Pediatric Annals

Healthy Baby/Healthy Child 

Acute Marijuana Intoxication in Children

M. Denise Dowd, MD, MPH

Abstract

As the number of states legalizing marijuana for medical and/or recreational use continues to grow, there are an increasing number of children exposed to marijuana-containing products in homes and communities. Increased exposure leads to a greater probability of accidental ingestion and toxicity. Because marijuana ingestion can cause a dangerous and potentially life-threatening toxicity for children, pediatric health care providers need an increased awareness of the danger. This article describes the growing problem and outlines clinical management as well as prevention. [Pediatr Ann. 2018;47(12):e474–e476.]

Abstract

As the number of states legalizing marijuana for medical and/or recreational use continues to grow, there are an increasing number of children exposed to marijuana-containing products in homes and communities. Increased exposure leads to a greater probability of accidental ingestion and toxicity. Because marijuana ingestion can cause a dangerous and potentially life-threatening toxicity for children, pediatric health care providers need an increased awareness of the danger. This article describes the growing problem and outlines clinical management as well as prevention. [Pediatr Ann. 2018;47(12):e474–e476.]

Marijuana is the most commonly used recreational drug in the United States with an estimated 22 million people using it monthly based on 2015 data from the National Survey on Drug Use and Health.1 According to one large survey, rates of marijuana use among teens have increased as perceptions about risk have decreased.2 In the survey, more than 1 in 3 high school seniors endorsed using marijuana in the preceding year.2 Based on an analysis of the National Poison Data System, there is a documented association of unintentional pediatric exposures with legalization of marijuana in the United States.3 An additional factor contributing to the severity and risk of marijuana intoxication is that the potency of marijuana has significantly increased in the last few decades. In the 1980s, the percentage of delta9-tetrahydrocannabinol (THC) in recreational marijuana was 4% but it had increased to 12% by 2012.4 Emergency department (ED) visits for marijuana have increased for both adults and adolescents in recent years, with the fastest increase in rates observed in those age 12 to 17 years. Between 2004 and 2011, rates of ED visits for marijuana doubled in this age group.5

Mechanism of Action

Marijuana contains approximately 60 pharmacologically active cannabinoids.6 The two for which there is the most information are THC and cannabidiol (CBD). The importance and impact of the other active components in marijuana is mostly unknown. THC is the main psychoactive compound in marijuana and functions in a dose-dependent manner, affecting several different areas of the brain and spinal cord. By exerting antagonistic effects on the CB1 receptor, THC causes mood changes, perception alteration, disturbance of memory function, and impaired judgement.6 Contrary to popular notions, marijuana is an addictive substance, with 9% of those using it recreationally becoming addicted.7 Compared to other forms of consumption, smoking marijuana has the highest addictive potential due to rapid and efficient drug delivery to the brain.3 When ingested orally, the absorption is slow and a significant portion of THC is degraded in the stomach, with bioavailability of 10% to 20%. Peak concentration usually occurs within 1 to 2 hours but can take as long as 8 hours.6

Uses, Available Forms, and Risks

Marijuana can be consumed in a variety of ways, including vaporization, smoking, oral ingestion, as well as via transcutaneous, rectal, and vaginal routes. Its legalization in several states has led to increasing availability in edible forms such as as candy, baked goods (eg, cookies, brownies), and beverages. Synthetic forms of THC are available via prescription (nabilone and dronabinol). These forms of THC do not have the hallucinogenic properties of naturally occurring marijuana, and their approved uses include treatment of anorexia in patients with AIDS and treatment of nausea and vomiting caused by chemotherapy for patients with cancer.8

In young children, the most common place of ingestion is in the patient's home,9 with more than one-half of them consuming an edible form of marijuana.10 Edible products are particularly attractive to young children as they are often in the form of a food that is highly attractive such as cookies, brownies, or candies. The amount of THC in a single product can be variable and potentially high. In many instances, a single chocolate bar or brownie can contain 10 to 50 adult doses of THC and thus is extremely toxic for a child.11 The documented increasing THC percentage in marijuana in the last several years has been recognized as a factor in the increased incidence of serious ingestions (ie, those causing seizures or requiring intubation).9,12

