George Sam Wang

Association of Unintentional Pediatric Exposures With Decriminalization of Marijuana in the United States

STUDY OBJECTIVE We compare state trends in unintentional pediatric marijuana exposures, as measured by call volume to US poison centers, by state marijuana legislation status. METHODS A retrospective review of the American Association of Poison Control Centers National Poison Data System was performed from January 1, 2005, to December 31, 2011. States were classified as nonlegal if they have not passed legislation, transitional if they enacted legislation between 2005 and 2011, and decriminalized if laws passed before 2005. Our hypotheses were that decriminalized and transitional states would experience a significant increase in call volume, with more symptomatic exposures and more health care admissions than nonlegal states. RESULTS There were 985 unintentional marijuana exposures reported from 2005 through 2011 in children aged 9 years and younger: 496 in nonlegal states, 93 in transitional states, and 396 in decriminalized states. There was a slight male predominance, and the median age ranged from 1.5 to 2.0 years. Clinical effects varied, with neurologic effects the most frequent. More exposures in decriminalized states required health care evaluation and had moderate to major clinical effects and critical care admissions compared with exposures from nonlegal states. The call rate in nonlegal states to poison centers did not change from 2005 to 2011. The call rate in decriminalized states increased by 30.3% calls per year, and transitional states had a trend toward an increase of 11.5% per year. CONCLUSION Although the number of pediatric exposures to marijuana reported to the National Poison Data System was low, the rate of exposure increased from 2005 to 2011 in states that had passed marijuana legislation.

Unintentional Pediatric Exposures to Marijuana in Colorado, 2009-2015

IMPORTANCE As of 2015, almost half of US states allow medical marijuana, and 4 states allow recreational marijuana. To our knowledge, the effect of recreational marijuana on the pediatric population has not been evaluated. OBJECTIVE To compare the incidence of pediatric marijuana exposures evaluated at a childrens hospital and regional poison center (RPC) in Colorado before and after recreational marijuana legalization and to compare population rate trends of RPC cases for marijuana exposures with the rest of the United States. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of hospital admissions and RPC cases between January 1, 2009, and December 31, 2015, at Childrens Hospital Colorado, Aurora, a tertiary care childrens hospital. Participants included patients 0 to 9 years of age evaluated at the hospitals emergency department, urgent care centers, or inpatient unit and RPC cases from Colorado for single-substance marijuana exposures. EXPOSURE Marijuana. MAIN OUTCOMES AND MEASURES Marijuana exposure visits and RPC cases, marijuana source and type, clinical effects, scenarios, disposition, and length of stay. RESULTS Eighty-one patients were evaluated at the childrens hospital, and Colorados RPC received 163 marijuana exposure cases between January 1, 2009, and December 31, 2015, for children younger than 10 years of age. The median age of childrens hospital visits was 2.4 years (IQR, 1.4-3.4); 25 were girls (40%) . The median age of RPC marijuana exposures was 2 years (IQR, 1.3-4.0), and 85 patients were girls (52%). The mean rate of marijuana-related visits to the childrens hospital increased from 1.2 per 100 000 population 2 years prior to legalization to 2.3 per 100,000 population 2 years after legalization (P = .02). Known marijuana products involved in the exposure included 30 infused edibles (48%). Median length of stay was 11 hours (interquartile range [IQR], 6-19) and 26 hours (IQR, 19-38) for admitted patients. Annual RPC pediatric marijuana cases increased more than 5-fold from 2009 (9) to 2015 (47). Colorado had an average increase in RPC cases of 34% (P < .001) per year while the remainder of the United States had an increase of 19% (P < .001). For 10 exposure scenarios (9%), the product was not in a child-resistant container; for an additional 40 scenarios (34%), poor child supervision or product storage was reported. Edible products were responsible for 51 exposures (52%). CONCLUSIONS AND RELEVANCE Colorado RPC cases for pediatric marijuana increased significantly and at a higher rate than the rest of the United States. The number of childrens hospital visits and RPC case rates for marijuana exposures increased between the 2 years prior to and the 2 years after legalization. Almost half of the patients seen in the childrens hospital in the 2 years after legalization had exposures from recreational marijuana, suggesting that legalization did affect the incidence of exposures.

Pediatric Concerns Due to Expanded Cannabis Use: Unintended Consequences of Legalization.

An “unintended consequence” of marijuana legalization is the impact on the pediatric population. From prenatal exposure to unintentional childhood exposures, through concerns of adolescence abuse and marijuana use for medicinal indications in children, marijuana exposure can affect pediatric patients at every stage in childhood. Regardless of the stage or reason of exposure, concerns exist about short-term and long-term consequences in a child’s physical and mental health. The use of cannabidiol (CBD) may have some benefit for the treatment of epilepsy, but emphasis needs to be on rigorous clinical trials to evaluate efficacy and safety. As more states allow both medical and recreational marijuana, availability and prevalence of use will likely increase and more surveillance and research is needed to evaluate the consequences on the pediatric population.

Flecainide toxicity in a pediatric patient due to differences in pharmacy compounding

Flecainide is a Vaughn–Williams class 1c antidysrhythmic. It is typically an oral medication administered for the treatment of atrial fibrillation or supraventricular tachycardia (SVT) [1,2]. It is sparingly used in the pediatric population, but can be used in the treatment of SVT [1,2]. We describe a 9 month old male who received an accidental overdose of his medication due to differences in pharmacy compounding. A 9 month old male with a history of Wolff–Parkinson White (WPW) and SVT was seen at a local childrens hospital the day prior to admission due to breakthrough SVT. At that time, he was initially refractory to adenosine, and his SVT resolved with propranolol. His maintenance medication was flecainide 15 mg (3 ml) twice daily. He was discharged home on an increased dose of flecainide to 21 mg (4 ml) by mouth twice daily. Later that morning, patient received 4 ml of his home flecainide when his mother noted him to be pale and fussy. EMS was called and brought him to a local emergency department. En route, he was noted to be in ventricular tachycardia (VT). Upon arrival to the emergency department (ED), his vitals were 37 ° C, RR of 24, and a HR of 180. He was alert, crying and fighting IV attempts. He was noted to be tachycardic on cardiovascular exam withoutmurmurs, rubs or gallops, no hepatosplenomegaly, and normal perfusion. ECG revealed sinus tachycardia with a PR interval of 160 ms and QRS interval of 180 ms. The patient had intermittent episodes of VT in the ED with normal pulses and without change in his clinical status (Fig. 1). It was eventually noted that his original concentration was changed to 20 mg/1 ml rather than the originally prescribed 5 mg/1 ml. Toxicology and cardiology were consulted at that time. IV access was obtained after 1 h in the ED, at that time, no episodes of VT were noted, and the QRS interval was 160 ms. Electrolytes including sodium, potassium, bicarbonate, magnesium, phosphorus, and calcium were all within normal range. Patient was admitted and placed on telemetry upon in the intensive care unit (ICU). Approximately 8 h into his hospital stay, QRS interval widened from 140 ms to 160 ms, his clinical status remained stable. Per toxicology recommendations, 2 mEq/kg of NaHCO3 IV was given and QRS interval was reduced to 120 ms. He subsequently remained hemodynamically stable during his ICU stay without further episodes of ventricular tachycardia, and his QRS narrowed to his baseline. Flecainide overdose can lead to seizures and cardiotoxicity including PR and QRS widening, bradycardia, ventricular tachycardia, and ventricular fibrillation due to its mechanism of action, Na channel blockade. Treatment for flecainide toxicity includes NaHCO3 boluses, hypertonic saline boluses, and extracorporeal circulatory support. Our patient presented immediately after a 4 fold overdose in a wide complex tachycardia, consistent with flecainide toxicity. Previous ECGs showed normal QRS complexes and he had never presented with a wide complex tachycardia due to his WPW. There have been four prior reports of pediatric patients and the toxic effects of flecainide, including an accidental double dose leading to toxicity, and reversal of medication syringes [3–6]. After further investigation for our patient, with the help of access to 2 separate electronic medical records (EMR), a difference in pharmacy compounding was discovered. The child had a flecainide prescription originally written for 15 mg using a 5 mg/1 ml concentration. However, his initial prescription was filled at another pharmacy which compounded the formulation to 20 mg/1 ml and no communication to the original prescribing facilitywasmade.When he returned to the ED, his dose was increased to 21 mg, but hospital records showed he was still using a concentration of 5 mg/1 ml. He was instructed to finish his home medication at the new dose prior to filling the new prescription. Consequently the patient took the correct volume, however at a higher concentration, leading to a 4 fold overdose. Since this case, all the pharmacies in the local metro area have agreed to compound the medication in one standard concentration of 20 mg/1 ml. Other common cardiac medications that are available as multiple concentrations for oral suspensions include verapamil, atenolol, carvedilol, labetalol, propranolol, and tacrolimus. Unverified concentrations in many of these medications can lead to serious morbidity and mortality. Flecainide is a Vaughn–Williams class 1c antidysrhythmic rarely used in pediatrics, indications include SVT. Cardiotoxicity stems from Na channel blockade and includes PR and QRS widening, bradycardia, ventricular tachycardia, ventricular fibrillation. Treatment for toxicity includes NaHCO3 boluses, hypertonic saline boluses, and extracorporeal circulatory support [7,8]. Our case is a reminder when dosing of medications are changed, especially in liquid formulations and with cardiovascular medications, both dosing and concentrations of medications must be confirmed, as accidental overdose and potentially poor comes can result. Finally, access to EMRs remotely can help quickly discover and prevent medical errors.

