April 16, 2013
Once mum, gum maker to disclose xylitol content
Company responds to dog poisoning complaint
By: Phyllis DeGioia
For The VIN News Service
When a 10-pound Maltese ingested most of a pack of Stride gum in mid-February, the dog’s veterinarian, Dr. Janet Dornhoff of Buffalo Grove, Ill., went to the Internet for the gum manufacturer’s phone number so she could ask how much xylitol — a sweetener toxic to dogs — was in Stride's spark kinetic berry flavor.
Photo courtesy of Country Court Animal Hospital
Dr. Janet Dornhoff, shown with her pets, had two frustrating experiences with a gum maker when she tried to figure out the level of xylitol in gum eaten by a patient. Dornhoff’s complaints led to significant changes in policy by the manufacturer, Mondelēz International.
After much clicking on the Stride website and the hard-to-navigate site of Stride maker Mondelēz International, Dornhoff finally found a customer service number and reached an agent.
Still, the information she needed to treat her patient was elusive. The gum maker’s representative said the veterinarian first had to sign a nondisclosure agreement.
It took at least half an hour for the paperwork to arrive. Dornhoff completed and faxed back the form as quickly as she could between appointments. Another hour passed before the doctor heard from the company with the answer. Venting later to colleagues on the Veterinary Information Network (VIN), an online community for the profession and the parent of VIN News Service, Dornhoff fumed, “Not once did anyone there ever ask how the dog was doing.”
She had good reason to wonder how much the company cares that xylitol, a popular sugar substitute, can kill dogs. Holding tight to what it considers a trade secret, Mondelēz is the only major gum maker that balked at disclosing xylitol levels, even in medical emergencies.
Since 2005, the Animal Poison Control Center (APCC), operated by the American Society for the Prevention of Cruelty to Animals, has sought product xylitol levels from companies that sell confections containing the sweetener.
APCC Medical Director Dr. Tina Wismer said it’s not unusual for a company to guard xylitol content as proprietary information, but the center has found most of the big gum makers to be forthcoming — namely, Wrigley, a subsidiary of Mars Inc., maker of Orbit; Perfetti Van Melle, maker of Mentos; and The Hershey Co., maker of Ice Breakers.
Mondelēz was an exception.
“Some companies give a range for their products, some made us sign a confidentiality agreement, but Mondelēz has been uncooperative,” Wismer said. “It's very frustrating because we're concerned about the animal,” she said. “We are not looking to go into competition with the gum manufacturers. We just want to save lives.”
On Monday, the company changed its position.
In response to queries from the VIN News Service, Mondelēz’s senior manager for corporate and government affairs, Stephanie Minna Cass, said the company will cooperate with the poison control center like its competitors. “Once we receive the confidentiality agreement from animal poison control, we will release xylitol levels,” Cass said by email.
Mondelēz is a multinational confection and snack-foods company formed last year after Kraft Foods Inc. separated its grocery staples line from its snack and candy business. Mondelēz describes itself as No. 1 in the world in sales of biscuits, chocolate, candy and powdered beverages, and No. 2 in gum and coffee. Its gum brands that contain xylitol are Stride (except berry melon flavor), Trident Layers, White, Splash and Xtra Care.
Wismer applauded the company’s decision to share product xylitol levels with her agency. “The APCC would like to thank Mondelēz for understanding our position on protecting animals,” she said.
Xylitol (ZI-luh-tohl) is a sweetener derived for commercial use from corn cobs or hardwood trees. Dogs metabolize it differently from humans. In people, xylitol generally has no effect on plasma insulin or glucose levels, whereas in dogs, it causes a surge in insulin. The resulting rapid drop in blood sugar may result in hypoglycemia, characterized by unsteadiness, depression, dilated pupils and, in severe cases, seizures.
A high dose of xylitol in a dog may lead to liver failure and death.
APCC began in 2007 to log xylitol cases. That year, the center received 1,764 calls about xylitol, according to Wismer. In 2012, the figure was 3,184. Most recent cases involved gum, although some were about mints, other candy or baked goods.
As with every poison, dose is key. A dog that consumes a small amount of xylitol relative to its size may not need treatment at all, says Dr. Sharon Gwaltney-Brant, a VIN toxicology consultant formerly with the APCC. It's like a person taking half an aspirin versus a bottle of aspirin, she explained. One situation is harmless; the other requires medical attention.
A toxic dose of xylitol for dogs is 75 to 100 mg/kg, according to Wismer. Based on information previously provided by cooperative manufacturers, Wismer said the quantity of xylitol in a single piece of gum ranges from less than 1 mg to 1,000 mg — a vast difference.
Moreover, levels may vary from flavor to flavor within the same brand, never mind among brands and manufacturers.
In cases where the level consumed is unknown, Wismer said the APCC advice is to err on the side of caution and treat the patient based on the highest possible dose. The problem with that approach is that a pet owner may unnecessarily spend hundreds or thousands of dollars for emergency care, and patients will needlessly undergo treatment that may cause discomfort or fright.
