HOW TO TREAT FLAT-CHESTED KITTEN SYNDROME

You can help your kitten(s):

Correct diagnosis - types of FCKS
Nutritional support and drugs
• Nutrition
• Vitamins
• Taurine
• Antibiotics
• Steroids
Massage
Splinting
Acupuncture
Oxygen

CORRECT DIAGNOSIS

This is essential - it is surprising (and worrying) how many vets do not seem to be able to diagnose this condition, nor know anything about it, despite the fact that it is very widespread, and relatively well-known in the breeding community. A large number of kittens with FCKS are mis-diagnosed as having pectus excavatum, or the vet simply does not notice a thoracic or spinal deformity. If this is the case with your vet please take copies of the literature to him/her, and ensure that your research is sufficient to help you support and treat your kitten if your vet is unable to help. Please read the section about diagnosis and recognising this condition (What is FCK or FCKS?) if you haven’t done so already.

NUTRITIONAL SUPPORT AND DRUGS


NUTRITION

Since putting this information on the web, I have had numerous enquiries from breeders who have had kittens develop this condition. I'm afraid I don't have any perfect answers, but I can pass on what feedback I've had regarding results and possible causes. This is a very sad thing to experience - we all want our babies to be perfect, and having things go wrong is heartbreaking. For most of us, the worst thing about sickness in a kitten is sitting and watching and not being able to do anything to help. Some vets believe that the condition is due to a vitamin deficiency, and the most commonly used vitamin supplement for kittens is Abidec. This is a liquid vitamin supplement for babies and toddlers available from an ordinary chemist (unfortunately it tastes disgusting). If in doubt ask your vet. Remember that these kittens are always very young and small, so any treatment is very difficult. You only need one drop of Abidec per kitten, so don't end up squirting it down their throats so that they choke. I have used Nutri-drops in a very mild case, and that seemed to help - Nutri-drops (available in the UK, and possibly elsewhere under a different name) is mainly glucose and vitamin A, and a cocktail of other vitamins. It will give a kitten energy to suckle more, which is helpful if your kitten fights against a hand-fed milk supplement.

One thing that everyone also recommends is to supplement-feed affected kittens with a very high-quality kitten milk supplement, even if they seem to be feeding OK from the mother. One breeder observed that FCK kittens seem to use far more energy than normal ones just to keep up, and this has been confirmed by Kit Sturgess, so it is reasonable to expect that the kitten would need supplementing. Often the first thing that alerts you to a problem is that the kitten stops putting on weight, so supplementing is a natural step to counter that stalling in growth and development.

Cimicat doesn't seem to be much use as it's not very rich, and I would only recommend KMR which is a marvellous creamy-rich milk substitute, and has saved the lives of countless kittens who did not thrive on Cimicat, regardless of whether they had FCK syndrome. In the UK the supplier is KRUUSE UK Ltd, tel 01977 681523. They have always been very helpful and will despatch the powder to you the same day if they can. However Kruuse are now only able to sell on a non-retail basis, so you would have to make a bulk order. I'm afraid it's not cheap! Your vet should also be able to get it for you, but will charge a retail price, which is about twice the price from Kruuse, but you don't have to buy in bulk. You can also get it from CANINE CHEMISTS Tel: 0870 225 4777 (thanks to Doris for sending me the details). In the US, KMR is available at the chain PetSmart. The US distributor is PetAg Inc., 255 Keyes Avenue, Hampshire, IL., 60140; 1-800-323-0877 (Many thanks to Don for this information).

The other alternative is evaporated milk (brand name Carnation in the UK) diluted with water (about 1 part Carnation to 3 parts water) with a raw egg yolk beaten in (as long as you are happy that your egg supply is free from Salmonella). This is VERY nutritious if you can't get KMR. I'd supplement often to make sure the kitten is getting enough nutrition, as we still don't know if poor nutrition from a poorly functioning teat could be a causal factor. The exercise of struggling against you (at first) and of suckling from a syringe will also help the lung development, but will also tire the kitten, and you may have to abandon hand-feeding if it is counter-productive because of exhausting the kitten.