Safety Profile of Cough and Cold Medication Use in Pediatrics

The safety of pediatric exposures to CCMs is described by using data from 2009 to 2014 from a multisystem surveillance program. BACKGROUND AND OBJECTIVES: The safety of cough and cold medication (CCM) use in children has been questioned. We describe the safety profile of CCMs in children <12 years of age from a multisystem surveillance program. METHODS: Cases with adverse events (AEs) after ingestion of at least 1 index CCM ingredient (brompheniramine, chlorpheniramine, dextromethorphan, diphenhydramine, doxylamine, guaifenesin, phenylephrine, and pseudoephedrine) in children <12 years of age were collected from 5 data sources. An expert panel determined relatedness, dose, intent, and risk factors. Case characteristics and AEs are described. RESULTS: Of the 4202 cases reviewed, 3251 (77.4%) were determined to be at least potentially related to a CCM, with accidental unsupervised ingestions (67.1%) and medication errors (13.0%) the most common exposure types. Liquid (67.3%), pediatric (75.5%), and single-ingredient (77.5%) formulations were most commonly involved. AEs occurring in >20% of all cases included tachycardia, somnolence, hallucinations, ataxia, mydriasis, and agitation. Twenty cases (0.6%) resulted in death; most were in children <2 years of age (70.0%) and none involved a therapeutic dose. The overall reported AE rate was 0.573 cases per 1 million units (ie, tablets, gelatin capsules, or liquid equivalent) sold (95% confidence interval, 0.553–0.593) or 1 case per 1.75 million units. CONCLUSIONS: The rate of AEs associated with CCMs in children was low. Fatalities occurred even less frequently. No fatality involved a therapeutic dose. Accidental unsupervised ingestions were the most common exposure types and single-ingredient, pediatric liquid formulations were the most commonly reported products. These characteristics present an opportunity for targeted prevention efforts.

Marijuana and acute health care contacts in Colorado

Over 22 million Americans are current users of marijuana; half of US states allow medical marijuana, and several allow recreational marijuana. The objective of this study was to evaluate the impact marijuana has on hospitalizations, emergency department (ED) visits, and regional poison center (RPC) calls in Colorado, a medical and recreational marijuana state. This is a retrospective review using Colorado Hospital Association hospitalizations and ED visits with marijuana-related billing codes, and RPC marijuana exposure calls. Legalization of marijuana in Colorado has been associated with an increase in hospitalizations, ED visits, and RPC calls linked with marijuana exposure. From 2000 to 2015, hospitalization rates with marijuana-related billing codes increased from 274 to 593 per 100,000 hospitalizations in 2015. Overall, the prevalence of mental illness among ED visits with marijuana-related codes was five-fold higher (5.07, 95% CI: 5.0, 5.1) than the prevalence of mental illness without marijuana-related codes. RPC calls remained constant from 2000 through 2009. However, in 2010, after local medical marijuana policy liberalization, the number of marijuana exposure calls significantly increased from 42 to 93; in 2014, after recreational legalization, calls significantly increased by 79.7%, from 123 to 221 (p<0.0001). The age group <17years old also had an increase in calls after 2014. As more states legalize marijuana, it is important to address public education and youth prevention, and understand the impact on mental health disorders. Improvements in data collection and surveillance methods are needed to more accurately evaluate the public health impact of marijuana legalization.

Pediatric tea tree oil aspiration treated with surfactant in the emergency department.

Tea tree oil is an essential oil containing a mixture of aromatic hydrocarbons. We describe an 18-month-old male patient who ingested tea tree oil, developed central nervous system depression, respiratory distress, and received early emergency department treatment with surfactant. Early treatment of hydrocarbon pneumonitis with surfactant has not been previously described. Early administration of surfactant should be further evaluated for treatment of hydrocarbon aspiration.

