Retrospective Review of Unintentional Pediatric Cannabis Poisonings in Saskatchewan after Federal Legalization

Abstract

Background: With the legalization of cannabis in Canada, safety concerns for children should be considered. Despite packaging and dose regulations for edibles and inhaled cannabis, unintentional poisonings are a clinical risk, and its impact on pediatric healthcare resources have not been clearly delineated.

Methods: This retrospective cross-sectional chart review evaluated all patients < 19 years presenting to Saskatchewan’s only pediatric trauma center between January 1st, 2020 to June 30th, 2021 with unintentional poisoning. Cannabis and non-cannabis unintentional poisonings were compared using difference of squares and Fisher’s exact test.

Results: There were fifty-two unintentional poisonings during the study period, with a mean age of 2.45 years (SD 2.11). Thirty one percent (n=16) were cannabis related, with edibles accounting for at least 63% (n=10) of those admissions. More than 40 percent were transferred from rural communities with an average transport distance of 160 kilometers. Over 18% (n=3) percent were admitted to PICU with no requirement for intubation or vasoactive medications.

Conclusions: Since legalization, one third of Saskatchewan’s pediatric unintentional poisonings were due to cannabis, largely from edible ingestions. An increased public awareness and federal government initiatives may attenuate the risk of these ingestions.

Keywords: Cannabis; Children; Poisoning

Abbreviations: COVID-19 Coronavirus disease of 2019; CPR cardiopulmonary resuscitation; NACA National Advisory Committee for Aeronautics; PICU Pediatric Intensive Care Unit; SD standard deviation; THC: delta-9-tetrahydrocannabinol

Introduction

The World Health Organization reports that cannabis is one of the most widely used mind-altering substances [1]. In Canada, recreational cannabis use was legalized by the federal government on October 17^th, 2018, and cannabis extracts were legalized for products such as vaping e-cigarettes and edibles on Oct. 17, 2019 [2,3]. To prevent serious poisonings, Canadian regulations require “child-resistant” packaging for edibles (not for plants or seeds), and limit the amount per package of edibles or per unit of inhaled use at 10mg THC (delta-9-tetrahydrocannabinol) [2-4].

A recent Canadian single center retrospective study found a significant difference between cannabis poisoning in the year post legalization and during the COVID-19 pandemic in 2020 [5]. In a cross-sectional study comparing pre and post-legalization, the proportion of hospitalizations after cannabis-related Emergency Department visits was significantly greater after the introduction of edibles [6]. Other reports have suggested that 3-13% of children seen in health care facilities for cannabis poisonings require admission to pediatric intensive care (PICU) [7- 10] secondary to hypothermia, bradycardia, hypotension, seizures, respiratory depression, encephalopathy, and coma [10]. These children required intubation and CPR in almost 5% and 0.3% of cases, respectively [10].

We hypothesized that unintentional cannabis-related poisonings would be prominent since legalization, with edibles being largely responsible.

Materials and Methods

Our retrospective cross-sectional chart review was approved by the University of Saskatchewan’s Biomedical Ethics Review Board. It was not possible to involve patients in the design, conduct, reporting or dissemination plans of this research. Patients were identified by an institutional search that included International Classifications of Diseases (ICD-10) codes for unintentional poisonings (X40 to X49), age < 19 years, between January 1^st, 2020 to June 30^th, 2021, and admission to Saskatchewan’s only pediatric trauma center. There were no specific exclusion criteria. After identification, patient demographics, pre-admission NACA (National Advisory Committee for Aeronautics) scores, transport data, hospital management, and outcomes including length of stay were recorded by a single reviewer. Rural was defined as > 20 km from a tertiary center. Quantitative data was summarized as means or proportions were appropriate. Cannabis and non-cannabis unintentional poisonings were compared using differences of squares and Fisher’s exact test. Analyses was performed using SPSS Statistics 28 (IBM Corp., Armonk, NY).

Results

Between January 1^st, 2020 to June 30^th, 2021, fifty-two unintentional poisonings occurred. There were no missing data. The mean age was 2.45 years (SD 2.11), and 51.9% (n=27) were female. Forty six percent (n=24) of the poisonings were rural with a mean transport distance of 197.9 km (SD 126.3), involving private vehicles (n=7; 29.2%), ground ambulance (n=10; 41.7%), fixed wing (n=6; 25%) and helicopter (n=1; 4.2%). Patient’s median initial GCS was 9 (IQ 8–11), and mean NACA scores were 4.04 (SD 0.39). Twelve patients required PICU, with a mean duration of 1.5 days (SD 0.65). Average admission duration was 1.42 days (SD 0.97). All were discharged home; there were no deaths.

Sixteen poisonings involved cannabis (30.8%), with edibles (pills, chocolates, cookies, gummies and butter) accounting for at least ten (63%) admissions. Over 40 percent were triaged from rural communities (Table 1), necessitating an average transport distance of 160 kilometres. Nearly twenty percent were admitted to PICU, but none required intubation or vasoactive medications. The non-cannabis poisonings were divided by ICD-10 classification as follows: X40 non-opioid analgesics and antipyretics (n=5; 9.6%), X41 anti-epileptics and sedativehypnotics (n=10; 19.2%), X42 narcotics and psychedelics (n=7; 13.5%), X43 acting on autonomic nervous system (n=1; 1.9%), X44 unspecified drugs and biologic substances (n=9; 17.3%), X45 alcohol (n=1; 1.9%) and X49 unspecified chemicals and noxious substances (n=3; 5.8%). Differences between cannabis and non-cannabis unintentional poisonings are summarized in (Table 1). Non-cannabis poisonings required significantly longer hospital admissions.

  

    
Variable
    
Cannabis

      (n=16)
    
Noncannabis

      (n = 36)
    
p-value
  
  

    
Age, yra
    
2.72 (2.54)
    
2.33 (1.41)
    
0.48
  
  

    
Ruralb
    
7 (43.8)
    
17 (47.2)
    
1
  
  

    
Distance of rural    transport, kma
    
159.4 (164.9)
    
213.8 (108.8)
    
0.17
  
  

    
NACA scorea
    
3.9 (0.2)
    
4.1 (0.4)
    
0.23
  
  

    
PICU Admissionb
    
3 (18.8)
    
9 (25)
    
0.73
  
  

    
Intubatedb
    
0
    
3 (8.3)
    
0.54
  
  

    
Vasoactive infusionsb
    
0
    
1 (2.8)
    
1
  
  

    
Length of PICU admission,    daysa
    
1.0 (0)
    
1.7 (0.7)
    
0.21
  
  

    
Length of hospital    admission, daysa
    
1.1 (0.4)
    
1.6 (0.7)
    
0.005
  
  

    
amean (standard deviation); bnumber    (percentage)

      NACA= National Advisory Committee for    Aeronautics; PICU= pediatric intensive care unit 
  

Table 1: Comparison between cannabis and non-cannabis unintentional poisonings.