Video Abstract
With legal commercialization of cannabis in a growing number of US states, increasing numbers of children have experienced unintentional cannabis exposure resulting in calls to poison control centers, health care visits,1 and hospitalizations.2,3 Edible cannabis products, which can have a high concentration of δ-9-tetrahyrocannabinol and may resemble foods that appeal to youth, have been implicated in many such exposures.4,5 In addition, edible products are often sold with multiple doses per package, meaning ingestion of large quantities is possible before effects are realized. Use of edible cannabis products has increased over time,6,7 but we lack national estimates of edible-involved pediatric cannabis exposures.
Methods
We obtained data on cannabis-involved human exposure calls for children aged 0 to 9 years reported to US poison centers from January 1, 2017, to December 31, 2019. Data were extracted from the National Poison Data System (NPDS) in March 2020. The NPDS records the type of product involved in an incident using standardized codes, with generic codes for products that have no reported manufacturer.8 Data were composed of all closed incidents involving a cannabis generic code, including the code for edible products (added to NPDS November 16, 2016). Cannabidiol-only and synthetic cannabinoid exposures were excluded.
We compared edible exposures to all other types of cannabis exposures (eg, dried plant, concentrated extracts) and examined differences by age, sex, intentionality, caller location, and medical outcomes as defined by NPDS.8 We evaluated changes in exposure counts per quarter using linear regression and testing for differences in trend between edible and nonedible exposures. For 2019, we compared cases in states with legal adult cannabis use to cases in states without, including states with medical cannabis. Comparisons were assessed by using χ2 tests. Stata 16 software (Stata Corp, College Station, TX) was used and α = .05. The Washington State University Institutional Review Board determined this study was exempt from review.
Results
There were 4172 cannabis exposure cases among children aged 0 to 9 years during the study period, of which 45.7% (n = 1906) were associated with edible cannabis products (Table 1). From 2017 to 2019, cannabis product exposures increased overall (slope coefficient [β] for quarter 31.6 [95% confidence interval [CI]: 26.0–37.3]), as did the proportion of cannabis cases that were associated with edible products (Fig 1). The increase in edible-related exposures per quarter (β = 26.0; 95% CI: 23.6–28.3) was greater than the increase in nonedible cannabis exposures (β = 5.7; 95% CI: 1.4–9.9), confirmed by a significant interaction term in a combined model (interaction term coefficient 20.3; 95% CI: 15.8–24.8; P < .001).
Cannabis-Related Exposures Reported to US Poison Centers for Patients Aged 0 to 9 years, 2017–2019
| Edible Product–Involved Cases | Other Cannabis-Involved Cases | P From χ2a | All Cannabis-Involved Cases | ||||
|---|---|---|---|---|---|---|---|
| n = 1906 | n = 2266 | n = 4172 | |||||
| n | % | n | % | n | % | ||
| Year | <.001 | ||||||
| 2017 | 223 | 11.7 | 664 | 29.3 | 887 | 21.3 | |
| 2018 | 615 | 32.3 | 707 | 31.2 | 1322 | 31.7 | |
| 2019 | 1068 | 56.0 | 895 | 39.5 | 1963 | 47.1 | |
| Sex | .006 | ||||||
| Female | 911 | 47.8 | 1027 | 45.3 | 1938 | 46.5 | |
| Male | 961 | 50.4 | 1219 | 53.8 | 2180 | 52.3 | |
| Unknown | 34 | 1.8 | 20 | 0.9 | 54 | 1.3 | |
