How should a child who ingested oral cannabis be evaluated and managed?

Management of Pediatric Oral Cannabis Ingestion

Children who have ingested oral cannabis should be evaluated for acute intoxication symptoms and monitored for delayed effects, as edible cannabis has unique pharmacokinetics with slower onset and higher risk of overconsumption due to first-pass hepatic metabolism producing more potent metabolites.

Immediate Clinical Assessment

Key Acute Intoxication Signs to Evaluate

• Neurological symptoms: Assess for sedation, obtundation, cognitive impairment, and psychomotor dysfunction 1
• Ocular findings: Look for dry or red eyes, which are common acute indicators 1
• Oral/gastrointestinal signs: Evaluate for dry mouth and increased appetite 1
• Cardiovascular monitoring: Check for tachycardia and assess for potential myocardial ischemia, particularly in cases of high-dose exposure 2
• Respiratory status: Monitor breathing rate and depth, as respiratory depression can occur 1

Critical Pharmacokinetic Considerations

Edible cannabis undergoes first-pass hepatic metabolism, converting THC to 11-hydroxytetrahydrocannabinol, which creates a longer latency to onset of drug effects than inhaled cannabis and results in higher blood concentrations of this more potent metabolite 1. This delayed onset frequently leads to overconsumption and explains why symptoms may worsen hours after ingestion 1.

Monitoring Protocol

Observation Period

• Extended monitoring is essential because edible cannabis has delayed onset compared to inhaled forms 1
• Symptoms may not peak for 2-4 hours post-ingestion due to gastrointestinal absorption kinetics 1
• Children should be observed until symptom resolution or clinical stability is clearly established 1

Symptom Progression Monitoring

• Serial neurological assessments for worsening sedation or obtundation 2
• Continuous cardiovascular monitoring if tachycardia or chest symptoms present 2
• Assessment for development of cyclic vomiting syndrome, which can occur with cannabis toxicity 3

Supportive Management

Primary Treatment Approach

• Supportive care is the mainstay of treatment for acute cannabis intoxication 1
• Maintain airway, breathing, and circulation as priorities 4
• Provide reassurance to the child and caregivers, as anxiety can exacerbate symptoms 1

Specific Interventions

• Intravenous hydration if oral intake is compromised or vomiting occurs 1
• Antiemetics for persistent nausea or vomiting 3
• Benzodiazepines may be considered for severe agitation or anxiety, though use caution as they can potentiate CNS depression 5
• Avoid activated charcoal unless ingestion was very recent (within 1 hour) and significant toxicity is anticipated, as risk often outweighs benefit 4

Laboratory and Diagnostic Testing

Urine Drug Screening

• Urine screening can confirm cannabis exposure with detection of 11-Nor-9-carboxy-THC metabolite 1
• Cannabis metabolites are detectable for 1-3 days after single use, up to 30 days or more with heavy use 1
• Testing should be performed with informed consent and proper counseling about results 1
• Be aware of false positives and false negatives; consult with laboratory for interpretation 1

Additional Testing

• Consider basic metabolic panel if altered mental status is severe 4
• ECG if cardiovascular symptoms are present 2
• Rule out co-ingestions or other causes of altered mental status 4

Neurotoxicity Risk Assessment in Children

Acute Neurotoxic Effects

Cannabis is neurotoxic, particularly in children and adolescents, causing measurable neuroanatomical damage through glutamate excitotoxicity and disruption of critical neurotransmitter systems 2. The developing brain shows increased susceptibility to cannabis-induced excitotoxicity compared to adult brains 2.

Long-term Concerns Following Exposure

• Early cannabis exposure can cause neuropsychological decline and disrupted brain development 2
• THC-induced CB1 receptor activation can inhibit neuronal growth and affect synapse formation during critical developmental periods 1
• Changes in hippocampal structure occur in regions with high CB1 receptor densities 1
• These neurotoxic effects may not be reversible, particularly when exposure occurs during critical neurodevelopmental periods 2

Disposition and Follow-up

Discharge Criteria

• Complete resolution of acute intoxication symptoms 1
• Stable vital signs for appropriate observation period 4
• Reliable caregiver present who understands monitoring instructions 4
• Safe home environment confirmed 1

Mandatory Follow-up Components

• Schedule outpatient follow-up within 1-2 weeks to assess for any delayed neuropsychological effects 2
• Screen for ongoing cannabis access in the home environment 1
• Provide education to caregivers about safe storage of cannabis products 1
• Consider referral to pediatric toxicology or addiction medicine if repeated exposures occur 1

Caregiver Education and Prevention

Critical Safety Counseling

• Cannabis products must be stored in child-proof containers and locked locations, as pediatric emergency department visits for unintentional cannabis exposure have increased with greater availability of recreational marijuana 1
• Edible cannabis products often resemble candy or baked goods, increasing ingestion risk 1
• Even small amounts can cause significant toxicity in children due to lower body weight and developing nervous systems 2

Harm Reduction Discussion

• Discuss the increased potency of modern cannabis products, with THC concentrations nearly doubling from 9% in 2008 to 17% in 2017, and concentrates reaching 70% THC 2
• Explain that edible products have unpredictable absorption and delayed effects 1
• Emphasize that cannabis use in the home increases risk of pediatric exposure 1

Common Pitfalls to Avoid

Clinical Errors

• Do not discharge too early before peak effects occur, given the delayed pharmacokinetics of edible cannabis 1
• Do not assume symptom resolution means no further risk; monitor for delayed or biphasic presentations 1
• Do not overlook cardiovascular complications, which can include myocardial ischemia even in pediatric patients 2

Assessment Mistakes

• Do not rely solely on history; children may have consumed more than initially reported due to the delayed onset encouraging overconsumption 1
• Do not miss co-ingestions of other substances or medications 1
• Do not fail to assess for underlying psychiatric conditions that may be exacerbated by cannabis exposure 1

Documentation and Reporting

• Document quantity and type of cannabis product if known, including THC content 1
• Consider mandatory reporting requirements based on local child protection laws if neglect or unsafe storage is suspected 1
• Provide clear discharge instructions with specific return precautions 4