TAURINE

The following information came from Jane Turner in Canada, a breeder of Maine Coons: "I have had in the past the odd FCK kitten in a litter, but have never had a whole litter affected, so I'm not sure if it is genetic or not. I now supplement most of my queens with Taurine as routine, I was using 500 mg a day. One queen I had not supplemented, as she had never had an FCK kitten in her previous 2 litters, had a kitten go flat chested at 6 days old, just suddenly, so we supplemented her straight away with a dose of 1000 mg Taurine once a day; within 2 days the kitten who was completely flat on the bottom was coming out of it and by 5 days you would not have known he had ever been flat. When he went flat his breathing was definitely faster and he didn't gain much weight for a couple of days, but he was still suckling and would not take KMR from us. His mum had lots of milk so we left him alone, now he is as large as his litter mates and feels perfectly normal when you pick him up; he is just over 4 weeks old and is eating solid food now (he was the first one to start eating!) ... I have never used such a high dose before, but when I have put queens on Taurine the kittens seem to survive and return to normal within a couple of weeks, always by the time they are 8 weeks old you can't tell they had anything wrong with them: even my vet couldn't feel anything wrong when they have been vaccinated. We moved from England to Canada nearly 2 years ago, and I had to buy a different brand of Taurine this time, I think it was better: it was capsules with a powder in it, rather than a solid tablet, so any difficult-to-pill queens just had it on their wet food no problem.

If you would like to contact this breeder you can reach her by e-mail: jane[at]dotcommainecoons.com

The more you can understand the condition of your kitten, the better you can help it, so spend time with the kitten observing the condition and how it affects the kitten, what makes it worse, and what makes it better. You can observe by watching and by feeling the kitten while it is lying at rest, feeding or moving around.

Flattening occurrs at any time from 3-10 days after birth, but is more likely to appear sooner than later. Although we do not know absolutely what causes the ribcage to flatten, it has been observed that cases of mild pneumonia can cause the ribcage to flatten to various degrees. In these cases the kitten exhibits abnormal rapid breathing BEFORE the ribcage flattens, and the effort of drawing breath in causes the ribcage to flatten. Note,: not all kittens who get pneumonia go flat.

For this reason there is no harm in putting a kitten with FCKS on a broad-spectrum antibiotic as soon as the condition is noticed.

The kitten may also be suffering a nutritional or vitamin deficiency, and therefore frequent administration of a vitamin and energy supplement is recommended (see the section above). Hand-feeding formulas may supply this need, but it is advisable to supplement with additional vitamins. An ideal source of additional energy (from glucose) and vitamin support is to be found (in the UK) in Nutri-drops, which are obtainable from www.purrsonaltouch.com. If you know of other sources of supply for this supplement, particularly outside the UK, please let me know so that I can put the information here.

Flattening takes place over the course of 2-3 hours. It happens gradually, so the kitten is not normal one minute and flat the next. Observation of the condition developing saw a large healthy kitten with no discernible symptoms become almost completely flat over the course of 2 hours. The kitten was sleeping, and the breeder checked the thorax by feel: as each breath drew the ribcage in slightly more, the development of the condition was very clear. Although light pressure was applied by hand to discourage the ribcage from adopting the unnatural shape the development of the condition was not arrested, but stabilised by itself.

Once the kitten reached a state where the ribcage was horizontal across the underside, the condition ceased to worsen, and the kitten stabilised. The kitten showed no obvious signs of distress during this process, woke and fed normally, and otherwise behaved as the other kittens in the litter did.

