Bates

Berny

Caloni

Clough

Cope

Degrandi

Gwaltney-Brant

McFarland

StataCorp

Sánchez-Vizcaíno

Noble, Peter-John M

Newman, Jenny

Wyatt, Alison M

Radford, Alan D

Jones, Philip H

University of Liverpool Repository

Vet RecoRD | 10.1136/vr.104762 1Short communicationHeightened risk of canine chocolate exposure at Christmas and EasterPeter J M Noble,1 Jenny Newman,2 Alison Mary Wyatt,3 Alan D Radford,4 Phillip H Jones5Chocolate has long been recognised as, and remains, a common cause of intoxication in dogs accounting for 25 per cent of acute presentations for intoxication.1 2 Case numbers in Europe and the UK have been reviewed, mostly based on reports to poisons centres.3–6 Chocolate toxicity results from the methylxanthine theobromine present in cocoa bean products, causing gastrointes-tinal (eg, vomiting), cardiovascular (eg, tachycardia) and central nervous (eg, agitation and seizure) signs.7 Chocolate intoxication is mostly seen in dogs6 8 and theobromine dose calculations based on the source of chocolate are well documented7 9 and available online . 10 11 The current study reviews cases of chocolate expo-sure presented to a large sentinel network of UK veteri-nary practices between 2012 and 2017.Electronic health records were collected from 229 UK veterinary practices (500 premises) by SAVSNET.12 Records included the consultation time, species, breed, sex and clinical free text (narrative) in which inadvert-ent personal identifying data contained in narratives had been redacted using deidentification software (Newman). Narratives were screened using a regular expression13 to identify the presence of the word ‘choc-olate’, including a range of misspellings and contrac-tions (eg, ‘choc’, ‘choclat’). Cases were tagged for study inclusion if on reading they matched a definition of po-tential chocolate exposure whereby ingestion triggered either specific treatment or a plan of monitoring for clinical signs of theobromine toxicity.Data were wrangled using the Pandas library14 in Python V.3.415 and analysed using Stata V.12.16 Five unmatched controls were randomly selected for each case using animals not identified by the initial screen-ing for chocolate. To analyse risk periods, a categorical variable was generated to indicate whether a consulta-tion occurred from one week before to two weeks after Christmas, Easter, Valentine’s Day or Halloween. Uni-variable analysis of the effect of sex-neutering status, age category (0 to <4 years, 4 to <8 years, 8 years and over) and risk period was undertaken. Variables that showed a significant effect were included in a multivar-iable logistic regression model. The effect of breed was analysed using Fisher’s exact tests for each breed sep-arately (to accommodate small numbers of individuals involved) and interpreting the P value following a Bon-ferroni adjustment.In total, 1722 consultations referring to chocolate were identified from 2.7 million narratives collected be-tween November 2012 and May 2017 and of these 386 (22  per  cent) narratives from 375 individual animals were identified as matching the chocolate exposure case definition. Where an animal appeared more than once, only the first consultation was retained. Many cases (101, 26 per cent) presented within one hour of ingesting chocolate and the majority (217, 56 per cent) presented within six hours. Vomiting following inges-tion was frequently noted (64 cases, 17 per cent), while neurological signs (agitation, restlessness) were uncom-mon (12 cases, 3 per cent). Seizures were not reported in any cases. Heart rate greater than 120 bpm was noted in 28 cases (7.5 per cent). None of the clinical signs seen were considered life-threatening. Age category and risk period showed significant univariable effects and were included in a multivariable model. Chocolate exposure was significantly less common in old dogs (odds ratio (OR)=0.42, 95  per cent, confidence interval (CI) 0.31 to 0.56, P<0.001) and potentially less common in mid-dle-aged dogs (OR=0.77, CI 0.59 to 1.01, P=0.058) than dogs under four years of age. No breed was associated 10.1136/vr.104762Veterinary Record (2017) doi: 10.1136/vr.1047621University of Liverpool, Institute of Veterinary Sciences, Small Animal Teaching Hospital, Neston, UK2Department of Epidemiology and Population Health, University of Liverpool, Institute of Global Health, Neston, UK3University of Liverpool, Institute of Veterinary Science, Neston, UK4Department of Infectious Diseases, University of Liverpool, Institute of Infection and Global Health, Neston, UK5Department of Epidemiology and Population Health, University of Liverpool, Institute of Infection and Global Health, Neston, UKE-mail for correspondence:   P. H. Jones@ liverpool. ac. ukProvenance and peer review Not commissioned; externally peer reviewed.Received November 1, 2017Accepted December 5, 201710.1136/vr.104762 | Vet RecoRD2with an increased risk. Chocolate exposure was more commonly recorded at Christmas (OR=4.74, CI 3.04 to 7.40, P<0.001) and Easter (OR=1.97, 95 per cent CI 1.36 to 2.86, P<0.001) in this population than at non-festival dates (Fig 1); the Valentine’s Day and Halloween ORs were not significantly different from 1.0 (OR=0.94, CI   −0.56 to 1.57, P=0.803 and OR=1.55, CI 0.97 to 2.46, P=0.065, respectively). Sources of chocolate included bars and boxes (often gift selections) of chocolate (35 cases), Easter eggs (31 cases), chocolate cake (22 cas-es), liqueurs (5  cases), chocolate rabbits, Santa Claus figurines, Advent calendars and Christmas tree deco-rations (10 cases), as