The rate of unintentional ingestion of edible cannabis products in young children is rising rapidly as laws decriminalizing both recreational and medical marijuana in the United States become more widespread.1 Cannabis poisoning in children can lead to a myriad of symptoms, most notably neurologic changes. The abrupt onset and severity of signs and symptoms after ingestion can cause diagnostic uncertainty for practitioners in the emergency department. Here, we present a case series of 5 children, 6 years of age and younger, who initially presented with altered mental status and were ultimately diagnosed with acute δ-9-tetrahydrocannabinol toxicity after cannabis ingestion confirmed by urine toxicology testing. Although urine toxicology testing is not routinely used as a diagnostic tool in pediatrics, the increasing accessibility of edible cannabis products suggests that more widespread urine toxicology testing in children with undifferentiated altered mental status is warranted.
The growing legalization of recreational cannabis and the increasing accessibility of edible cannabis have been accompanied by a rapid increase in the number of unintentional ingestions in young children.1,2 The inappropriate storage of edible cannabis places young children at risk for unintentional or exploratory ingestions.3 Edible cannabis products are manufactured by infusing food items with cannabis extract containing cannabinoids, including δ-9-tetrahydrocannabinol (THC), the primary psychoactive cannabinoid from marijuana. Other cannabinoids, cannabidiol, and δ-8-tetrahydrocannabinol, and synthetic cannabis products, have also recently gained popularity and become more available to consumers. These products are sold in a variety of forms, and some are packaged so that they are nearly indistinguishable from common household snacks.
Because of the lack of standardized dosing and serving sizes of edible cannabis products, the ingestion of a package in its entirety can cause life-threatening toxicity due to THC.1 Signs of THC toxicity in children include altered mental status (AMS), ataxia, tachycardia, mydriasis, seizures, hypotonia, and respiratory depression.1 Despite other popular cannabinoids and synthetic cannabinoid products, THC is the only cannabinoid present on a standard urine toxicology test. This case series focuses on pediatric edible cannabis exposures containing THC, although depending on the clinical scenario, health care professionals should also consider other cannabinoids and synthetic cannabinoid substances.
Obtaining urine toxicology testing early in the evaluation of a pediatric patient with undifferentiated altered mental status has been suggested in recent literature in an effort to expedite diagnosis and minimize invasive and costly interventions.4–8 Traditionally, urine toxicology testing has been recommended in only select cases because its use has generally not been shown to alter management.9–13 Because of this, clinicians may not routinely order urine toxicology in cases of undifferentiated AMS in young children despite the widespread availability of a reliable qualitative urine test for identifying THC. As a result, THC toxicity may be missed or the diagnosis may be delayed, leading to extensive evaluations, unnecessary interventions, and/or prolonged hospitalizations.
Case Report
The objective of this case series is to describe the clinical course of young children with edible cannabis ingestion containing THC and the utility of the urine toxicology screen as a diagnostic test. We present 5 cases of children 6 years of age and younger who presented to a pediatric emergency department (ED) for neurologic changes and were ultimately found to have THC toxicity confirmed by positive urine toxicology (Table 1). The data presented were compiled by the New York City Poison Control Center and the associated Toxicology fellowship programs at New York University Grossman School of Medicine and North Shore University Hospital & Long Island Jewish Medical Center between the years 2021 and 2022. It should be noted that recreational cannabis has been legal in the state of New York since 2021. Consent for publication was obtained from the caregivers of all 5 children.