Gwaltney-Brant said no one wants to send a dog to the emergency room if a veterinarian can determine that the level ingested is not a problem. "If it's going to cost several hundred dollars, some people will put the animal to sleep if they can't afford it,” she said.
Treatment involves drawing blood to measure glucose and liver enzyme levels, and if warranted, supportive care. That care may include a special diet, medication and subcutaneous or intravenous fluids. The treatment cost may range from less than $100 to several thousand dollars. One family interviewed in 2011 by the VIN News Service spent $7,000.
The Maltese that ate the xylitol-sweetened gum in February ended up fine, thanks to Dornhoff’s persistence with the gum maker.
In a VIN message board discussion, Dornhoff expressed exasperation with the company’s requirement that she sign a nondisclosure statement, and with how long it took to complete and process the form:
“After being reassured that it would only take a couple of minutes, they'd fax the form and I could sign it and fax it right back — ‘two minutes, honestly,’ and she'd call back ‘immediately‘ — I was faxed a full-page form requiring info such as ‘Did your patient ask you to contact us?’ (um, my patient can't talk...) and ‘Reason for the request’ (which I answered, ‘Figure out if this cute little Maltese is going to DIE from eating your product!’) and then asking me to sign that ‘I agree to use this information for the sole purpose of treating my patient and will not disclose the information to anyone else. The information provided will be kept separate from the patient's records and will be returned to Mondelēz once I have completed my evaluation.’
"Okay, so now they are dictating that I not keep complete medical records? ... Not wanting to put my patient's life at risk, I went ahead and signed their form and faxed it back. And waited almost an hour for them to call back. ... They definitely did not call back 'immediately,' " she wrote.
Two weeks later, the same dog got into more Stride gum, which her owner forgot to remove from her purse. The gum was a different flavor, which meant it might have a different amount of xylitol. Dornhoff called Mondelēz again. It was a Friday after business hours.
"The department that had the required information had gone home,” Dornhoff told the VIN News Service. “Someone answered the number labeled for emergency medical information but all they could say was that no one was there who could look. I'm not sure what the point is of having someone answer the phone at the number for after-hours emergency if they don't have any information."
Dornhoff kept pushing. The agent eventually offered to contact an on-call customer service representative she thought could help. When that person came on the line, Dornhoff said, she provided generic information along the lines of: "There have been cases of dogs weighing 20 pounds getting sick after eating two to three pieces of at least one flavor from their extensive number of possibilities, so that should be the guideline for treating." But following that guideline would have meant a hospital stay for the dog and bill of a few hundred dollars for the owner, Dornhoff said.
Since the Maltese was running around “like a maniac” with no signs of hypoglycemia, and a blood test showed her liver was fine, the doctor decided to send the dog home.
On the Monday afterward, about midday, a Mondelēz representative called Dornhoff to provide the xylitol content. The veterinarian was unimpressed.
"I told them that was nice, but the dog could be dying by now,” Dornhoff related on VIN.
After learning of the episode from the VIN News Service, Mondelēz manager Cass investigated and said she discovered that the process for handling medical calls was different during and after business hours, but it should not have been.
“Mistakes do happen and we corrected it immediately,” Cass said. “We’re glad the pet was OK.”
She said doctors now should be able to obtain the needed information in fewer than 30 minutes, regardless of when they call, provided they sign the confidentiality agreement.
That confidentiality agreement troubles Dornhoff because it comes with a company directive not to document the xylitol content of their gum in the patient’s medical record. Is that even legal? she wondered.
According to VIN counsel Raphael Moore, the situation poses separate, if conflicting, legal obligations for the practitioner.
"A company can certainly protect its proprietary information," Moore told the VIN News Service by email. "And they can require you to agree to disclosure terms. On the other hand, you have a duty to include in the medical file all pertinent information, which would include these details."
Moore said he would not advise practitioners to sign any agreement they do not intend to honor. However, if a veterinarian insisted on obtaining the data for proper treatment, he said, damages from breaching the contract could be mitigated by sealing the information in an envelope kept separate from the file and placing a note in the file that the information was obtained, but without referencing any of the values. The practitioner could further obtain agreement from the pet’s owner that he or she is not entitled to the data, Moore said.
Dornhoff came up with a different solution, which was to put in the record that the amount was or was not within the danger range. She did not place any proprietary information in the file.
Cass of Mondelēz said she could not speak to a veterinarian’s legal requirement to keep a complete medical file. “The confidentiality agreement is to make them understand our need,” she said.
Whether other major gum makers require promises of secrecy is unclear. In emailed responses to queries by the VIN News Service, Wrigley and Hershey did not answer the question.
VIN toxicology consultant Gwaltney-Brant said she understands a company's right to protect intellectual property, but sharing information with the Animal Poison Control Center is safe. “Just give us a ballpark," she said. "We're not going to make gum in the garage.”
VIN News Service commentaries are opinion pieces presenting insights, personal experiences and/or perspectives on topical issues by members of the veterinary community. To submit a commentary for consideration, email firstname.lastname@example.org.
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