Marijuana Misadventures in Children: Exploration of a Dose-response Relationship and Summary of Clinical Effects and Outcomes

Objectives This study aimed to explore a dose-response relationship of delta-9-tetrahydrocannabinol (THC) in THC-naïve children after unintentional acute exposure and compare clinical outcomes with non-naïve children. Methods A retrospective review was performed on children aged 31 days to 20 years who presented to Childrens Hospital Colorado for care related to acute THC toxicity. The children were divided into groups based on exposure: group 1 (THC naïve) and group 2 (THC non-naïve). Results A total of 38 children (age, 3.5 [3] years) met inclusion for group 1 and an equal number of children (age, 15.1 [3.9] years) met the criteria for comparison in group 2. Eight naïve patients had documentation of estimated THC dose ingested (mean [SD], 7.13 [5.8] mg/kg; range, 2.9–19.5 mg/kg). A direct relationship between estimated oral THC dose, level of medical intervention required, and hospital disposition was observed. Lethargy/somnolence was more common in the naïve group (84% vs. 26%, P < 0.0001) whereas problems in cognition, perception, and behavior were more common in the non-naïve group (4% vs 11%, P = 0.01). The duration of clinical effect and length of hospital stay were longer in the naïve group (19.3 vs 5.0 hours, P < 0.0001) and (0.73 vs 0.19 days, P < 0.0001) respectively. Conclusions There seems to be a direct relationship between the estimated oral THC dose (mg/kg), hospital disposition, and level of medical intervention required. Symptoms and duration of effects after THC exposure varied based on the route of exposure, age of patient, and history of previous THC experience.

Evaluation of drug use and medication compliance in adolescents admitted to a psychiatric facility from the pediatric emergency department

OBJECTIVES Knowledge of drug use and medication compliance during mental health evaluation can help guide evaluation and treatment. The objective was to evaluate drug use and medication compliance in a pediatric emergency department (PED) psychiatric population by comparing medical history, standard urine drug screen (EIA), and expanded urine drug screen (HPLC-MS/MS). METHODS A prospective cohort study of admitted psychiatric patients ≥13years and ≤18years in a tertiary-care childrens hospital psychiatric ED from January 31, 2013 through April 16, 2014. RESULTS 100 patients in our PED were enrolled. Marijuana was the most commonly admitted and detected substance; 43% had co-ingestions. HPLC-MS/MS revealed 36 additional substance exposures than identified by history. All substances detected by EIA were also detected by HPLC-MS/MS. Combination of history and HPLC-MS/MS revealed the most substances used. HPLC-MS/MS identified antidepressants in 76% of patients prescribed a detectable antidepressant. CONCLUSION Marijuana use was greater than nicotine use and was associated with concomitant polysubstance abuse. A combination of history and HPLC-MS/MS was the most thorough in obtaining history of drug use. Almost a quarter of patients did not have their prescribed antidepressant detected by HPLC-MS/MS. A rapid, affordable expanded drug screen should replace the more standard limited drug screen particularly for patients who are refractory to treatment.

Medication organizers (pill minders) increase the risk for unintentional pediatric ingestions

Abstract Objective: Medication organizers may help improve medication compliance; however, they may increase the risk of having an unintentional pediatric exposure. The objective of this study was to measure the association between a pediatric emergency department (ED) visit for an unintentional pharmaceutical ingestion and the use of a medication organizer in the household. Methods: This was a cross-sectional case control study at a tertiary care children’s hospital ED. Cases included subjects <6 years of age who were evaluated in the ED for an unintentional pharmaceutical ingestion. The control group presented to the ED for a non-injury complaint and was matched using age and sex. Results: The unadjusted odds ratio (OR) of risk for unintentional pharmaceutical ingestion with use of a medication organizer was 2.0 (95% CI, 1.3, 2.9). After adjusting for the presence of prescription medications in the home, the OR of risk for ingestion remained statistically significant at 1.8 (95% CI, 1.1, 2.7). The child obtained the exposure medication from the medication organizer in 63% of cases where a medication organizer was present in the home. Cases were more likely to have knowledge of, and previous contact with poison control centers (PCC) than non-injury controls. Overall, a large number of caregivers (36%) did not have any knowledge of PCC. There were also differences in smoking and use of seat belts between cases and controls. Conclusions: The use of medication organizers may be a risk factor for unintentional pediatric pharmaceutical ingestions, even when controlling for the use of prescription medications in the home. Further research is needed to evaluate the specific role of medication organizers, and subsequently, improve prevention strategies.