More Marijuana More Problems for Young Children Part 2: Additional Problems for the Aforementioned Children

In the summer of 2018, when the SARS-CoV-2 pandemic was on the distant horizon and full facial nudity was rampant in our nation’s hospitals, I wrote about the problem of increasing numbers of young children becoming ill after accidental ingestion of cannabis as laws, social norms, and perception of risk continued to relax. I particularly focused on a 2017 systematic review of unintentional cannabis ingestions in children which had several interesting findings:

1. Children with cannabis toxicity more commonly present with lethargy, difficulty walking, poor muscle tone, fast heart rates, and low respiratory rates.
2. Young children explore their environment with their mouths, so ingestions most likely result from discovery of cannabis-infused food items left unsecured by an adult.
3. Older children like to eat things that look and/or taste good, and many edibles come in the form of cookies, candies, and cakes in attractive and familiar packaging.
4. Commercial edibles can contain extremely high doses of THC and are meant for consumption over time, but kids like to eat the whole damn thing.
5. Hashish is often mistaken for chocolate by young children.
6. Unintentional pediatric ingestions have increased in states where marijuana has been legalized, particularly recreational use, and this is expected to continue.
7. In these states, the perception of toxicity risk is lower compared to states where marijuana is not legal.
8. Acute and chronic marijuana use by adults can impair cognitive and executive function, attention, and memory, which might increase the risk of improper storage.
9. There are no federal regulations on the packaging of cannabis products, as there are with all other toxic household products, OTC medications, and prescription medications.
10. This is going to get worse before it gets better.

In May of 2023, a full decade later in COVID years, there are still no federal regulations on the packaging of cannabis products. Many states, however, have enacted specific laws regarding labeling and child-resistant packaging. For example, my home state of Massachusetts has some of the strictest rules and regulations. Obviously states like Texas, where neither medical or recreational marijuana has been legalized, have no such safety regulations. And no laws on the books are capable of preventing caregivers of young children from haphazardly leaving their stash of edibles where kids can get their grubby mitts on them.

The last interesting tidbit from the 2017 systematic review on that list was sadly, and unsurprisingly, extremely accurate. In fact, according to a paper published in February in Pediatrics, there was a roughly 1,400% increase in the number of young children that were unintentionally exposed to edible cannabis products from 2017 through 2021 based on the most recent available national poison control center data. That wasn’t a typo.

The authors of the paper found that in 2021 there were 3,054 reports of children in the United States under the age of 6 years that had ingested edible cannabis. In 2017, that number was 207. Virtually all of these ingestions occurred at someone’s home, with 90% of them taking place at the home of the child. Also of note, these events increased from .2 per every 1,000 national poison data system (NPDS) cases to 3.6 per 1,000 at the end of the 5 year study period.

During the period of 2017 to 2021, just over seven thousand edible cannabis exposures were reported in infants and toddlers. And despite the fact that cannabis has a largely undeserved health halo and is often thought of as low risk, it is far from harmless. This is particularly true in children, from newborns to adolescents, who have developing brains that can be negatively affected in ways that weren’t appreciated when exposure was less frequent and the potency of THC delivery systems was much lower.

The study found that 22.7% (1,600) of the reported cases resulted in a hospital admission, with 8.1% of them, or around 600 of these young children requiring PICU level care. 2.2% (155) involved a major adverse effect, which is defined in the NPDS as “life-threatening or causing residual disability or disfigurement.” Almost 22% (1,539) of the cases were moderate. The NPDS defines moderate effects as “more pronounced, more prolonged or more of a systemic nature than minor symptoms.” Moderate effects typically require medical treatment but are not life-threatening and allow a return to a pre-exposure level of health.

Not surprisingly, the organ most commonly affected by cannabis ingestion was the the brain. Central nervous system depression was documented in 70% of the almost 5,000 where clinical effects were documented. Of these, just under 2% had “more severe CNS effects, including major CNS depression or coma.” Other concerning effects documented were ataxia (poor muscle control and difficulty with balance and walking) and agitation, both in over 7% of cases, as well as confusion (6.1%), seizures (1.6%), and respiratory depression (3.1%). 35 children, or about .7%, required placement on a mechanical ventilator.

A few more interesting tidbits from the study:

1. While the number of NPDS cases involving edible cannabis exposures were increasing, the overall case volume in this age range decreased substantially from 956,871 to 846,296.
2. The severity of acute cannabis toxicity increased significantly, with more hospitalizations, more requiring PICU care, and a decrease in young children being “treated and streeted” by the emergency department.
3. Less than 2% of exposures occurred in infants, which makes sense because they have limited mobility and ability to open things. Toddlers aged 2 and 3 years beat the 4 and 5-year-olds 52% to 31%, likely because they are mobile, can open things surprisingly well, and more resistant to behavior manipulation.
4. It looks like the pandemic threw gas on the fire as there was a 300% increase in reported cases in 2020-2021 compared to 2017-2019. This was likely a result of more edibles and more kids around the home during quarantines and school/childcare closures.
5. There was also a 50% increase in both moderate and severe cases during the two pandemic years included in the study.

Conclusion: Education and regulation are still vital in protecting curious kids from edible ingestions

Sadly, my conclusion is essentially unchanged from what I wrote back in the summer of ’18:

Marijuana obviously isn’t going anywhere, and I personally don’t think that the issue of pediatric ingestion should be used as an unwieldy cudgel in someone’s fight against legalization. As is often the case, education and regulation is the key. This means recognition of this potential problem by healthcare professionals and frank discussions with families. Public health campaigns need to be implemented. In addition, our elected leaders need to step up and enact laws that will help to protect children.

Here in the future…I mean the present, we still need to educate the public on the risks of unintentional (and, well, also intentional) ingestion of cannabis products on many levels, which doesn’t mean that adult people can’t still have fun. But, you know, try harder to keep it out of the reach of children.

The authors of the study make the following recommendations:

Because most of these exposures occur in the child’s home (90.7%), educating caregivers and other adults in the home on how to safely store their cannabis products could significantly reduce exposures in young children. Ideally, these products should be stored in a location unknown to the children and kept in a locked container. Using locations outside the kitchen, away from other food items, may help reduce the risk of a child viewing these products as normal food items. Adults should be cautioned against using cannabis edibles in front of children because they may be likely to imitate the adult and attempt to ingest these products. Primary care providers can help prevent exposures by incorporating screening questions about cannabis use in the home and counseling caregivers on these practices.

And there are still no federal laws regulating how these products can be packaged and labeled, or how much THC they can contain. It’s absurd that only children in states where cannabis containing products are legalized in some fashion benefit from local laws that might require safer packaging and warning labels. But even those kids might be exposed to products imported from other, more Texas-like states, such as Texas, for example.

What will the data from 2022 look like once it’s available? It’s hard to imaging that it will be better. But now that the pandemic is over, perhaps I should be more optimistic and throw my bad attitude in the trash along with these face masks, bottles of hand sanitizer, and streaming service subscriptions. I’m going to go hug a stranger. See you in two weeks!