FCKS does not leave the kitten with the ribcage in a fixed position. The thorax is flexing all the time, and the degree of flatness changes during each inhale-exhale breathing cycle. When the kitten breathes in, the sides move outwards and the underside comes up towards the spine, increasing the flatness. On exhalation the sides collapse inwards, and the underside of the chest moves downwards away from the spine. Thus when the lungs are supposed to be full, the condition is noticeably worse. The chest goes flat because the lungs are not inflating properly - we do not yet know what causes the lungs to collapse, but it is evidently NOT caused by the chest: the chest collapses because the lungs are not inflating. OXYGEN WILL NOT HELP this condition, and indeed is likely to worsen the problem. You should only use oxygen if the kitten is in distress to support it on the way to the vet to be put to sleep.

Because the thorax is flexible, it can be pushed into the correct position by squeezing the kitten's sides. The best way of doing this is not to apply continuous pressure, but to apply greater pressure on exhalation when the more natural position is reached, and gentler pressure when the kitten is inhaling and the flattening is most extreme so that you do not prevent the kitten from inhaling. The more active the kitten is, the more extreme the position of the ribcage, so it is better to keep the kitten calm and quiet, particularly during massage. Quite strong pressure may be necessary, and most kittens, far from being distressed by this, seem to enjoy it. A good time to massage is during feeding. This has two purposes: the kitten is relaxed, so the condition is less extreme; the activity ensures the kitten remains alert and suckling when it might otherwise fall asleep, so it suckles for longer. Since kittens with FCKS use more energy than normal kittens, encouraging them to feed longer and waking them for extra feeds is highly desirable. 

You may have to utilise different types of massage. The first and most effective is simply to put thumb and fingers on either side of the body and press on the ridge of the ribs as they stick out. For quite a lot of affected kittens this seems to cause them no distress. If a kitten fights against this and cries out, a different method is necessary, which involves again using the thumb and fingers on either side of the body, but instead of squeezing, you rub the ribcage gently in a downward position from the spine down, applying inward pressure as you do so, as far as the angle made by the flattened ribs. You have to do this in time with the natural in-out movement caused by breathing. This seems to be much more comfortable.

Massage should be maintained for at least as long as a kitten is feeding, and longer if possible. The longer you massage, and the more frequently it is done, the more help it is to the kitten. After massage the chest is noticeably less flat than before, but usually the time between massages allows it to flatten again.

You can observe easily that when a kitten is fighting for a teat or crying for its mother, the chest is much flatter than when it is at rest or feeding unchallenged. If the kitten continues to gain weight this is a good sign. If weight-gain stalls or the kitten begins to lose weight you may be losing the battle If the underside of the ribcage collapses inwards so that pressure on the sides makes the centre of the chest cave in rather than push out, the kitten will almost certainly not survive.

NEW INFORMATION
I recently observed a kitten with a very mild case of FCKS: his weight gain never stalled, and he was not flat all the time (this is very unusual). The important point to note was that he ONLY WHEN FLAT WHEN HE WAS FEEDING. It was clear that whatever he did with his breathing or body while suckling, this cause him to go quite severely flat.

I encouraged him to lie on his side between feeds, which made his chest go to a normal shape, and if I persuaded him to lie on his side while feeding he did not go as flat as if he was lying tummy-down. This may explain why some kittens with FCKS improve if they are hand-supplemented: if they suckle less, then the cause of the ribcage flattening doesn’t happen so often, and the ribcage is able to normalise by itself. This means that some forms (NOT ALL) of FCKS may be exacerbated by suckling, and possibly taking a kitten away from its mother and hand-feeding it may allow it to recover.

As the flattening is clearly caused by the lungs collapsing (and we don’t know why they collapse yet), try holding the kitten upright in a ‘standing’ position as if it is a human standing on its back legs. If the problem is caused by a malfunctioning diaphragm this may ease the flatness.

