There has been a consistent increase in pediatric edible cannabis exposures over the past 5 years, with the potential for significant toxicity. It is important for providers to be aware of this in the
- Jul 31
- 5 min read
A total of 2216 cases were not followed to a known outcome (eg “lost to follow-up” or “not followed – toxic effects possible”) and were excluded from the total of 7043 cases over the 5 years of the study, which left 4827 cases for the evaluation of clinical effects and therapies used. These cases were excluded because the data were incomplete and would not provide an accurate frequency of clinical effects seen after ingestion. For analysis of clinical symptoms, the top 30 clinical effects codes were gathered and presented as percentage of exposures followed to a known outcome. Clinical effects coded as “other-organ system” were removed from the top 30 effects because there is no uniform definition for what falls into these categories. Statistical analyses were performed on various clinical effects spread among the organ systems to determine if there was a difference seen in effects between 2017 and 2019 and 2020 and 2021. In 2019, the codes for decreased mental status (drowsiness/lethargy and coma) were replaced by degrees of central nervous system (CNS) depression (mild, moderate, major). The relevant clinical codes were combined into a single “CNS depression” category to standardize the analysis. Therapies used were analyzed, and the top 20 therapies as a percentage of exposures followed to a known outcome were provided.
Using AAPCC NPDS data, we analyzed unintentional cannabis exposure trends in children aged ≤5 years and determined that these exposures increased substantially (1375%) from 2017 to 2021. This increase occurred in an environment in which overall case volume in the 0 to 5 years of age group to poison centers decreased from 956 871 to 846 296 during the 5-year study period. There has also been a significant increase in the severity of acute toxicity, as indicated by increasing critical care admissions, more patients admitted to noncritical care beds, and fewer patients being treated and released from the ED. Although the specific number of cases attributed to each state could not be determined by this study, these increases are believed to be associated with more states allowing adult, recreational use of cannabis. This study adds to a growing body of literature highlighting the increasing frequency and potential for acute toxicity of pediatric cannabis ingestions associated with widespread legalization.3–11
From 2017 to 2021, the percent of noncritical care admissions increased, whereas the percent of patients treated and released from the ED decreased (Table 2). It is unknown why these changes occurred. Etiologies may include provider comfort with disposition, bed availability during the pandemic, severity of clinical effects, or other factors. It is possible that products contained more THC per package or a larger number of edible products was purchased in the pandemic years of the study. It is also possible that providers became more experienced managing these cases and more comfortable placing less severely symptomatic patients in non-ICU beds. Additionally, it is unclear if fewer patients being treated and released from the ED was due to provider discomfort with discharging these patient or to the increased severity of acute clinical effects seen, such as CNS depression. Multiple factors could be at play between provider preference, increase in acute clinical effects, and an increase in either THC concentrations in products or the amount of product consumed. The COVID-19 pandemic may also have played a role in bed availability and disposition.
Moderate and major effects increased significantly during the last 2 years of the study. The total number of children requiring intubation during the study period was 35, or approximately 1 in 140. Although this was a relatively rare occurrence, it is important for clinicians to be aware that life-threatening sequelae can develop and may necessitate invasive supportive care measures.
The COVID-19 pandemic also may have affected the epidemiology of these ingestions. In the prepandemic years, there were 1780 cases, and for the 2 years during the pandemic, there were 5263 cases, an increase of 295.7%. The biggest increase in cannabis exposures in children aged <6 years happened between 2019 and 2020, which increased from 983 to 2209 exposures (+124.7%). It is possible that COVID-related quarantines and school/daycare closures played a role, with young children having more opportunity for exposure while at home.
Two- and 3-year-old children were at highest risk for cannabis exposure in the <6-year-old age group. They are capable of opening containers and climbing to high spaces to access items of interest. Interestingly, 4- and 5-year-old children accounted for fewer exposures despite having reached more advanced developmental milestones. Children aged <1 year, who have the most limited mobility, made up the smallest portion (1.9%).
Although awareness of pediatric cannabis exposures is growing, much more can be done from a poison prevention standpoint. The American College of Medical Toxicology released a position statement in April 2019 outlining recommendations for changes in packaging as well as suggestions regarding home storage techniques and responsible habits for home cannabis use.16 Our study shows a continued increase in pediatric cannabis exposures after these guidelines came out and highlights how important it is to increase efforts to educate the public about prevention strategies. Providers in various clinical settings have an important opportunity to educate parents regarding the dangers of such exposures as well as discuss risk mitigation strategies to implement at home.
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.16
Unlike with tobacco or alcohol products, there are no nationwide laws regarding how cannabis products are packaged. Products continue to be offered in brightly colored, enticing packaging that is identical in style to how candy and snack products are marketed. Not only should cannabis products be placed in child-resistant packaging, but they should be in opaque packages with simple labels. In addition, there should be clear warning labels on the product cautioning against excessive use, and the national poison center phone number should be included on the package. California was the first state to enact these practices into law.17 Several states now have risk-reduction laws, such as limiting the amount of THC that can be contained within a single package and requiring cannabis products to be sold in opaque packaging. However, noncompliant products may be imported from other states and bypass these regulations.13
Our results should be considered in the context of several limitations. Data from the NPDS includes only exposures that were reported to US PCCs. The numbers in our study are an underestimation of the actual number of cannabis exposures in this age group. Also, it is unknown whether other factors such as increased reporting to poison centers or decreased stigma surrounding cannabis use over the course of the study period may have contributed to the observed increase in exposure rates. Finally, the NPDS is compiled of information shared from patients/families and health care personnel; it must then be appropriately coded by poison center staff. Limited information provided and patients lost to follow-up can result in missing data and an incomplete picture of exposures and affect our analysis on adverse events, clinical effects, and outcomes.
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