Cocaine Crawlies and Marijuana Munchies: Accidental Pediatric Ingestions
Written by Omar Hilal MD, Edited by Akshay Elagandhala MD
Patients frequent the ER with complaints pertaining to drug and substance abuse/misuse often. These substances can range from heroin to cocaine to sulfonylureas, and the spectrum of the clinical presentation can vary greatly. Recently, drugs of abuse have been a hot topic in politics and medicine alike and the greater political and public health implications of the presumed drug epidemics have been heavily scrutinized and debated. However, it is important to draw attention to issues with accidental ingestion of cocaine and cannabis in the pediatric population. These drugs can be lethal in small doses and the children affected can present with non-specific symptoms, further complicating the danger of these ingestions.
For the pediatric population, there is always high alert for accidental consumption of potential toxic substances. As children often explore their surroundings by putting whatever they find in their mouth, anything within reach has potential for harm. Common board questions and clinical scenarios draw attention to the possibility of accidental ingestion of grandma's TCA or of dad's methadone as they can be lethal to children under 6 years old in minuscule doses. However, recent studies have shed light on the dangers of accidental cannabis and cocaine ingestion in the pediatric population as well, indicating that these substances should also be on the differential when caring for children presenting with AMS or nonspecific symptoms with high risk for accidental ingestion and an unknown source of symptoms.
A recent retrospective cohort study by Armenian et al attempted to fill the gap in under reported accidental pediatric cocaine exposures in medical literature and to assess the clinical characteristics of such exposure based on cases reported to the California Poison Control system between the years of 1997-2010. 1 The authors examined all cocaine exposures reported to the California poison control in the above listed year span for patients 6 years old. The most common clinical manifestations of cocaine exposure were tachycardia and seizures. Also reported were altered level of consciousness and agitation with a small subset developing GI symptoms including abdominal pain, nausea, vomiting, diarrhea. This study demonstrated that of the 36 patients with positive exposure, 2/3 had moderate or major outcomes, which were defined as symptoms that were “more pronounced, more prolonged or more of a systemic nature than minor symptoms” for moderate and “life-threatening or resulting in significant disability or disfigurement” for major. For an ER provider, a child with fever, tachycardia, and seizures can easily be dismissed as a febrile seizure as it is very common. However, I urge that providers keep in mind accidental cocaine ingestion/exposure, as the outcomes illustrated in this study are severe and sending a UDS on this patient might not seem warranted but can certainly help differentiate a cause for persistent and worrisome seizures or AMS. Screening parents for history of drug use or abuse can be very helpful in elucidating which pediatric patients may benefit from drug screen testing.
Another issue in pediatrics pertaining to recreational drug use comes from cannabis, especially in areas that the drug has become decriminalized. Although cannabis is believed to be one of the more relatively harmless recreational drugs, cannabis exposure in the pediatric population can also lead to serious morbidity and mortality. A systematic review of unintentional cannabis ingestion in the journal of pediatrics conducted a literature search of published studies and case series of unintentional cannabis ingestion in children under the age of 12. The most common presenting symptoms for these patients were lethargy, ataxia, hypotonia, mydriasis, tachycardia, and hypoventilation. Many of these symptoms, when taken out of context, can be concerning for brain mass, space-occupying lesion, or meningitis. Again, screening parents by history for risk of drug use or abuse can help to avoid unnecessary testing and treatment such as CT scans, LPs, and unneeded empiric antibiotics which would be warranted in other clinical scenarios.
As cannabis becomes legalized in different states, accidental ingestion and toxicologic emergencies pertaining to this will increase, particularly when considering the many forms of cannabis and their packaging. Richards et al 2 present an interesting public health concern. The fact that cannabis can be baked and made into sweets ranging from cakes, to cookies, to candy with no limitation in the potency makes it an enticing and dangerous option with tremendous potential for overdose . According to Richards et al, some of these attractively packaged sweets can “contain up to 1000mg of THC in a single cookie, intended to be ingested in multiple doses over time.” Even in an experienced user, an ingestion of this size can cause an overdose, which should put into perspective the danger it presents to a THC-naïve child.
As the decriminalization of cannabis is a relatively new movement, there aren't many laws addressing safe packaging or packaging that won't draw the attention of children. The Poison Prevention Packaging Act of 1970, which states “opaque child resistant packaging for toxic household products, over the counter medication, and prescribed medication,”3 does not apply to recreational cannabis as the laws restricting the drug have not kept pace with the decriminalization of cannabis. As stated in the aforementioned article, children have a tendency to be "exploratory" when it comes to accidental ingestions and some of the colorful packaging. Therefore, availability of homemade products, and lack of legislation requiring safe storage and regulation of cannabis may lead to increased accidental cannabis ingestion by the pediatric population, and subsequently may increase serious medical outcomes requiring hospitalization or even ICU level care.
References
1. Armenian, P, et al. “Unintentional Pediatric Cocaine Exposures Result in Worse Outcomes than Other Unintentional Pediatric Poisonings.” The Journal of Emergency Medicine, https://www.ncbi.nlm.nih.gov/pubmed/28408236.
2. Richards, JR, et al. “Unintentional Cannabis Ingestion in Children: A Systematic Review.” The Journal of Pediatrics, https://www.ncbi.nlm.nih.gov/pubmed/28888560.
3. US Consumer Product Safety Commission. "Poison prevention packaging: a guide for healthcare professionals." Washington, DC: US Consumer Product Safety Commission (2005).