Clinical Presentation

As the amount of THC in marijuana products may be high, young children who ingest them are usually symptomatic. There is a direct relationship between the estimated milligrams of THC per kilogram of body weight ingested and the level of medical intervention needed.13 Most commonly, young children who generally are naïve to marijuana present with altered mental status.14 Parents often report that the lack of responsiveness happens suddenly, but it should be noted that symptom onset may happen 1 or 2 hours after ingestion.15 Children may become ataxic, somnolent, confused, and difficult to arouse.13 Seizures have been reported, and generalized hypotonia is not uncommon.12 Many become agitated and may vomit. Respiratory depression with a range of severity is possible, and in some instances it requires supportive intervention. Older children and adolescents may present with anxiety, dysphoria, ataxia, slurred speech, injected (ie, red) eyes, tachycardia, and increased respiratory rate.16

Medical Management

Supportive care is the first order of consideration, with initial attention to airway, breathing, and circulation. Cases of young children presenting in a coma requiring respiratory support are not unusual, so the ability to perform rapid sequence intubation should be assured.10 After stabilization of cardio-respiratory status, a broad evaluation for presenting symptoms should take place. Most commonly, an evaluation of altered mental status will be needed. Assessment includes bedside glucose measurement, electrolytes, complete blood count, toxicology screen, and computed tomography scan of the head. If the clinical picture is consistent with meningitis, a lumbar puncture should be considered.

A urine toxicology screen can identify cannabinoids and can be positive up to 30 days after ingestion by chronic users.16 A single ingestion in a nonuser typically results in a urine drug screen that will be positive only up to 72 hours.17 In any possible ingestion with diminished level of consciousness and respiratory depression, a dose of nalaxone can be given. Improvement after naloxone indicates possible opiate or clonidine toxicity but will not be effective for those with THC toxicity.18 Co-ingestion with other recreational drugs (eg, cocaine, phencyclidine) should also be considered, and a urine toxicology screen for drugs of abuse should reveal this.

Treatment is supportive and based on symptoms. Seizures should be treated with benzodiazepines, which are indicated for treatment of anxiety and dysphoria in older children as well. Reassurance and reduction of environmental stimulation/comfort measures are also useful in children with anxiety.

Use of activated charcoal is not recommended because symptoms are often delayed by 1 to 3 hours.18

The duration of symptoms after marijuana exposure can vary from 4 to 48 hours depending on the amount ingested.19 Hospital admission and observation in the ED should be guided by the severity of the symptoms. Social work evaluation to assess home safety and parental supervision is highly recommended.

Social Trends and Prevention

The number of states legalizing medicinal and recreation marijuana is growing. Nine states and the District of Columbia have legalized marijuana for recreational use in adults age 21 years and older, and medical marijuana is legal in an additional 30 states.20 Attitudes toward cannabis use and legalization have become more positive over time, with the latest Gallup poll finding 66% of Americans supporting legalization.21 As legal and attitudinal trends become more favorable and as retail accessibility of marijuana increases, THC-containing products will be found more frequently in homes with children. Because many of the forms of edible marijuana products are identical to common and attractive food products, their risk to small children is particularly great. Parents must understand the danger of all forms of marijuana, so education on safe storage is imperative. Parents should also have an appreciation for the toxic effects of edible marijuana on children and that toxicity can happen with small ingestion due to high THC levels in edible products.

Most states have regulations that require clear labeling on marijuana product packaging, including warnings to keep in its original packaging and out of reach of children. Yet, clearly this is not enough. The American Academy of Pediatrics advises storing marijuana products in locked locations or in child-resistant packaging, never consuming marijuana edibles in front of children, and talking to friends and family members about storage of their products.22,23 Using the example of Colorado child health providers, pediatricians can advocate for legislation that requires mandatory child-resistant packaging for recreational marijuana.3,24

References

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Authors

M. Denise Dowd, MD, MPH

M. Denise Dowd, MD, MPH, is the Associate Director, Office for Faculty Development, and the Medical Director, Community Programs, Department of Social Work, Children's Mercy Hospital; and a Professor of Pediatrics, University of Missouri-Kansas City School of Medicine.

Address correspondence to M. Denise Dowd, MD, MPH, via email: ddowd@cmh.edu.

Disclosure: The author has no relevant financial relationships to disclose.

10.3928/19382359-20181119-02

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