Grandma’s brownies are not what they used to be: Acute intoxication from cannabis ingestion

A previously healthy, fully vaccinated 18-month-old boy presented to the emergency department (ED) because his mother noted that he vomited twice at home, was very sleepy and seemed off balance when she returned from work. The child was watched by his grandmother who lives in the basement of the same house. He had no other infectious symptoms and no history of trauma. His vital signs on presentation were as follows: Temperature 37.2°C, heart rate 142/min, respiratory rate 26/min, blood pressure 96/58 mm Hg, and oxygen saturation of 98% on room air. His pupils were 4 mm bilaterally and reactive to light. His physical examination was normal, except for a notably somnolent but rousable child. There were no focal neurological deficits. A urine dip and a point of care glucose was completed. Both results were unremarkable. Upon further questioning, the patient’s mother spoke with the grandmother and discovered that the child may have eaten a marijuana brownie that the patient’s grandmother had left out on the kitchen table. A urine toxicology screen confirmed cannabinoids. The ED physician and the social worker reinforced the importance of safe storage practices for cannabis in the home, similar to other medications, drugs and alcohol. The child was observed for several hours in the ED. He tolerated oral intake and was later discharged home with normal vital signs. There has been an increase in cannabis-related ED visits in all age groups (1). With the legalization of cannabis in Canada, the prevalence of what was once the country’s most commonly used illicit drug may also increase. Most of the evidence regarding paediatric cannabis intoxication is from Colorado, where medical cannabinoids were legalized in 2000 and cannabis was legalized in 2014 (2). If Canada follows the pattern, there will also be an increase in cannabis ingestions among children, both from increasing availability, as well as from a decreased perception of harm of cannabis, as illustrated by the case (3). Paediatric cannabis ingestions have increased in states where cannabis is legal compared to other states within the USA where cannabis is illegal (3). In the highest cannabis consuming country in Europe, France, there has been an increase in unintentional paediatric cannabis intoxication and an increase in severe presentations in children over a 10-year period (4). In the United States, there has also been dramatic increase in poison control calls in states pre- and postlegalization of medical cannabinoids (5). In children, the most common place of ingestion is within the child’s own home (4). Similar to other accidental paediatric ingestions, grandparents are also a frequent source of the cannabis (6). A systematic review by Richards et al. revealed that the most common paediatric ingestion of cannabis was cannabis resin, followed by edibles and joints (7). Other possible cannabis exposures include passive smoke, drinks, medical cannabis, and hemp oil. Young children are especially vulnerable to edible products as they are often in the form of candies, cookies, or brownies. The amount of delta9-tetrahydrocannabinol (THC) in edibles is variable and can be potentially high. There has been an increasing THC concentration in cannabis in the past few years (4). With the legalization of cannabis in its different forms entering the market, paediatricians should routinely be asking about potential of cannabis exposure when assessing children in any setting. Children can present with CNS depression, such as lethargy or somnolence, with the most serious effect being respiratory depression and coma. While lethargy is the most common presenting sign, anxiety, nausea, vomiting, dizziness, ataxia, agitation, and seizure have all been described in paediatric case reports of cannabis ingestion (7). Physical examination findings may include tachycardia, mydriasis, injected conjunctiva, hypotonia, or ataxia (8). Urine drug screens can be misleading as they can remain positive for a prolonged period postexposure (9). As such, a positive screen does not necessarily exclude other possible diagnoses. Management of acute intoxication from cannabis ingestion in children is mainly supportive and symptom based. Depending on the effective dose, the child may recover after some observation or require admission to the hospital wards (10). Some children have even required admission to the paediatric intensive care unit for persistent altered level of consciousness and/or respiratory depression (6,10). The plasma peak is estimated to be 1 hour for inhalation, 4 hours for ingestion, and the effects last between 6 and 24 hours, although an even longer effect has been documented (11). Anticipatory guidance with regards to safe storage of cannabis products, including edibles, is also important prior to discharge of patients. If neglect or abuse is suspected, it is imperative that child protective agencies should be contacted. There is a decreasing perception of harm of cannabis that goes along with its legalization. With this, there is an increasing risk of paediatric cannabis exposures through passive smoke, edible products, and hashish or joints that are left out in homes with children (12). It is important to consider acute intoxication from cannabis ingestion when assessing altered level of consciousness, and paediatricians need to be familiar with the symptoms of cannabis ingestion. A delay in recognition of cannabis exposure is associated with an increased length of stay in hospital, higher resource utilization, and more medical testing (13). Paediatricians have an important role in identifying and advocating for regulations and effective prevention strategies for cannabis ingestion in children. Physicians should routinely be asking about potential of cannabis exposure when assessing children Management of acute intoxication from cannabis ingestion in children is mainly supportive Early recognition is key to avoid over investigation and a prolonged length of stay Anticipatory guidance around safe storage of cannabis containing products in homes with children is important at well child visits and prior to discharge from the ED The author would like to thank the families, patients, physicians, nurses and staff of McMaster Children’s Hospital Emergency Department and colleagues in the Department of Paediatrics at McMaster University for their support. Potential Conflicts of Interest: The authors No reported conflicts of interest. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. Funding: The work on which this manuscript is based did not receive funding from any agency in the public, commercial, or not-for-profit sectors.

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