochemical profiles of
anorexic reptiles may include a reduction in blood
glucose levels, increased concentrations of
creatinine phosphokinase from protein
catabolism, and decreased electrolytes.47,48
Reptiles need to be warmed gradually, if
necessary, to the appropriate environmental
temperature for that species. While the reptile is
being warmed, fluid rehydration should be
initiated. Dehydration can be assessed clinically in
reptiles by eyelid turgor, position of the eyes (e.g.,
sunken/bright), mucous membrane moisture or
tackiness, tenaciousness of saliva (e.g., does it form
durable strands or not), skin turgor/dermal
elasticity (e.g., thickness and durability of skin tent
or folds), abdominal doughiness, packed cell
volume, total protein level (e.g., total solids by
refractometer), plasma sodium level, and plasma
chloride level.47
As plasma proteins are reduced in reptiles
compared with mammals, it should be noted that
the osmolarity of reptile plasma is typically lower
than that of mammals, and consequently solutions
osmotically balanced for mammals (e.g., 0.9%
normal saline) are likely to be hypertonic for
reptiles and may further deplete the intracellular
compartment.48 Some authors48 suggest that to
meet maintenance requirements, providing 2.5%
FIGURE 2. Gavage feeding of a lizard using a stainless
steel mouth speculum.
dextrose in 0.45% saline (280 mOsm/L) is closer
to the osmolality of reptile blood. Many reptiles
will drink when placed in shallow pans of water.
This can be used by the owner for rehydration.
Fluids can be replaced in reptiles through
subcutaneous, intracoelomic, intraosseous, and
intravenous routes. After rehydration, enteral
support can be initiated if the GI tract is functional.
Nutritional support in reptiles can be
accomplished by syringe feeding (Figs. 2 and 3),
gavage feeding, and the use of a pharyngostomy
tube; the route used should be based on the
patient’s needs.
The enteral formula should be selected according
to the nutritional requirements of the type/species
of reptile being treated. In general, cachexic reptile
patients should receive only 10% to 20% of their
DERs over the first few days of hospitalization. This
can be gradually increased over time until the
calculated energy requirement is met. This will
allow the gut to adjust to the diet and will reduce
the potential for refeeding syndrome.46 Snakes can
be fed a carnivore diet, whereas tortoises need a
diet designed for herbivores. Vetark Professional’s
Critical Care Formula provides adequate basic
short-term critical nutrition for all reptile species.25
Lafeber Carnivore Care can be used long term or as
an alternative for species that are whole-prey
predators or insectivores in the acute phase of
cachexia, whereas the Oxbow Carnivore Diet
would benefit those patients in the chronic phase.
For herbivorous species, the Lafeber diet should be
used during the acute and early chronic phase of
cachexia, whereas longer-term species can use the
Supreme Petfoods or Oxbow critical care diets.
CONCLUSION ________________________________
EN is indicated in alert patients, whether
mammalian, reptilian, or avian, when they exhibit
anorexia, have undergone a 5% to 10% weight
loss, have a decreased level of serum albumin, or
when there are clinical indications of protein loss
Orosz/Journal of Exotic Pet Medicine 22 (2013), pp 163–177
FIGURE 3. Anatomy of the turtle demonstrating exten-
sion of the neck and the approximate location of the
stomach. The straight stainless steel gavage feeding tube
should be carefully passed to the distal end of the
esophagus.
(i.e., reduced pectoral mass, birds; or body mass in
reptiles and small mammals). EN should be used
with caution and knowledge in its administration.
Gavage feeding should always be performed by a
veterinarian that knows and will guard against
possible complications. Avian patients should be
weighed at approximately the same time each day
(preferably in the morning) and prior to gavage
feeding. After the enteral diet has been fed, the
patient should be returned immediately to its
hospital cage without stress or touching the crop to
avoid aspiration. This is also true with gavage-fed
reptile patients. Tracking weight helps to determine
if the supplemental diet and volume is appropriate
to meet the metabolic demands of the patient.
Other patients, from small mammals to reptiles,
may be hand-fed as a means to provide enteral
nutritional support and to rapidly move the
patient from the catabolic phase to an anabolic
phase during treatment.
The veterinary clinician needs to understand the
types of EN products that can be used and how to
match the correct ingredients with the clinical
disease signs of the patient. Elemental diets that are
calorically dense owing to fat content are
appropriate for use in debilitated patients. These
patients need adequate levels of amino acids to
meet the metabolic demands and to rebuild tissues
after gluconeogenesis has reduced their body mass.
Those patients that have liver failure and/or are
hypoglycemic need simple carbohydrates as well as
adequate levels of carbohydrates to meet the
immediate need for glucose. Diets that are gavage-
fed should be adapted to the physical conditions of
the patient to enhance the overall treatment
success. It is hoped that the information in this
article will provide the veterinary clinician that
treats companion exotic animals a foundation to
provide appropriate nutritional support for
critically ill and debilitated patients.
1 7 5
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