Initial studies suggest that pediatric exposures are up, but adverse effects are low
Lethargy, coma, and ataxia don’t sound like your typical marijuana high. But with almost half the country decriminalizing marijuana and a few states legalizing recreational marijuana, this could be a much more common presentation in your emergency department.
This is in part due to the increasing possibility of unintentional pediatric exposures to marijuana. While adults usually experience conjunctival injection, increased appetite, dry mouth, and tachycardia with normal doses [1], children are more susceptible to severe neurological effects, like coma and ataxia with the same dose [2]. Because of their smaller body weight, and an often unintended higher dose when unknowingly eating marijuana-infused foods, a dose that would make an adult less nauseous, euphoric, and hungry could make a child unconscious [3,4].
Ingesting marijuana as a plant is both unappetizing and difficult; but as marijuana assimilates into medical and recreational use, it is more commonly baked into fudge, cookies, brownies, gummy bears, hard candy, gelato, sauces, and oils, where kids can access and eat them more easily, and unknowingly. While smoking marijuana is an option for patients with recognized legal indications, like HIV-associated wasting, glaucoma, cancer-related nausea and cachexia [5], it is most often prescribed in pills as marinol, or as a tincture (oil), which can be baked into foods. Packaging and labeling of these foods has yet to be regulated, so to a young child, these foods can be indistinguishable from a normal dessert.
These changes in marijuana formulations parallel changing state laws, as states can have one of four legal takings on marijuana. Washington, Oregon, Alaska and Colorado allow recreational use. Twenty-two states, including DC, allow medical use, and the rest either decriminalize it by imposing small fines on offenders or leave it as a crime punishable with jail time. To legally possess and use the drug, the marijuana dispensaries and consumers must both have permits, although the source of marijuana plants is not yet necessarily government regulated [6], leaving the exact composition and source of marijuana sometimes unclear.
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In states that haven’t decriminalized marijuana yet, or have only done so recently, there hasn’t been much of a change in exposures. In Illinois, for instance, medical marijuana has been legalized, but dispensaries have yet to be licensed, leaving patients in limbo. Both individual providers and statewide poison control centers report no real change. “I haven’t really seen any cases in my time here, nor do I expect much of a change,” said Susan Fuchs, MD, Associate Head of Pediatric Emergency Medicine at Ann & Robert H. Lurie Children’s Hospital of Chicago. “I don’t think legalized medical marijuana will change anything here in Illinois.” Alison Tothy, MD, pediatric emergency physician at the University of Chicago, just eight miles south of Lurie Children’s, said she also does not expect a change in visits. “I haven’t seen many cases… The symptoms described in [recent]studies do make sense, though, since it takes a smaller dose to have a significant impact based on the size and weight of a child, compared to an adult.”
The Illinois Poison Control Center corroborates what the providers are saying: there hasn’t been much of a change. Unlike legalized states, Illinois and others have not closely been studied, leaving providers and the public mostly with anecdotes, and information from other states. “I imagine states like Illinois will learn from others, like Colorado, in terms of how to handle these cases as our laws advance,” Steve Aks, DO, director of Illinois Toxikon said. “But for now, we haven’t seen much. I think as the infrastructure for marijuana establishes itself here, we’ll see more cases.”
The studies haven’t always agreed on whether or not things have changed either. For instance, a 2012 Annals of Epidemiology study found no change in adolescent marijuana use between 2002 – 2008 [7], while another article a year later found it had increased [8]. Other articles from the same period also arose, again, with opposing conclusions [9,10]. One thing they did have in common is they mostly focused on adolescents, who often consumed the drug intentionally.
The authors of a July 2014 study from Annals of Emergency Medicine entitled “Association Of Unintentional Pediatric Exposures With Decriminalization Of Marijuana In The United States” finally focused more on children and unintentional exposures. They looked at the rate of children’s exposures to marijuana before and after legalization of recreational marijuana in Colorado and found a new increase in unintentional marijuana ingestions; a 30.3% increase in poison control call volumem [11] and a 2.4% increase in actual emergency department visits after marijuana exposure between 2005 and 2011 in states that had passed marijuana legislation [12].
Sure enough, national data supports this as well. The National Poison Data System annual reports show a 19.5% increase marijuana single exposures from 2006 to 2013 for those younger than 19. Unintentional exposures was at 65.8%, although that also included adults [13].
The data seem to represent the experience providers are having in legalized states with increased call volumes and emergency department visits. After 14 years of medical marijuana being legal there, Colorado became the first to legalize recreational marijuana on January 1, 2014, giving providers in that state the most experience in dealing with the potential consequences of exposures. “For the first time, we’re seeing people come to the ER with marijuana exposure as a primary complaint,” said Kennon Heard, MD, PhD, Chief of Toxicology at University of Colorado, and co-author of Wang’s article. “When I was in residency, that simply wasn’t true. But ever since the government left each state up to enforce marijuana laws, and we legalized medical marijuana, we’ve seen at least a couple per month. Before that, we saw zero in probably five years. Kids get into foods with THC in them, without realizing that not only do they have adult doses of THC in them, but each brownie tends to be multiple doses. And these foods are often unlabeled, so to a four year old, it just looks like a normal brownie and they end up with a whopping dose. Even then, most kids are fine.”
In addition to the common neurological effects, marijuana exposure in kids has led to presentations previously unfamiliar to providers. “We’ve also seen a cannabinoid hyperemesis, which is absolutely a thing now,” Dr. Heard said. “It surprises patients because most people think of marijuana as an antiemetic, but with high doses in kids, it seems to present differently.”
Not only has the legal status changed in some states, but its form has changed as well.
“The THC is more potent than it used to be, and it’s tasty now,” Dr. Heard continued. “Kids wouldn’t get exposure through the plant, because the plant didn’t look good or taste good, and even if they ate it, it’s not pharmacologically active unless it’s heated. Now that it’s in candy and food, unintentional pediatric exposures are much more common. Screening for marijuana exposure and use is routine in our ER now.”
Since emergency rooms aren’t the only group on the front lines, primary care will likely see an increase in states where marijuana is legal. Dilek Bishku, MD, a pediatrician in Oregon says she mostly sees children after second-hand smoke exposure, and they’re usually asymptomatic. Oregon will be the fourth state with legalized recreational marijuana come July 1, and already has legalized medicinal marijuana. “Although I haven’t seen any brownie eaters, we do see kids with secondary smoke exposure to weed – interestingly through grandparents more than parents. Since parents probably do not tell us anything if they are the smokers themselves from a lingering stigma of weed, there are probably many cases that do not get called in to poison control, or brought to the ER or here.”
Zane Horowitz, MD, Medical Director at the Oregon and Alaska Poison Center, said they’ve seen about 30 cases of preschoolers getting into marijuana in the last three years. “I think the biggest change has already happened. People get marijuana with or without ‘medical cards’ or permits, and I don’t think the legalization of recreational marijuana in Oregon July 1 will make much of a difference. The medical marijuana seemed to make the biggest difference, because that is what built the infrastructure. I think using common sense and keeping marijuana-laced edibles out of reach of children is important in helping reduce these exposures.”
So although there is an increase in visits, it seems with only a 1.3% admission rate, zero fatalities [14], and many physicians on the front lines and studies reporting no significant change in severity, pediatric marijuana exposures may be more of an educational issue than a medical one. “When kids present with fatigue, or scleral injection, or even coma, and it’s hard to know what the etiology is, and marijuana may not even be on your initial differential diagnosis,” Aaron Schneir, MD, the Director of Medical Toxicology Education at University of California San Diego explained. “It is therefore important to consider marijuana exposure in a child who has a sudden change in behavior, is not acting right, or is even comatose, as parents may be reluctant to provide marijuana as a possible exposure. Educating providers to consider an accidental marijuana exposure as the cause of a presentation is key – hopefully avoiding testing and interventions that may not be necessary. I am actually more concerned about the consequences of medical workups and interventions that may done appropriately in a child when a clear exposure history is not provided, than a serious adverse medical complication from the exposure itself. Death from marijuana use or exposure in children is possible, but extremely unlikely.”
In addition to the acute effects of marijuana, there is also the potential for chronic effects like addiction potential, mental illness and impaired brain development. These are mentioned by a 2014 Schizophrenia Bulletin article, claiming marijuana use was linked with disrupted brain development and mental illness, including schizophrenia [15]. Several also claim small loss of IQ [16], impaired school performance [17], stroke [18], atrial fibrillation [19] and increased addiction potential [20]. These effects, while significant, mostly affect intentional users, however. Children who are unintentionally exposed while eating a brownie are less susceptible, as they usually have only an isolated exposure to marijuana.
As with almost anything in medicine, prevention is the best step for children. Adding child-proof caps to prescription medications and toxic household chemicals significantly reduced unintentional exposures, and as both a prescription medication and a potential toxic substance, THC products should have poison prevention packaging. Since marijuana laws have only recently been changing, studies and experience in dealing with exposed patients is scarce. In time, these anecdotes and case studies will become large studies and protocols using evidence-based medicine, further educating providers and the public on how to safely handle medical and recreational marijuana and its consequences.
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