There is a problem in applying a splint, or 'corset' to a kitten with FCKS, since the splint will be fine while the kitten is resting, but as soon as it needs to draw a deeper breath, the corset will restrict the movement of the ribcage, causing a sensation of suffocation, and the kitten will panic. This in turn makes it struggle and cry far more, and feel more restricted. Unless a kitten is happy with the corset during all periods of activity, it must not be left alone. This being the case, the owner may as well massage the kitten as put it into a corset while it is watched. Older kittens seem more amenable to wearing a corset 24 hours a day.

A more useful purpose of the corset is to prevent the kitten resting its weight on the flat underside of the thorax. In doing this, it encourages the flat position and effectively prevents the thorax from rounding out by itself. A tubular corset will allow a kitten to lie on its stomach (which is a natural position) without putting pressure on the flat chest. However if the corset is loose enough to ensure breathing is not inhibited, it will often slide off. There have been numerous ingenious ways tried of keeping a corset in place, however the construction must not prevent natural movement and inhibit the kitten from finding its mother for milk, or rolling upright if it gets tipped over. Since adequate nutrition is so crucial in survival, the kitten needs to be able to feed whenever it is hungry, and not just when the breeder is on hand to help it get to a teat. Encourage the kitten to lie on its side while feeding and sleeping. Kittens normally seem quite amenable to this. Lying on the side will help gravity to do what you would otherwise be doing by squeezing. I have also found that kittens who do not respond well to splinting can be helped by laying other kittens on top of them when they are sleeping, but ONLY if they are sleeping on their side! Be careful as, again, the pressure may not be tolerated by the kitten.

One breeder noticed a very useful side-effect of a corset: a kitten with both kyphosis and FCKS was put into a corset, which he tolerated well. After a little more than 2 weeks like this, the owner noticed that not only had the flattening improved and was almost normal, the spinal deformity had also improved and apparently disappeared. Without x-rays we don't know much more about this, but it sounds as though the corset had a similar effect on the spine to an orthodontic brace on a child's teeth, putting traction on the spinal compression by the shoulder blades and making it move into a correct position. This is worth consisdering if you have a kitten without FCKS, but with kyphosis.

Swimmer Puppies

DOGS have problems with a condition similar to FCK, and breeders sometimes call it 'Swimmer Puppy'. It seems to be very similar to kittens (although it may not be the same condition), and a useful website that suggests a way of helping the puppies may offer hope to cat breeders with FCKs.

According to this website, the normal sleeping position for a puppy is on its side, but ones that develop FCK end up sleeping on the chest: this exacerbates the flatness, as well as keeping the puppy in an unnatural position, which may be bad for lung development. The key to the puppies is to force them to lie on their sides, and the breeders do this by a combination of sitting over the puppies and continually turning them onto their sides both when resting and when feeding, and also by putting them into a sock stuffed with cotton balls that makes a rounded shape on the underside of the body, thus rolling the puppy onto its side when it is relaxed.

Kittens, however, spend at least 50% of their time lying on their chests under normal circumstances so, although lying on the side is not abnormal, it is not abnormal for them to lie on their stomachs.

If you are not able to devote this sort of time to your kittens, then please give them to someone who can. It would be terrible to lose one of these brave little lives because your other commitments prevent you from caring for it. Think very carefully about continuing to breed if you cannot take time off to look after kittens if anything goes wrong: breeding is time-consuming and often requires sacrifices, and if your work or life prevents you from being there to support a struggling kitten then breeding may not be the right thing for you. I have been criticised for saying this, but I'm afraid I believe it is true. We choose for our cats to breed, they don't, so we have a responsibility to be there to care for them if they need it.

In late 2004 and early 2005 four breeders with affected kittens had success in taking action on the physical symptom (the flattened ribcage) by 'splinting' the ribcage in a corset and several breeders have since tried it succesfully. The first two did this with a cardboard toilet roll, cut to shape. This was curled tightly around the body and tied in place so that it pressed on the sides of the ribcage, pushing the flattened underside back outward. The curved underside meant that even lying on its front, the kitten was not putting pressure directly on the ribcage, so its sleeping position was not making the condition worse.