| Age, y | <.001 | ||||||
| 0–2 | 512 | 26.9 | 794 | 35.0 | 1306 | 31.3 | |
| 3–5 | 944 | 49.5 | 853 | 37.6 | 1797 | 43.1 | |
| 6–9 | 450 | 23.6 | 619 | 27.3 | 1069 | 25.6 | |
| Coingestants | <.001 | ||||||
| Only cannabis | 1873 | 98.3 | 2082 | 91.9 | 3955 | 94.8 | |
| Other substances involved | 33 | 1.7 | 184 | 8.1 | 217 | 5.2 | |
| Route of exposure | <.001 | ||||||
| Inhalation | 2 | 0.1 | 136 | 6.0 | 138 | 3.3 | |
| Ingestion | 1674 | 87.8 | 1330 | 58.7 | 3004 | 72.0 | |
| Other | 33 | 1.7 | 43 | 1.9 | 76 | 1.8 | |
| Unknown | 197 | 10.3 | 757 | 33.4 | 954 | 22.9 | |
| Intent of exposure | <.001 | ||||||
| Intentional | 11 | 0.6 | 28 | 1.2 | 39 | 0.9 | |
| Unintentional | 1837 | 96.4 | 2111 | 93.2 | 3948 | 94.6 | |
| Other | 27 | 1.4 | 50 | 2.2 | 77 | 1.9 | |
| Unknown | 31 | 1.6 | 77 | 3.4 | 108 | 2.6 | |
| Medical outcome (excludes cases with any with coingestants, n = 217)b | <.001 | ||||||
| Death | 0 | 0 | 0 | 0 | 0 | 0 | |
| Major effect | 28 | 1.5 | 29 | 1.4 | 57 | 1.4 | |
| Moderate effect | 298 | 15.9 | 310 | 14.9 | 608 | 15.4 | |
| Minor effect | 634 | 33.9 | 555 | 26.7 | 1189 | 30.1 | |
| No effect | 295 | 15.8 | 394 | 18.9 | 689 | 17.4 | |
| Unable to follow, judged potentially toxic | 365 | 19.5 | 372 | 17.9 | 737 | 18.6 | |
| Not followed, minimal or unrelated effects | 253 | 13.5 | 422 | 20.3 | 675 | 17.1 | |
| Caller location | .207 | ||||||
| Health care facility | 859 | 45.1 | 1019 | 45.0 | 1878 | 45.0 | |
| Residence (own, other) | 890 | 46.7 | 1075 | 47.4 | 1965 | 47.1 | |
| Other | 137 | 7.2 | 161 | 7.1 | 298 | 7.1 | |
| Unknown | 20 | 1.1 | 11 | 0.5 | 31 | 0.7 | |
| State policy status (2019 only)c | <.001 | ||||||
| Legal adult use in 2019 (estimated total population <10 y = 10 895 136) | 608 | 57.5 | 367 | 41.3 | 975 | 50.1 | |
| Not legal adult use in 2019 (estimated total population <10 y = 28 200 136) | 450 | 42.5 | 522 | 58.7 | 972 | 49.9 | |
| Edible Product–Involved Cases | Other Cannabis-Involved Cases | P From χ2a | All Cannabis-Involved Cases | ||||
|---|---|---|---|---|---|---|---|
| n = 1906 | n = 2266 | n = 4172 | |||||
| n | % | n | % | n | % | ||
| Year | <.001 | ||||||
| 2017 | 223 | 11.7 | 664 | 29.3 | 887 | 21.3 | |
| 2018 | 615 | 32.3 | 707 | 31.2 | 1322 | 31.7 | |
| 2019 | 1068 | 56.0 | 895 | 39.5 | 1963 | 47.1 | |
| Sex | .006 | ||||||
| Female | 911 | 47.8 | 1027 | 45.3 | 1938 | 46.5 | |
| Male | 961 | 50.4 | 1219 | 53.8 | 2180 | 52.3 | |
| Unknown | 34 | 1.8 | 20 | 0.9 | 54 | 1.3 | |
| Age, y | <.001 | ||||||
| 0–2 | 512 | 26.9 | 794 | 35.0 | 1306 | 31.3 | |
| 3–5 | 944 | 49.5 | 853 | 37.6 | 1797 | 43.1 | |
| 6–9 | 450 | 23.6 | 619 | 27.3 | 1069 | 25.6 | |
| Coingestants | <.001 | ||||||
| Only cannabis | 1873 | 98.3 | 2082 | 91.9 | 3955 | 94.8 | |
| Other substances involved | 33 | 1.7 | 184 | 8.1 | 217 | 5.2 | |
| Route of exposure | <.001 | ||||||
| Inhalation | 2 | 0.1 | 136 | 6.0 | 138 | 3.3 | |
| Ingestion | 1674 | 87.8 | 1330 | 58.7 | 3004 | 72.0 | |
| Other | 33 | 1.7 | 43 | 1.9 | 76 | 1.8 | |
| Unknown | 197 | 10.3 | 757 | 33.4 | 954 | 22.9 | |
| Intent of exposure | <.001 | ||||||
| Intentional | 11 | 0.6 | 28 | 1.2 | 39 | 0.9 | |
| Unintentional | 1837 | 96.4 | 2111 | 93.2 | 3948 | 94.6 | |
| Other | 27 | 1.4 | 50 | 2.2 | 77 | 1.9 | |
| Unknown | 31 | 1.6 | 77 | 3.4 | 108 | 2.6 | |
| Medical outcome (excludes cases with any with coingestants, n = 217)b | <.001 | ||||||
| Death | 0 | 0 | 0 | 0 | 0 | 0 | |
| Major effect | 28 | 1.5 | 29 | 1.4 | 57 | 1.4 | |
| Moderate effect | 298 | 15.9 | 310 | 14.9 | 608 | 15.4 | |
| Minor effect | 634 | 33.9 | 555 | 26.7 | 1189 | 30.1 | |
| No effect | 295 | 15.8 | 394 | 18.9 | 689 | 17.4 | |
| Unable to follow, judged potentially toxic | 365 | 19.5 | 372 | 17.9 | 737 | 18.6 | |
| Not followed, minimal or unrelated effects | 253 | 13.5 | 422 | 20.3 | 675 | 17.1 | |
| Caller location | .207 | ||||||
| Health care facility | 859 | 45.1 | 1019 | 45.0 | 1878 | 45.0 | |
| Residence (own, other) | 890 | 46.7 | 1075 | 47.4 | 1965 | 47.1 | |
| Other | 137 | 7.2 | 161 | 7.1 | 298 | 7.1 | |
| Unknown | 20 | 1.1 | 11 | 0.5 | 31 | 0.7 | |
| State policy status (2019 only)c | <.001 | ||||||
| Legal adult use in 2019 (estimated total population <10 y = 10 895 136) | 608 | 57.5 | 367 | 41.3 | 975 | 50.1 | |
| Not legal adult use in 2019 (estimated total population <10 y = 28 200 136) | 450 | 42.5 | 522 | 58.7 | 972 | 49.9 | |
Missing values were excluded from χ2.
Minor outcomes involved some signs or symptoms, but they were minimally bothersome and generally resolved rapidly. Moderate outcomes involved more pronounced, more prolonged, or more systemic symptoms. Major outcomes involve signs or symptoms that were life-threatening or resulted in significant residual disability or disfigurement.8
States with legal adult use in 2019 included Alaska, California, Colorado, Illinois, Massachusetts, Maine, Michigan, Nevada, Oregon, Vermont, Washington state, and Washington, District of Columbia. A total of 42 exposures were excluded because the state was unknown (n = 19) or refused to give (n = 8) or exposure occurred outside of US states and the District of Columbia (Puerto Rico [n = 6], US Virgin Islands [n = 1], other US territory [n = 4], Mexico [n = 2], other foreign country [n = 2]). Total 2019 populations <10 y are from the US Census Bureau, table S0101.
![FIGURE 1. Cannabis product exposure among US children aged 0 to 9 years (quarterly counts for 2017–2019). All cannabis generic codes were obtained from the NPDS. Exposures were deduplicated (ie, if >1 cannabis type was involved [n = 6]), and those with final medical outcomes of “confirmed nonexposure” (n = 38) or “unrelated effect, the exposure was probably not responsible for the effect(s)” (n = 34) were excluded. The “edibles” category includes only the NPDS code for edibles 0310121. The “other cannabis products” included concentrates 0310124 (n = 424), dried plant 0083000 (n = 1479), capsule or pill 0310122 (n = 23), unknown preparation 0310126 (n = 177), pharmaceutical 0200618 (n = 64), topical 0310125 (n = 13), undried plant 0310123 (n = 11), vaporizer liquid or unknown if flavored 0310096 (n = 46), vaporizer liquid with flavoring 0310034 (n = 5), vaporizer liquor without flavoring 0310033 (n = 2), marijuana liquid flavor unknown 0310097 (n = 15), marijuana liquid with flavor 0310036 (n = 6), and marijuana liquid without flavor 0310035 (n = 3). Q1, quarter 1; Q2, quarter 2; Q3, quarter 3; Q4, quarter 4.](https://aap2.silverchair-cdn.com/aap2/content_public/journal/pediatrics/147/4/10.1542_peds.2020-019893/1/m_peds_2020019893_f1.png?Expires=1736148661&Signature=FX2sN4QUVeLQcoFKM8ZR04l1qSNUCOo~VytP~yGiDzN3wziPrmfCRGM3o8JBs~Ycq2VfQMEVeMRtUval84gNvfI~oph4SeKzPSTyIaq0Yb-29GN7IRErNGKRKJHakY7flJeZJ5Cc7~rIhcLdL3cYTlqNUVUXcuFNaZHgL3mjkYk9~xfQwtHcKgHx0TR4ul4qhdU4lXJT-Zn6LMTWzmcnjBshaUTVaMWvNfJZ~q4HWPs5h4vrApxW60k34b0NS02yuTOdKWCbFcP0xRcI9bsFcui6A4uGMNuTCTg3XcieAzjYB~THDGxwM4YmeByRx7Ai-z2uI-6CadOZcMxenwh3wQ__&Key-Pair-Id=APKAIE5G5CRDK6RD3PGA)