Summary and Features of Patient Presentations
| Case . | Patient Demographics (Age/Sex) . | Cannabis Product Ingested, Source . | Chief Complaint . | ED Vital Signs . | Physical Examination Findings . | Urine Toxicology Test (Qualitative) . | Diagnostic Tests . | Imaging . | Interventions . | Disposition . | Hospital Length of Stay . |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 6-y-old male | Gummy candy, Outside of home | Altered Mental Status, Tachycardia | BP 96/53, HR: 135, RR: 20, Temp: 36.4°C, O2 Sat: 100%, Tachycardic | Limp, pale appearing, unresponsive | THC Detected | POC glucose, VBG, CBC, CMP, EKG | CT head and cervical spine CT chest XR chest | Transferred to Pediatric Trauma Center Consulted Toxicology, Social Work | Admitted to PICU | 48 h |
| 2 | 3-y-old female | Gummy candy, family member’s home | Altered Mental Status, Hypotonia | BP 92/58, HR: 109, RR: 20, Temp: 36.6°C, O2 Sat: 100%, Normal | Arouse to verbal stimuli | THC Detected | CBC, CMP, EKG | CT head | Consulted Toxicology, Neurology, Child Protective Services, Social Work | Admitted to the pediatric floor | 72 h |
| 3 | 2-y-old female | THC-infused candy, patient’s home | Altered Mental Status | BP: 105/54, HR: 122, RR: 26, Temp: 37.1°C, O2 Sat: 100%, Normal | Minimally responsive to verbal stimuli. Patient had a clenched left hand and plantar flexed left foot | THC Detected | CBC, CMP, EKG | CT head | Consulted Toxicology, Child Protective Service, Social Work | Observed in ED | 7 h |
| 4 | 2-y-old female | THC-infused candy, family member’s home | Altered Mental Status | BP: 96/46, HR: 104, RR: 20, Temp: 36.9°C, O2 Sat: 99%, Normal | Sleepy, rousable to stimuli | THC Detected | CBC, CMP | CT head | Transferred to Pediatric Emergency Department Consulted Toxicology, Social Work | Observed in ED | 12 h |
| 5 | 4-y-old male | THC-infused candy, patient’s home | Altered Mental Status | BP: 106/48, HR: 76, RR: 18, Temp: 36.9°C, O2 Sat: 98%, Normal | Sleeping, rousable to tactile stimuli | THC Detected | CBC, CMP, Acetaminophen, Salicylate, Ethanol, TSH | Transferred to Pediatric Emergency Department Consulted Toxicology Child Protective Services, Social Work | Admitted to PICU | 12 h |
| Case . | Patient Demographics (Age/Sex) . | Cannabis Product Ingested, Source . | Chief Complaint . | ED Vital Signs . | Physical Examination Findings . | Urine Toxicology Test (Qualitative) . | Diagnostic Tests . | Imaging . | Interventions . | Disposition . | Hospital Length of Stay . |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 6-y-old male | Gummy candy, Outside of home | Altered Mental Status, Tachycardia | BP 96/53, HR: 135, RR: 20, Temp: 36.4°C, O2 Sat: 100%, Tachycardic | Limp, pale appearing, unresponsive | THC Detected | POC glucose, VBG, CBC, CMP, EKG | CT head and cervical spine CT chest XR chest | Transferred to Pediatric Trauma Center Consulted Toxicology, Social Work | Admitted to PICU | 48 h |
| 2 | 3-y-old female | Gummy candy, family member’s home | Altered Mental Status, Hypotonia | BP 92/58, HR: 109, RR: 20, Temp: 36.6°C, O2 Sat: 100%, Normal | Arouse to verbal stimuli | THC Detected | CBC, CMP, EKG | CT head | Consulted Toxicology, Neurology, Child Protective Services, Social Work | Admitted to the pediatric floor | 72 h |
| 3 | 2-y-old female | THC-infused candy, patient’s home | Altered Mental Status | BP: 105/54, HR: 122, RR: 26, Temp: 37.1°C, O2 Sat: 100%, Normal | Minimally responsive to verbal stimuli. Patient had a clenched left hand and plantar flexed left foot | THC Detected | CBC, CMP, EKG | CT head | Consulted Toxicology, Child Protective Service, Social Work | Observed in ED | 7 h |
| 4 | 2-y-old female | THC-infused candy, family member’s home | Altered Mental Status | BP: 96/46, HR: 104, RR: 20, Temp: 36.9°C, O2 Sat: 99%, Normal | Sleepy, rousable to stimuli | THC Detected | CBC, CMP | CT head | Transferred to Pediatric Emergency Department Consulted Toxicology, Social Work | Observed in ED | 12 h |
| 5 | 4-y-old male | THC-infused candy, patient’s home | Altered Mental Status | BP: 106/48, HR: 76, RR: 18, Temp: 36.9°C, O2 Sat: 98%, Normal | Sleeping, rousable to tactile stimuli | THC Detected | CBC, CMP, Acetaminophen, Salicylate, Ethanol, TSH | Transferred to Pediatric Emergency Department Consulted Toxicology Child Protective Services, Social Work | Admitted to PICU | 12 h |
BP, blood pressure; HR, heart rate; RR, respiratory rate; O2 Sat, oxygen saturation; CBC, complete blood count; CMP, complete metabolic panel; VBG, venous blood gas; POC glucose, point-of-care glucose; IV, intravenous; THC, δ-9-tetrahydrocannabinol; US, ultrasound.
Case 1
A 6-year-old healthy transgender male presented to a community ED with unresponsiveness. The patient’s mother reported that he felt dizzy and vomited once after his 3-year-old sibling struck him in the head with an empty metal water bottle. The injury had not been witnessed by the parent. His initial vital signs were notable for tachycardia. On physical examination, he was pale and limp. There were no external signs of trauma. He was intubated for airway protection. A computed tomography (CT) scan of the head, cervical spine, and chest did not reveal any acute injury. Initial serum laboratory studies were reassuring. The patient was transferred to a pediatric trauma center, in which further laboratory studies were obtained, including a urine toxicology test. Two hours after the patient’s arrival at the trauma center, the urine toxicology test was reported to be positive for THC. Toxicology and Social Work were consulted, and he was admitted to the PICU for further management. The patient was extubated ∼24 hours after initial presentation. On further investigation, the patient reported eating a “gummy candy” at a neighbor’s house.
Case 2
A 3-year-old healthy female presented to a community ED with lethargy. The patient was at her aunt’s home before arrival and had depressed mental status after waking from a nap. On physical examination, she had normal vital signs. She responded to verbal stimuli but was noted to have decreased tone and was unable to sit without support. A CT scan of the head did not reveal any acute changes and serum laboratory studies were within normal range. The patient was transferred to a tertiary pediatric hospital. Urine toxicology was sent after admission to the pediatric hospital and resulted positive for THC. Toxicology, Neurology, Child Protective Services, and Social Work were consulted. On further investigation, the patient’s aunt reported having THC-containing gummies in the home. The patient returned to her baseline mental status 36 hours after presentation and was discharged from the hospital after 3 days.
Case 3
A 2-year-old healthy female presented to a community ED for unresponsiveness. Her parents reported that shortly after waking in the morning, she “giggled” and then became unresponsive. On physical examination, she had normal vital signs. She did not open her eyes spontaneously and was noted to have a clenched left hand and plantar flexion of the left foot. A CT scan of the head revealed no acute injuries. A urine toxicology test was obtained ∼1 hour after arrival at the ED and was positive for THC. Toxicology, Child Protective Services, and Social Work were consulted. On further investigation, the parents reported having edible cannabis in the house. Approximately 7 hours after initial presentation, the patient returned to her baseline mental status and was discharged from the hospital from the ED.
Case 4
A 2-year-old healthy female was brought to a community ED for somnolence after visiting her grandparents. On arrival, her vital signs were normal. On physical examination, she was drowsy but rousable. Additional history revealed she had slurred speech and an episode of non-bloody, non-bilious emesis before arrival. Serum laboratory studies were normal, and a CT scan of the head without contrast was reassuring. She was transferred to a Pediatric ED for further evaluation and management. Once the patient arrived at the Pediatric ED, urine toxicology testing was obtained and reported to be positive for THC. Further discussion with the family revealed that edible cannabis gummies belonging to a family member were missing. Toxicology and Social Work were then consulted. She had an episode of oxygen desaturation to the 80s while asleep but required no respiratory intervention. She was observed in the ED for 12 hours and discharged from the hospital to her parent’s care.