One of the breeders who tried this said the tube did not make the kitten roll over onto its side (see below), but although lying on the side helps, simply lifting the chest off the floor of the bed will relieve the immediate pressure on the flattened area, allowing it to expand out naturally if it is able to do so. It is clear that pushing the sides of the ribcage in can provide immediate relief to a kitten that is having breathing problems. I think this could be a life-saving solution to the condition. We still don't know what causes FCK (and there IS definitely a genetic component, or we would not be able to predict it happening in certain lines), but if this turns out to be an effective treatment we have won a very large battle. The puppy breeders use a sock, but because kittens are so much smaller and more delicate to handle, I think the toilet roll solution is far better.

IMPORTANT
There are warnings to be aware of if attempting or considering splinting:

Very few cases of FCKS are suitable for splinting. To find out if your kitten is suitable, lay it on its side when sleeping or suckling and put gentle pressure on the ridge of the side of the ribcage. You will be able to see if the breathing is easier or impaired when you do this Look particularly at the soft tissue below the ribcage: if the pressure causes this area to be sucked inward more than when there is no pressure applied, you should not splint the kitten. Massage is the only alternative in this case, and even that may not help if it distresses the kitten.

Another type of FCKS which is not suitable for splinting is where the corset makes it more difficult for the kitten to breathe, or the distress makes the condition worsen. Some kittens are fine in a splint if they are resting, but cannot expand the ribcage sufficiently to draw breath when they are active. If your kitten falls into this category you cannot splint, but you should be able to massage without difficulty

If the ribcage is beginning to poke inwards, or the sternum (breastbone) is already poking in, pressing on the sides will force the sternum inward rather than outward and kill the kitten - make sure that before you try anything you are CERTAIN that the sternum will move outwards when the ribcage is compressed. Use your fingers to press the sides so that you can see what is happening before you put on a splint/corset, which will hide the thorax so you won't be able to tell what is happening.

If you decide a splint is going to work, just put the roll on loosely and work on making the kitten lie on its side. This will make a difference even without putting pressure on the sides. It is always a good idea to consult your vet about anything like this, and he or she should be able to advise you on whether your kitten has an inverted sternum or not if you are unsure. Many vets are skeptical about information found on the internet: if this is the case, please direct them to this page where they can access the veterinary article for themselves, or else print the article off and take it to them.

Be patient and gentle - tighten the splint gradually in stages (over hours or days) or you could harm the kitten or break ribs by forcing. One breeder of Maine Coons had a kitten who was struggling with breathing, but as soon as she splinted him he could breathe again - this is obviously a type of condition that is different from the ones who are made worse by the splint. She is not the only breeder who has tried this and been successful. Splinting is easier with larger kittens, but the longer you wait before splinting or treating with massage,  the more the ribcage becomes habituated to the abnormal shape, and the harder it is to restore it to the correct shape. Many thanks to this little fellow's mummy, who kindly took these excellent photographs. He's now doing very well and only wore the corset for a week.

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Another breeder was kind enough to send me his thoughts and some photos of what he thought about this solution... 'Your pic of a kitten in a cardboard tube would do nothing to keep kitten on its side or put pressure on his sides instead of front of chest. I did something else. The ridge keeps the kitten sleeping on his side and he can not put pressure on his tummy side'. Although some people seem to have been successful with the tube version, we have no way of knowing if the kitten would have survived anyway or not, so it's a good idea to consider everything that may help. The younger a kitten is, the more likely physical therapy intervention will succeed, and the quicker it will show results. However you have to be careful if a kitten seems all right and you remove the corset, in case the chest flattens again. If caught within a few days of developing, a week in a splint seems to be enough to reverse the damage. Older kittens may need a lot longer. You can take the splint off to check the condition and massage the ribcage, though if it is hard to get it on and off in the right position then you may find it easier just to leave it in place.