Cannabis product exposure among US children aged 0 to 9 years (quarterly counts for 2017–2019). All cannabis generic codes were obtained from the NPDS. Exposures were deduplicated (ie, if >1 cannabis type was involved [n = 6]), and those with final medical outcomes of “confirmed nonexposure” (n = 38) or “unrelated effect, the exposure was probably not responsible for the effect(s)” (n = 34) were excluded. The “edibles” category includes only the NPDS code for edibles 0310121. The “other cannabis products” included concentrates 0310124 (n = 424), dried plant 0083000 (n = 1479), capsule or pill 0310122 (n = 23), unknown preparation 0310126 (n = 177), pharmaceutical 0200618 (n = 64), topical 0310125 (n = 13), undried plant 0310123 (n = 11), vaporizer liquid or unknown if flavored 0310096 (n = 46), vaporizer liquid with flavoring 0310034 (n = 5), vaporizer liquor without flavoring 0310033 (n = 2), marijuana liquid flavor unknown 0310097 (n = 15), marijuana liquid with flavor 0310036 (n = 6), and marijuana liquid without flavor 0310035 (n = 3). Q1, quarter 1; Q2, quarter 2; Q3, quarter 3; Q4, quarter 4.
Cannabis product exposure among US children aged 0 to 9 years (quarterly counts for 2017–2019). All cannabis generic codes were obtained from the NPDS. Exposures were deduplicated (ie, if >1 cannabis type was involved [n = 6]), and those with final medical outcomes of “confirmed nonexposure” (n = 38) or “unrelated effect, the exposure was probably not responsible for the effect(s)” (n = 34) were excluded. The “edibles” category includes only the NPDS code for edibles 0310121. The “other cannabis products” included concentrates 0310124 (n = 424), dried plant 0083000 (n = 1479), capsule or pill 0310122 (n = 23), unknown preparation 0310126 (n = 177), pharmaceutical 0200618 (n = 64), topical 0310125 (n = 13), undried plant 0310123 (n = 11), vaporizer liquid or unknown if flavored 0310096 (n = 46), vaporizer liquid with flavoring 0310034 (n = 5), vaporizer liquor without flavoring 0310033 (n = 2), marijuana liquid flavor unknown 0310097 (n = 15), marijuana liquid with flavor 0310036 (n = 6), and marijuana liquid without flavor 0310035 (n = 3). Q1, quarter 1; Q2, quarter 2; Q3, quarter 3; Q4, quarter 4.
Children aged 3 to 5 years experienced the highest proportion of all exposures (43.1%). Most cases were exposed by ingestion (72.0%). A small proportion experienced major (1.4%) or moderate (15.4%) medical outcomes. In 2019, areas with legal adult cannabis use reported greater pediatric cannabis exposures compared with states without this policy: 975 exposures (8.9 per 100 000 population) versus 972 exposures (3.4 per 100 000 population). The proportion of calls due to edible cannabis product exposures was greater in legal states than in states without this policy: 62% vs 46% (P < .001).
Discussion
Poison center calls associated with pediatric exposure to cannabis increased in the United States from 2017 to 2019; the increase appears to be largely composed of unintentional exposures to edible cannabis products. Pediatric exposures were more frequent, and more often involved edible products, in states with legal adult cannabis use.
A limitation of these data is that they rely on self-reports, potentially leading to underestimation of cases. Data were extracted from the NPDS before the annual “locking” of the database,8 so the 2019 data may be subject to minor changes.
The trend we observed could be expected to continue or increase. Cannabis consumers may shift from combustible to edible products because of the epidemic of e-cigarette– and vaping product–associated lung injury in late 2019. In addition, as many states close or restrict access to school and child care centers to mitigate the coronavirus disease pandemic, increases in unintentional ingestions of potentially harmful substances at home are of growing concern. State governments, particularly those with legal adult use, should consider issuing additional warnings about safe storage of cannabis. Regulators should ensure that packaging policies require child-resistant plain and opaque containers and that products, particularly edible products, do not appeal to children.
Acknowledgment
We thank Nathaniel Pham of the American Association of Poison Control Centers for assistance with data retrieval.
Dr Whitehill conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Dilley conducted the analyses and reviewed and revised the manuscript; Dr Brooks-Russell conceptualized and designed the study and critically reviewed and revised the manuscript; Ms Terpak contributed to data analysis and critically reviewed and revised the manuscript; Dr Graves conceptualized and designed the study, obtained funding, and critically reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Supported in part by funds provided for medical and biological research by the State of Washington Initiative Measure No. 171. The funder/sponsor did not participate in the work.
Comments
Reply to Edible Cannabis Exposures Among Children: 2017-2019
From January 1, 2020 to September 30, 2020, NJPIES received 98 calls regarding pediatric edible cannabis, 93 of which were exposures and 5 were informational. Among these 93 exposures reported to NJPIES, 71 resulted in ED visits and 22 were managed at home. The 93 exposure calls represent an overall increase of 370 % and 683% compared to the corresponding time periods in 2019 and 2018, with 20 and 12 calls r, respectively. This change was seen across all age groups, with children ≤5 years consistently accounting for the largest proportion of the increase for all 3 periods. In patients ≤5 years of age, 100 % (42/42) of exposures were unintentional, whereas in the 13-19-year age group, 88% (23/26) were intentional. Furthermore, of the 61 cases in which the medical outcome was known, the majority of the exposure cases exhibited no to moderate effect: no effect (12), minor (21), moderate (27), major (1), and deaths (0).
Increased cannabis access in the United States has significantly impacted the incidence of childhood cannabis exposures, (1) the majority of which are due to edibles. (2, 3) Regulatory efforts such as child-resistant packaging and look-alike product restrictions have sought to mitigate risk in young children from exploratory exposures, and laws restricting tetrahydrocannabinol (THC) content and labeling aim to protect the recreational user from overdose. However, the risks of unintentional exposure and overconsumption remain for these respective groups. (4)
To date, cannabis in New Jersey is currently available for medicinal use, while recreational cannabis was approved for adult-use by New Jersey voters as of November 3, 2020 but not yet available. Furthermore, the expansion of New Jersey's Medicinal Marijuana Program, such as the Jake Honig Compassionate Use Medical Cannabis Act (5) passed in July 2019, may contribute to the observed rise in pediatric edible cannabis exposure through increased access to medical marijuana. While a causal relationship cannot be demonstrated and exposures were rising prior to the COVID-19 pandemic, the timing of this dramatic increase in pediatric edible exposures corresponds to the beginning of quarantine and state stay-at-home-directives. Moreover, pandemic-related household changes including parental stressors, distance learning, childcare disruptions, and increased mental health challenges of social isolation and stress on adolescents may create a milieu conducive to both childhood exploratory poisoning and intentional exposures in teens.
References:
1. Boadu O, Gombolay GY, Caviness VS, El Saleeby CM. Intoxication From Accidental Marijuana Ingestion in Pediatric Patients: What May Lie Ahead. Pediatr Emerg Care. 2020;36(6): e349-e354. doi:10.1097/PEC.0000000000001420
2. Barrus DG, Capogrossi KL, Cates SC, et al. Tasty THC: Promises and Challenges of Cannabis Edibles. Methods Rep RTI Press. 2016; 2016:10.3768/rtipress.2016. op.0035.1611. doi:10.3768/rtipress.2016. op.0035.1611
3. Wang GS, Le Lait MC, Deakyne SJ, Bronstein AC, Bajaj L, Roosevelt G. Unintentional Pediatric Exposures to Marijuana in Colorado, 2009-2015. JAMA Pediatr. 2016;170(9): e160971. doi:10.1001/jamapediatrics.2016.0971
4. MacCoun RJ, Mello MM. Half-baked--the retail promotion of marijuana edibles. N Engl J Med. 2015;372(11):989-991. doi:10.1056/NEJMp1416014
5. Division of Medicinal Marijuana, New Jersey Department of Health. Available at: https://www.https://www.nj.gov/health/medicalmarijuana. Accessed December 20th, 2020.