Pediatric presentations and risks from consuming cannabis edibles

In Canada, the federal government’s proposed Cannabis Act aims to create a “strict legal framework for controlling the production, distribution, sale, and possession of cannabis across Canada.”[1] One area of concern is the possibility that regulations on the production, sale, and use of cannabis edibles will not be part of the initial laws. The ongoing unregulated availability of cannabis edibles poses a particular risk to children who are more likely to unintentionally ingest such products. In Colorado, the rate of hospitalization from unintentional pediatric exposures to cannabis was almost double 2 years after legalization when compared with 2 years before legalization, with almost half of those exposures being from cannabis edibles.[2]

When assessing and advising patients, physicians need to be aware of the health risks associated with cannabis edibles. Edible products containing tetrahydrocannabinol (THC) are typically indistinguishable from noncannabis products in their look and taste. Efforts to limit accidental exposure to edibles in Colorado, similar to other states, include regulations requiring child-resistant packaging, laws against mass-marketing campaigns, regulations to limit the THC serving size to 10 mg per product serving and 100 mg per package, and requirements for a universal warning symbol to be on all edibles packaging.[3] Even with such regulations, risks of overconsumption and intoxication remain for all ages.[4] For instance, older children can overcome child-resistant packaging. 

Younger children can gain access to previously opened or partially consumed products. Moreover, warnings and limitations on THC-containing products and packages target only older users. Children, and some adults, would not distinguish a THC serving size, for example a single piece of candy, from a typically larger food serving size. 

A review of the National Poison Data System in the United States between January 2013 and December 2015 identified 430 calls associated with cannabis edibles for children and adults. Children 5 years and younger had the highest rate at 0.15 calls per 100 000 population per year. In this study, this age group was more likely to have drowsiness/lethargy, ataxia, and red eye/conjunctivitis.[5]

Unlike the range of presentations in older children and adults, infants and toddlers with cannabis intoxication primarily present with altered levels of consciousness ranging from mild encephalopathy to coma. Ingestion of cannabis cookies is the most common route of exposure for this age group. Serious events primarily occur in children under the age of 3. The acute encephalopathy often has few systemic clinical signs to indicate intoxication, but commonly associated features include dilated pupils, hyporeflexia, and hypotonia. In many cases, nonspecific neurological presentations can result in delays in diagnosis.

Treatment consists of supportive measures including intravenous fluid hydration. Deep comas may require airway support for obstruction and ventilation. At least 6 hours of observation has been recommended; however, some cases have symptoms persisting beyond 24 hours. Lack of an initial ingestion history is common, and specific history of therapeutic and recreational drugs for all recent caregivers should be sought. Early consideration of a urine toxicology screening may prevent other unnecessary investigations. Histories must include assessment of child protection issues in such cases of poisonings.[6-8] To date, there have not been any reported cases of pediatric deaths from cannabis edibles.

To mitigate the risks of cannabis edibles on children, governing authorities should consider implementing improved education for parents (and all consumers); requirements on packaging, labeling, and marketing; and limitations on THC content. To effectively treat cases of cannabis poisoning in children, physicians need to be aware of the potential risks and presentations associated with the ingestion of cannabis edibles. 
—Michelle Murti, MD, FRCPC

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This article is the opinion of the Emergency and Public Safety Committee, a subcommittee of Doctors of BC’s Council on Health Promotion, and is not necessarily the opinion of Doctors of BC. This article has not been peer reviewed by the BCMJ Editorial Board.

References

1.    Government of Canada. Legalizing and strictly regulating cannabis: The facts. Accessed 17 July 2017. www.canada.ca/en/services/health/campaigns/legalizing-strictly-regulatin....
2.    Wang GS, Le Lait MC, Deakyne SJ, et al. Unintentional pediatric exposures to marijuana in Colorado, 2009-2015. JAMA Pediatrics 2016;170:e160971.
3.    Department of Revenue. Laws: Constitution, statutes and rules—marijuana enforcement. Accessed 17 July 2017. www.colorado.gov/pacific/enforcement/laws-constitution-statutes-and-rule....
4.    MacCoun RJ, Mello MM. Half-baked—the retail promotion of marijuana edibles. N Engl J Med 2015;372:989-991.
5.    Cao D, Srisuma S, Bronstein AC, Hoyte CO. Characterization of edible marijuana product exposures reported to United States poison centers. Clin Toxicol (Phila) 2016;54:840-846.
6.    Appelboam A, Oades PJ. Coma due to cannabis toxicity in an infant. Eur J Emerg Med 2006;13:177-179.
7.    Lavi E, Rekhtman D, Berkun Y, Wexler I. Sudden onset unexplained encephalopathy in infants: Think of cannabis intoxication. Eur J Pediatr 2016;175:417-420.
8.    Onders B, Casavant MJ, Spiller HA, et al. Marijuana exposure among children younger than six years in the United States. Clin Pediatr (Phila) 2016;55:428-436.