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Feedback from breeders is essential to learn more about FCK and different ideas and experience can refine our ideas and solutions. I am very grateful to Barbara, a Burmese breeder in Germany, who read this information and made a website with very clear and informative pictures showing her kitten and his progress with the splint. She and her vet also thought that the join in the tube should be below the ribcage rather than above the back, to encourage the kitten to lie on its side and her results were really encouraging. Her website is here. Sadly, Chester died after initially improving dramatically, but it is clear that the splinting did relieve his problems while he was alive.

More information from someone who read this page: 'We have an FCK and we printed the information you gave on the internet and brought it to our vet so she could see about the brace. We made a brace/splint only we made it differently. Ours doesn't go over the front legs. To make this brace use a soft curved piece of plastic about 1 1/2 inches wide and about 3-3 1/2 inches long depending on the size of your kitten. We got our plastic from an 8.75 oz Sunny-Delight bottle. Then took the plastic and covered it with horse wrap, so the plastic would not irritate the kitten. Envelop the 6'' horse wrap around the plastic piece leaving enough of the horse wrap extended to go around twice. Wrap it snuggly yet comfortably around the kitten's chest under the front legs. You should change the horse wrap every 2-3 days, for it loses its stickiness. (it sticks to itself not the kitty) Our baby is doing quite well.'

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If splinting is done carefully it could save the life of your kitten(s), but bear in mind that sometimes the FCK seems to be caused by poor lung or heart development (or pneumonia), not the other way around, so even if the ribcage is rounded out again it may not solve the underlying problem, and the kitten may still die. However this is much more hopeful than any of the other things that have been suggested in the past, giving instant relief to a kitten having difficulty breathing. We do know that sometimes the internal damage is caused by the FCK and not the reverse, so please let me know if you are trying splinting, and please do let me know the outcome. The cases I have been told about so far are of single FCK kittens in a litter; it would be very useful to know of a case where this is tried with a whole litter that has gone flat, as the condition tends to be more serious where a whole litter is involved, and the mortality rate is higher.

Vets in Holland seem to have more experience of FCK than those in the UK, including it in their training, and have taken a more pro-active attitude to treatment: they recommend physiotherapy and massage on the thorax every three hours for 24 hours a day or more often if you can do it. This is combined with treatment using anabolic steroids (Bolbane) pioneered by a practice in Zeist which they believe speeds up the changes initiated by the physical therapy. Unfortunately for English speakers the site is only in Dutch, but since the Dutch usually speak very good English, your vet may be able to contact this practice for more information (the vet is called Nico Dijkshoorn). A success story from Holland using this protocol can be read here: http://www.felinefantasy.nl/, look at: a cat's tale > Smirnoff's Story.

Some vets also recommend making a flat-chested kitten move more by pulling it away from the mother so that it has to work to get to the milk, and also encouraging it to cry, though without distressing it unduly. The thinking behind this is that it will strengthen the muscles used in breathing and this may encourage the ribcage into the correct shape. I do not advocate this approach: as described above, the effort of increasing lung capacity during activity causes the flattening to increase, and also I suspect the extra energy the kitten is forced to expend is not helpful if it is already losing weight because it is not feeding well.

Finally on splinting: some kittens are extremely distressed by splinting, and the distress it causes is counter-productive in attempting alleviate symptoms. One breeder reported that her kitten was gasping for breath after screaming because it did not like the splint. You need to gauge how the kitten is reacting to make sure that the pressure you are providing is not too great, and also that having a splint on is not going to upset the kitten so much that it expends too much energy fighting or crying, and that it stops feeding because it feels it cannot move. If you cannot splint because it distresses the kitten too much, then use massage and pressure on the ribcage to keep encouraging it to a normal shape. Do this as often as you can. DON'T do it while the kitten is suckling if it is distressed by it, but most seem to find it pleasurable (!).

SUMMARY OF TREATMENT PROTOCOL: