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How Common Is Unintentional Cannabis Ingestion?

Patient Presentation
A full-term female was born to a 26 year old G4P4 female by vaginal delivery without complications. She was given routine care and was doing well at 24 hours after delivery. The social history revealed that the mother was known to smoke marijuana frequently, and had a positive urine drug testing for marijuana during this pregnancy. A male sibling had also been admitted for an unintentional cannabis exposure after the toddler had ingested his mother’s unfinished marijuana cigarette. The father of the baby smoked cigarettes and smokeless tobacco, and had some beers on the weekend. He denied any substance abuse. Both parents were employed and all of the children were living with them.

The pertinent physical exam showed a healthy female with normal vital signs. She had a weight and head circumference at the 10% and length of 50%. She had no physical anomalies noted and had a normal exam. The diagnosis of a healthy female with prenatal cannabis exposure was made. A urine toxicology screening was sent on the infant and eventually was positive for cannabis only. The state’s Department of Human Services was contacted and continued to follow the family over the next year. The mother had entered a substance abuse treatment program but was inconsistent in going to the program.

The patient’s clinical course showed her to continue to grow appropriately but she still was at the 10-15% for head circumference and weight over the next year. She also had normal development. The family was lost to followup after the 12 month appointment.

Discussion
“[Cannabis] is a genus of flowering plant with three main varieties: sativa, indica and ruderalis.” It has been used for hundreds of years for hemp or fiber and also for psychoactive and medicinal effects. The active compounds are collectively called cannabinoids, of which delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) are the most abundant. The floral buds or calyxes of the plant have the most cannabinoids, but other parts of the plant are also used such as leaves. Hash oil, hashish (or resin) and marijuana (dried leaves) are the common products from strongest to least strongest products. (Hash oil is not the same as Hemp oil. Hemp oil is often sold over the counter and contains little cannabinoids). Cannabis is smoked (like or with tobacco) or vaporized (like an e-cigarette) or ingested in drinks or food. Cannabis like many psychoactive drugs is lipophilic which allows it to easily cross the blood-brain or placental barriers and to remain within the fat tissue and therefore can be concentrated and its effects can last up to weeks. THC half-life is several days to a week. Cannabis’s “[a]cute effects include … Relaxation, euphoria, heightened perception, sociability, sensation of time slowing, increased appetite and decrease pain, and on the other hand paranoia, anxiety, irritability, impaired short-term memory, poor attention and judgment, and poor coordination and balance. Physiologic effects include tachycardia, hypertension, dry mouth and throat, and conjunctival injection.”

Cannabis is used by about 3.9% of the world’s population. For drug users, it is the most commonly abused drug. Up to ~40% of adults have used cannabis at some time in their lifetime. It is commonly used in pregnant and lactating women (~2.5 – 5.0% depending on the population). Marijuana use is on the increase for teens with an overall use of ~7% and ~23% of 12th graders in the U.S. have used it in the past month (Data from 2013).

Cannabis research has been difficult because different definitions (such as defining what is regular or significant use) or confounding factors such as concurrent substance abuse (e.g. tobacco, alcohol, other), poor nutrition, lifestyle, and parenting effects. Infants, whose mother’s used cannabis, have an increased associated with low birth weight and growth restriction, smaller head growth (that continues through adolescence), cognition, visual-perceptual skills, verbal-reasoning skills, language skills, specific learning problems, attention and depression. Regular cannabis use by adolescents has been linked to a decline in intelligence quotient through age 38 that is not reversed with discontinuation of cannabis use. Adolescent cannabis use has also been linked to depression (but not suicide) and possibly anxiety disorders. Cannabis use during times of critical brain development such as fetal and young children and adolescence, increases the risk of neurological impairment.

Medical use has been proposed and mainly studied in adult populations. Potential indications include cancer-related nausea, appetite enhancement, neurogenic pain, glaucoma and epilepsy. In pediatrics some of the most common use is for seizures, but also chronic pain and muscle spasms. CBD is the more common form of cannabis used for seizures. Currently available data for developmental or behavioral conditions such as ADHD, oppositional defiant disorder, or autism spectrum disorder are case-studies or small series. Research agendas have been proposed to try to answer many of the important but unclear or not available research voids.

Learning Point
Unintentional ingestion by young children is increasing as cannabis is available legally or illegally within their environments. When comparing data from states where cannabis is not legal or legal, the numbers of phone calls to poison control centers from 2005-2011, showed an increase of 1.5% in non-legal states, but a 38.5% increase in legal states. In legal states, there was also an increase in the number of moderate or major effects and hospital admissions (overall admission = 16%). There was also a small number but increased admissions to intensive care settings.

Young children are more likely to orally ingest cannabis as resin, food (cookies) or unfinished marijuana cigarettes (joints). They can also be exposed through candies and beverages or other food products which are often marketed to look like non-cannabis food products. Hash resin itself looks similar to a chocolate candy bar. There is little data about passive exposure to cannabis smoke exposure but cannabis smoke has been shown to have similar components to nicotine/tobacco smoke including potential carcinogens. Cannabis products such as hash oil or resin are being used by some though vaporization (similar to e-cigarettes). The most common symptoms of unintentional ingestion were lethargy, followed by tachycardia, mydriasis and hypotonia.
“The unintentional ingestion of cannabis by children is a serious public health concern and is well-documented in numerous retrospective studies, case-series, and case reports. Clinicians should consider cannabis toxicity in any child with a sudden onset of lethargy or ataxia. Hypotonia, mydriasis, tachycardia, and hyperventilation represent other common clinical findings of cannabis toxicity. As cannabis legalization, availability, and potency increases so does the possibility for the rising incidence of unintentional pediatric cannabis intoxication, which frequently requires hospitalizations, and, in some cases, admission to the PICU for airway support.”

Questions for Further Discussion
1. What types of body fluids or tissues can be tested for cannabis?
2. What is the legal status of cannabis in your state or country? If legal in some form, how is medical cannabis prescribed and distributed?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Marijuana and Pregnancy and Substance Abuse.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Jaques SC, Kingsbury A, Henshcke P, Chomchai C, Clews S, Falconer J, Abdel-Latif ME, Feller JM, Oei JL. Cannabis, the pregnant woman and her child: weeding out the myths. J Perinatol. 2014 Jun;34(6):417-24.

Hadland SE, Knight JR, Harris SK. Medical marijuana: review of the science and implications for developmental-behavioral pediatric practice. J Dev Behav Pediatr. 2015 Feb-Mar;36(2):115-23.

Richards JR, Smith NE, Moulin AK. Unintentional Cannabis Ingestion in Children: A Systematic Review. J Pediatr. 2017 Nov;190:142-152.

Wang GS. Pediatric Concerns Due to Expanded Cannabis Use: Unintended Consequences of Legalization. J Med Toxicol. 2017 Mar;13(1):99-105.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Are the Types of Tracheoesophageal Fistulas?

Patient Presentation
A full-term male was born by vaginal delivery to a 24 year G1P1 female. In the delivery room, he had some difficulty breathing and was taken to the transition bed for monitoring. The nurse noted that he seemed to have more secretions and needed frequent suctioning. She tried to pass an NG tube to suction his stomach but was not able to pass it more than a few centimeters. He was taken to the neonatal intensive care unit, where his respiratory distress seemed to improve, but when he attempted to eat, he had a poor suck and had regurgitation. His tachypnea resumed. Again a nasogastric tube was tried, but could not be passed and on radiograph was found coiled in the proximal esophagus. The diagnosis of esophageal atresia and tracheoesophageal fistula was made. He was taken to the operating room and found to have proximal blind pouch esophageal atresia with a distal tracheoesophageal fistula. He was extubated on day 3 of life and was discharged on day 15 after surgical recovery and being able to take full oral feedings.

Discussion
Respiratory problems in infants can caused by many things including any type of obstruction from the nose to lung. Neonates and infants are particularly susceptible to changes in the size of the airway because of the physics of airflow resistance. Important reminders about infant airways:

  • Resistance = 1/radius4 (Poiseuille’s equation) therefore even a 1 mm decrease in the airway circumferences increases the airflow resistance x16.
  • Increased airflow causes less pressure along the walls, which can lead to collapse of the walls (Bernoulli’s and Venturi effects).
  • Neonates have smaller lungs relative to the rest of their body therefore they have less pulmonary reserve.
  • Neonates have higher oxygen consumption rates (about 50% more) than older children and adults.
  • Neonates are preferential nose breathers.
  • Neonates have immature regulation of vital functions and when stressed may do the opposite of what is expected. For example, they may become apneic with respiratory distress instead of increasing their respiratory rate.

Therefore anything that changes the airflow dynamics of the infant airway can cause dramatic effects for a neonate. Health care personnel need to be aware of subtle changes and may need to respond quickly to the infant’s respiratory status, even while trying to determine the cause of the problem.

Learning Point
Esophageal atresia (EA) with tracheoesophageal fistula are anomalies in the continuity of the esophagus with or without tracheal communication.
EA/TEF occurs in about 2500-3000 live births with most being a sporadic/non-syndromic. Familial or syndromic cases are about 1% with examples being CHARGE, VATER or VACTERL associations. To learn more about associations click here.

Presentations can vary depending on the particular type of EA/TEF. Prenatally, polyhydramnios, small or absent stomach bubble on prenatal ultrasound may indicate a EA/TEF. At birth, respiratory distress or cyanosis can occur. At birth or within a short time, increased salivation, regurgitation, coughing or choking on feeding may indicate a problem. Older children may present with recurrent coughing, wheezing, regurgitation or frequent pulmonary infections.

Chest/abdominal radiographs may show an air filled abdomen, or failed placement of NG tube (i.e. curled up in esophagus). H-type fistulas are difficult to detect by many means including upper gastrointestinal radiographic studies and even endoscopy.