Case 5
A healthy 4-year-old male was brought to a community ED by his mother after she noticed that he had become less responsive. On arrival at the ED, he was sleeping but responsive to tactile stimuli. Urine toxicology obtained on arrival resulted positive for THC. On further questioning, the patient’s mother reported having THC edibles in the home. The patient was then transferred to a tertiary children’s hospital for admission to the PICU. While in the PICU, Toxicology, Social Work, and Child Protective Services were consulted. He was observed for 12 hours and was discharged from the hospital in the care of his mother.
Discussion
Cannabis use is on the rise worldwide, and unintentional pediatric cannabis exposures are increasing rapidly.2,14–16 A study of children presenting to a Pediatric ED for unintentional edible cannabis ingestion revealed that there was a >1000% increase in cases between 2017 and 2021. In addition, 97.7% of ingestions occurred in a residential setting.17 Other data reveal that, since 2016, the number of pediatric edible cannabis exposures reported to America’s Poison Centers has increased by 23-fold.18 Because young children with acute THC toxicity can have many different signs and symptoms, the diagnosis may not be immediately obvious. In fact, a recent study revealed that the time to diagnose marijuana ingestion was 5 times longer in children than in adolescents. The delay in diagnosis can lead to a 3-fold increase in potentially avoidable diagnostic tests and a 4-fold increase in medical costs per patient.7 To address these concerns, urine toxicology testing in children presenting with AMS has been recommended.4–8
We presented 5 cases of undifferentiated AMS caused by THC toxicity that were ultimately diagnosed with the aid of urine toxicology testing. In each of these cases, there was no initial history to suggest cannabis ingestion, although further questioning revealed sources of potential exposure.
At our institutions, a urine toxicology test assesses for the presence of amphetamines, barbiturates, benzodiazepines, cocaine, opiates, phencyclidine, and tetrahydrocannabinoids. The urine toxicology tests provide semiquantitative results in which any THC concentration >50 ng/mL is reported as “detected,” and any level below that is resulted as “not detected.” Initial testing is done by urine immunoassay with confirmation of positive results by gas chromatography/mass spectrometry, the gold standard. The immunoassay has a sensitivity of 92.5% and specificity of 92.4% after the acute ingestion of edible cannabis.19 Quantitative serum testing for THC is available if there is question in the patient’s history and, therefore, the accuracy of the urine toxicology test result. However, the results of serum testing often return hours to days after the patient’s initial presentation and, because of the delay, do not typically alter acute clinical management.
Unlike adolescents and adults who intentionally smoke cannabis and possibly have a positive urine toxicology test for THC in the absence of acute intoxication, a positive urine toxicology test for THC in a child should prompt concern because secondhand smoke has been rarely shown to produce positive urine drug tests.20,21 An additional consideration for providers regarding edible cannabis ingestion is that, although THC can be detected by the standard urine toxicology assay, other pharmacologically active cannabinoids (eg, cannabidiol) do not typically cause a positive THC result and can be associated with significant toxicity.22 As always, providers must carefully consider the patient’s presentation and history when interpreting a urine toxicology test. For all the above cases, further discussion with the families revealed that the child had access to edible cannabis products and given the presenting signs and positive THC, unrecognized ingestion of cannabis best explained their clinical presentations.
Time to urine toxicology testing results was variable in our patients, ranging from immediately on presentation in the ED to 24 hours after hospitalization. Notably, in case 5, the positive result for THC on the urine toxicology test obtained immediately after presentation to the ED in conjunction with targeted family discussion obviated the need for further invasive diagnostic procedures or imaging. In contrast to the other cases, case 5 illustrates that prompt urine toxicology testing in patients with undifferentiated AMS may decrease the need for unnecessary diagnostic evaluation.