well as one case involving a hot chocolate drink. Dogs ingested chocolate oranges (15 cases) and Toblerone (6 cases) and in one case, both (six of each). Chocolate co-ingestion alongside raisins (three cases) and single cases of paracetamol, ibupro-fen, xylitol and onion were noted without evidence that these caused disease. While chocolate doses were often small, exceptions included ingestion of a garden of Easter eggs hidden for a large party of children. Doc-umented treatments included activated charcoal (121 cases), apomorphine (114 cases), intravenous fluid therapy (12 cases) and anti-emetics (31 cases, usually following apomorphine). Activated charcoal therapy of-ten followed induced emesis but in 65 cases, it was the sole therapy. Theobromine dose was noted or could be inferred from chocolate dose details in 185 narratives of which 75 narratives (41 per cent) reflected non-toxic doses (less than 20 mg/kg).17 In 34 of these cases, pa-tients were still given apomorphine as a safety measure.Here the authors describe significant peaks of choc-olate intoxication, most notably at Christmas and to a lesser extent Easter, presumably reflecting the enhanced availability of seasonally related chocolate such as East-er eggs, chocolate Santa Claus figurines and Christmas tree decorations, possibly in the hands of younger mem-bers of society. Peaks of chocolate exposure around Valentine’s day and Halloween described in German and US reviews4 6 were not seen in the UK, perhaps re-flecting alternative romantic gift choices (or more fas-tidious curation by their recipient) and different festi-val priorities although data to support this conjecture were not available. Use of apomorphine in cases where theobromine dose appeared to be non-toxic probably reflects a belief that the low risk of toxicity in these cas-es outweighs that of emesis but runs contrary to recent recommendations which point out the lack of evidence for use of emetics in these cases.17Chocolate ingestion has a unique seasonal pattern which merits highlighting this risk to clients, particu-larly in the run-up to Christmas and Easter as chocolate becomes more accessible within the household. Given the frequent use of emetics in animals with document-ed non-toxic doses of theobromine, further research into the risks and consequences of emetic therapy is indicated.Funding Biotechnology and Biological Sciences Research Council, BB/NO19547/1.Competing interests None declared.Open Access This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: http:// creativecommons. org/ licenses/ by/ 4. 0/© British Veterinary Association (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.References	 1	 ClougH gW. Theobromine poisoning in the dog. The Veterinary Journal (1900) 1942;98:196–7.	 2	 CoPe RB, WHiTe KS, MoRe e, et al. exposure-to-treatment interval and clinical severity in canine poisoning: a retrospective analysis at a Portland veterinary emergency center. J Vet Pharmacol Ther 2006;29:233–6.	 3	 BeRNy P, CAloNi F, CRouBelS S, et al. Animal poisoning in europe. part 2: companion animals. Vet J 2010;183:255–9.	 4	 gWAlTNey-BRANT SM. ToxiCology V, epidemiology of animal poisonings in the united States: elsevier, 2012:80–7.	 5	 CAloNi F, BeRNy P, CRouBelS S, et al. Chapter 7 epidemiology of animal poisonings in Europe. Veterinary toxicology. 2nd edn, 2012:88–97.	 6	 MCFARlAND Se, MiSCHKe RH, HoPSTeR-iVeRSeN C, et al. Systematic account of animal poisonings in germany, 2012-2015. Vet Rec 2017;180:327.	 7	 gWAlTNey-BRANT S. Chocolate intoxication. Vet Med 2001;96:108.	 8	 DegRANDi C, HeRMANNS-ClAuSeN M, HoFeR Ke, et al. Chocolate poisonings in dogs: a consecutive case series. Clinical Toxicology 2016;54:515.	 9	 BATeS N, RAWSoN-HARRiS P, eDWARDS N. Common questions in veterinary toxicology. J Small Anim Pract 2015a;56:298–306.	10	 PetSci. Chocolatetoxicity calculator for dogs. 2017 http:// petsci. co. uk/ chocolate- toxicity- calculator- dogs/ (accessed 6 oct 2017).	11	  VeterinaryClinic. com. Chocolate toxicity calculator. 2017 http:// veterinaryclinic. com/ chocolate/ calc. html (accessed 6 oct 2017).	12	 SáNCHez-VizCAíNo F, NoBle PM, JoNeS PH, et al. Demographics of dogs, cats, and rabbits attending veterinary practices in great Britain as recorded in their electronic health records. BMC Vet Res 2017;13:74.	13	 Regular expression operations. |6.2. re — Regular expression operations|. https:// docs. python. org/ 3/ library/ re. html (accessed 4 Dec 2017).	14	 MCKiNNey W. Data structures for statistical computing in python proceedings of the 9th python in science conference, 2010:51–6. http:// pandas. pydata. org	15	 Python Software Foundation. Python language reference version 3.4. http://www. python. org	16	 StataCorp. Stata statistical software: release 12. College Station, Tx: StataCorp lP, 2011.	17	 BATeS N, RAWSoN-HARRiS P, eDWARDS N. Common questions in veterinary toxicology. J Small Anim Pract 2015b;56:298–306.Chocalate exposure through the yearOdds ratio for presenting with chocolateexposureConsults per weekWeek number101234567150306 11 16 21 26 31 36 41 46 51Weekly  countOdds ratio at valentine’sOdds ratio at easterOdds ratio at halloweenOdds ratio at christmasOR = 1FIG 1: Weekly count of chocolate exposure consultations (blue line, left axis) with odds ratio for presenting with chocolate intoxication during given celebration periods (bars±95% CI, right axis). Note: Easter occurs in different weeks each year.

Heightened risk of canine chocolate exposure at Christmas and Easter

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