Cannabis cookies: A cause of coma

J. Paediatr. Child Health (1996) 32,194-195

Cannabis cookies: A cause of coma CA BOROS,' DW PARSONS? GD ZOANETTI? D KETTERIDGE3 and D KENNEDY2 Departments of General Paediatrics and zPulmonary Medicine, Women's and Children's Hospital and Department of Paediatrics, University of Adelaide, and 3Department of Chemical Pathology, Women's and Children's Hospital, North Adelaide, South Australia, Australia

Abstract: Despite the prevalence of cannabis use in the community, reports of adverse effects in young children are rare. Two cases of cannabis-induced coma are reported following accidental ingestion of cannabis cookies. The possibility of cannabis ingestion should be considered in cases of unexplained coma in a previously well young child if signs of conjunctival hyperaemia, pupillary dilatation and tachycardia are present and other causes such as CNS infection or trauma are unlikely. Specific screening for cannabinoids should be undertaken. Key words:

cannabis; coma; cookies.

Coma in childhood is a medical emergency. Its causes are protean and prompt diagnosis and treatment are imperative. Cannabis, in the forms of marijuana or hashish, has been used as both a therapeutic and recreational drug since the first reference to its use in China's Nung Dynasty 2327 EC.' As a recreational drug its popularity has not waned with the passage of time. In the USA in 1985 approximately 17 million adults and 3 million teenagers regularly smoked cannabis2 The drug can also be ingested, usually in the form of hashish/mariiuana biscuits or cookies. These provide an unwitting temptation for children. Given the ubiquity of cannabis and the fondness of children for cookies, reports of cannabis intoxication in young children have been surprisingly few. This is most likely due to both parental reluctance to volunteer the history of possible ingestion and physicians' failure to recognize the clinical picture.

CASE REPORTS Case 1 A previously well 18 month old boy was referred to the Women's and Children's Hospital with a 3 h history of rapid onset of drowsiness. Trauma and possible drug ingestion were discounted by his parents. His Glasgow Coma Score was six. He was afebrile, pale and had bilateral conjunctival hyperaemia. His pulse rate was 92/min, respirations 20/min. blood pressure 105/43mmHg. His pupils were mildly dilated and reacted sluggishly to light. Fundoscopy was normal. Both corneal and gag reflexes were present. Limb reflexes were depressed. Laboratory investigations, which included a full blood count,

Correspondence Dr JD Kennedy, Department of Paediatrics, Women's and Children's Hospital. 72 King William Rd , North Adelaide. South Australia 5006, Australia CA Boros MB BS Medical Registrar DW Parsons, PhD. Senior Hospital Scientist GD Zoanetti, BApplSc. Hospital Scientist D Ketteridge. ME, BS FRACP, Senior Visiting Medical Officer Accepted for publication 13 November 1995

blood sugar, electrolyte profile, plasma ammonia level and liver function tests, were normal. Urine toxicology testing demonstrated the presence of cannabinoids. No other drugs were detected. He remained unresponsive for a further 6 h and then gradually regained full consciousness. Although not directly admitting the possession of hashish cookies, his mother subsequently reported that hashish cookie crumbs were found under a bean bag following a party at the child's home.

Case 2 A previously well 3% year old boy was referred to a rural hospital with rapid onset of drowsiness. His Glasgow Coma Score was six at the time of presentation. He was pale and his pupils were moderately dilated but reacted equally to light. He had mild conjunctival hyperaemia. Limb reflexes were brisk. He was transferred after 3 h to the central district hospital. On arrival, his conscious level had improved and he responded to commands. He was afebrile, pulse rate was 1 lO/min, respirations 24/min, blood pressure 140/80mmHg. Gastric lavage was performed and charcoal given although no history of drug ingestion was volunteered by parents. He subsequently became comatose and was transferred by air with a medical escort to The Women's and Children's Hospital. On arrival he was fully conscious but hyperreflexic. Urinary toxicology analysis demonstrated cannabinoids. Only then was it reported that he had ingested a hashish cookie that he had found in the refrigerator. In neither case were the parents suspected substance abusers and their psychosocial circumstances were unremarkable. A frank discussion of the dangers of drug ingestion was undertaken in both cases.