Pediatric providers are in the midst of a public health crisis because, with greater access to edible cannabis, young children are increasingly at risk for exploratory ingestions. The American College of Medical Toxicology and the American Academy of Pediatrics have both released position statements addressing pediatric cannabis exposures that emphasize the need for regulated packaging and labeling, education on safe storage, and prevention strategies.23,24 Education on safe storage practices, signs of toxicity, and resources is needed for both caregivers and practitioners. In addition, it is crucial to involve the regional Poison Control Center (or local Toxicologist) and Social Work in the management of these patients. Injury prevention research and advocacy to change legislation regarding THC potency, packaging, and available forms must be prioritized so that we may best address this public health crisis.25
Conclusion
The unintentional ingestion of edible cannabis containing THC in children is a serious and growing public health concern. Given the national trend to legalize cannabis, there is potential for an even steeper rise in the number of unintentional pediatric ingestions. Providers must have a high index of suspicion for edible THC toxicity in young patients who present with undifferentiated abnormal neurologic findings or AMS, even when caregivers do not initially report a potential cannabis exposure. A urine toxicology test is critical for this diagnosis and may both change management and minimize further unnecessary testing in these patients.
Acknowledgments
We thank Dr Ellen Duncan for her expertise and assistance throughout all aspects of our study and for their help in reviewing the manuscript.
Drs Van Oyen, Su, Barney, and Grabinski conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; Drs Chang, Oliff, and Nogar collected data, conducted the initial analyses, and 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: No external funding.
CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest relevant to this article to disclose.
Comments
More on Urine Drug Testing for THC with Children
Adult studies from emergency departments have questioned the clinical value of urine drug screening2, and this doubt has been extended to children.3 Urine testing for drugs in the acute care setting is best obtained when the test result may: answer a diagnostic mystery, change medical management, or be felt necessary to inform child protection efforts. Children with known THC ingestion do not pose a diagnostic dilemma nor management challenge. Children with unrecognized THC poisoning are clearly subjected to increased testing and interventional care, and benefit from early diagnosis.4
Poisoning is an important diagnostic consideration within the etiologies of altered mental status in children. For Van Oyen’s call for enhanced urine drug screening for children to transform care, some systemic medical improvements are necessary. Urine drug tests need to result quickly if they are to obviate interventions of imaging, further testing, or endotracheal intubation. As implicit biases are likely to exist among healthcare providers charged with deciding child protection responses, national guidance may be warranted as to where a curious child finding an attractive candy, that just happens to have THC, falls in the spectrum of child endangerment. And all hospitals are recommended to have good procedures for confirmation of drug screening when warranted, as was described to happen at the authors’ institutions. It is also recommended, amid a co-existing fentanyl epidemic, that urine drug screens in pediatric hospitals include specific testing for fentanyl.
As a final note, I disagree with the authors’ descriptor of “unintentional ingestion” as it has been applied to children and edible cannabis forms. Edible THC products such as gummies, suckers and candy are obviously attractive to children who very purposely eat them. This is a clear and present target for injury prevention policy change.5
REFERENCES
1. Van Oyen A, Barney N, Grabinski Z, et al. Urine toxicology test for children with altered mental status. Pediatrics. 2023; 152(5):e2022060861
2. Stellpflug SJ, Cole JB, Greller HA. Urine drug screens in the emergency department: the best test may be no test at all. J Emerg Nursing. 2020; 46(6): 923-931.
3. Christian M, Lowry JA, Algren DA, et al. Do rapid comprehensive urine drug screens change clinical management in children? Clin Toxicol. 2017; 55(9): 977-980.
4. Toce MS, Dorney K, D’Ambrosi G, et al. Resource utilization among children presenting with cannabis poisonings in the emergency department. Am J Emerg Med. 2023; 73: 171-175.
5. Osterhoudt K, Longo L. Rise in child injury from cannabis: Not the high we wanted. CIRP Research in Action. 2022 (Mar 1); Available at https://injury.research.chop.edu/blog/posts/rise-child-injury-cannabis-not-high-we-wanted