DISCUSSION

Cannabis ingestion in young children is potentially harmful. Cannabis intoxication should be considered in a comatose child if there has been a rapid onset of drowsiness in a previously

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well child, if conjunctival hyperaemia, pupillary dilatation, tachycardia coexist, and if other causes such as trauma, CNS infection or fits are ~ n l i k e l yThe . ~ child’s caregivers should be questioned directly about possible cannabis ingestion as it is likely that they may be reluctant to divulge the information because of the legal implications of its possession and use. Cannabis use is prevalent in the community. A recent survey of the use of licit and illicit drugs among 12-17 year old students in New South Wales reported that 40% of males and 26% of females aged 16 years had tried cannabis. Weekly use peaked at 15 years for males (14%) and 16 years for females (6%)4 Over the 6 year period 1983-89 a consistent decline was found in the use of cannabis both occasionally and regularly in female but not in male students5 A recent prevalence study from New Zealand reported that approximately 10% of 15 year olds had tried cannabis at least once, with 75% reporting the experience as being positive, inducing happy and relaxed feelings.6 A potential limiting factor in conveying the message of cannabis’ deleterious effects to adolescents is that many of today’s parents grew up in the 60s and 70s, the ‘Woodstock generation’, where the popular misconception was that cannabis was relatively innocuous. The science underpinning such a belief has changed, however, in the past 20 years; for example, smoking 3-4 marijuana cigarettes daily results in the same degree of airway damage as more than 20 tobacco cigarettes daily.’ Given the widespread availability and use of cannabis in adults and teenagers, it is surprising that there have been so few reports of acute intoxication in young ~ h i l d r e n . This ~ . ~ ~is~ probably due to a combination of factors: under-reporting because of parental concern of litigation, physicians lack of recognition of the clinical picture, and the relative absence of cannabinoid screening during routine toxicology analysis. Neither set of parents of the present cases volunteered the possibility of cannabis ingestion despite the fact that possession

of small amounts of marijuana in South Australia results in a fine rather than criminal conviction. Cannabinoids should be specifically screened for in cases of coma where drug ingestion is suspected. The request for a ‘drug screen’ is not sufficient as cannabinoids may not be part of the routine drug screening protocol. Only two Australian children’s hospitals routinely screen for cannabinoids during toxicology testing. It is unlikely that children’s interest in eating cookies will wane. Parents and doctors need to be informed of the potentially serious consequences of cannabis cookie intoxication in young children.

REFERENCES Selden BS, Clark RF, Curry SC. Marijuana. Emerg. Med. Clin. North Am. 1990; 8: 527-39. American Thoracic Society. Marijuana and the lungs (Position Paper). ATS News 1985; 11: 7. Macnab A, Anderson E, Susak L. Ingestion of cannabis: a cause of coma in children. Pediatr. Emerg. Care 1989; 5: 238-9. Donnelly N, Quine S, Oldenburg B etal. Prevalencesand perceptions of licit and illicit drugs among New South Wales secondary school students, 1989. Aust. J. Public Health 1992; 16: 43-9. Donnelly N, Oldenburg B, Quine S et a/. Changes in reported drug prevalence among New South Wales secondary school students, 1983-1 989. Aust. J. Public Health 1992; 16: 50-7. Fergusson DM, Lynskey M, Horword W. Patterns of cannabis use among 13-14 year old New Zealanders. N.Z. Med. J. 1993; 106: 247-50. Wu TC, Tashkin DP, Djahed B, Rose JE. Pulmonary hazards of smoking marijuana as compared with tobacco. N. Engl. J. Med. 1988; 318: 347-51. Pettinger G, Duggan MB. Black stuff and babies: Accidental ingestion of cannabis resin. Med. Sci. Law 1988; 28: 310-11. Weinberg 0,Lande A, Hilton N,Kerns DL.Intoxication from accidental marijuana ingestion. Pediatrics 1983; 71: 848-9.