The Gross Classification of EA/TEF includes:

  • A – Isolated EA without TEF, 7-8.5%
  • B – EA with proximal TEF, 1 to 2%
  • C – “Blind pouch”, proximal EA with a distal TEF attached posteriorly to trachea, 85 – 86%
  • D – “Double fistula”, EA with proximal and distal TEF, ~1%
  • E – “H-type fistula”, TEF present between intact esophagus and trachea, 4%

The Vogt classification is similar but also includes absent esophagus. Concurrent anomalies occur in about 50% of patients including “…cardiovacular (29%), anorectal (14%), genitourinary (14%), gastrointestinal (13%), vertebral/skeletal (10%), and respiratory (6%) may be present.” Tracheomalacia is not considered a concurrent anomaly by most people, but part of the EA/TEF process. It occurs in about 75% of patients.

Surgery includes ligation of the TEF and anastomosis of the EA. This has been traditionally done by thoracotomy but is being done more often recently by thoracoscopy. Patients usually do well with only an ~2% mortality rate usually because of concurrent anomalies. Short term surgical complications include anastomatic leaks, esophageal stenosis or web, recurrent fistula, vocal fold paralysis, dysphagia, eating problems, gastroesophageal reflux disease and pulmonary infections. Longer term followup shows problems with GERD and pulmonary problems including wheezing or infections. Generally development is normal but children may have communication problems. There are few studies of adults who had EA/TEF as a child so data is sparse but shows GERD and pulmonary problems.

Questions for Further Discussion
1. What are the components of CHARGE association?
2. List other types of tracheal disorders?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Esophagus Disorders and Tracheal Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Roberts K, Karpelowsky J, Fitzgerald DA, Soundappan SS. Outcomes of oesophageal atresia and tracheo-oesophageal fistula repair. J Paediatr Child Health. 2016 Jul;52(7):694-8.

Javia L, Harris MA, Fuller S. Rings, slings, and other tracheal disorders in the neonate. Semin Fetal Neonatal Med. 2016 Aug;21(4):277-84.

Vijayasekaran S, Lioy J, Maschhoff K. Airway disorders of the fetus and neonate: An overview. Semin Fetal Neonatal Med. 2016 Aug;21(4):220-9.

van der Zee DC, Tytgat SHA, van Herwaarden MYA. Esophageal atresia and tracheo-esophageal fistula. Semin Pediatr Surg. 2017 Apr;26(2):67-71.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What Is the Most Common Type of Cardiomyopathy?

Patient Presentation
A 15-week-old male came to clinic to establish care in the general pediatric clinic at an academic children’s hospital. The past medical history showed he had been born full-term to a 19 year old G1P1 female with little prenatal care. After delivery he was noted to have respiratory distress that did not improve. A chest radiograph showed an enlarged cardiothoracic ratio and initially he was thought to have either a congenital infection causing myocarditis or neonatal thyrotoxicosis. Eventually he was diagnosed with dilated cardiomyopathy because of Barth syndrome. The social history revealed that he had been discharged from a children’s hospital in another city, and his mother moved to the new city to be with her parents. The infant had already seen the pediatric cardiologist in the new city.

The pertinent physical exam showed a small infant with weight at the 15% but he had gained appropriate weight. His head circumference and length were 25%. His heart rate was 138 beats/minute, and respiratory rate was 44 per minute with a saturation of 95% on room air. He had prominent cheeks and relatively large ears. His heart showed S1 and S2 with a low-pitched S3. He seems slightly hypotonic, but the rest of his examination was normal.

The diagnosis of Barth syndrome was made. The pediatrician worked with the clinic social worker to help set up transportation for medical appointments, supplemental food programs, and appropriate maternal medical care, in addition to a followup appointment in 1 month.

Discussion
Barth syndrome is characterized by a dilated cardiomyopathy, proximal skeletal muscle weakness, neutropenia and short stature that usually presents at birth or soon after. It is a rare X-linked recessive disease process caused by mutations in the TAZ gene. The TAZ gene codes for tafazzin which alters cardiolipin in mitochondria. Characteristic facies can be seen especially in infancy including a tall and broad forehead, prominent chin and full cheeks, larger ears, and deep-set eyes. Most patients present at birth or soon afterwards but some may not until later in life. Life expectancy is reduced with many children dying in infancy and young childhood because of cardiomyopathy.

Myocarditis is inflammation of the myocardium that causes cardiac dysfunction. It is usually caused by infectious diseases particularly viruses, but also drugs, toxins and systemic diseases.

Causes include:

  • Infectious diseases
    • Virus
      • Adenovirus**
      • Coxsackie virus**
      • Cytomegalovirus
      • Epstein-Barr virus
      • Hepatitis C**
      • Human immunodeficiency virus
      • Human herpes virus 6**
      • Influenza
      • Parvovirus B-19**
    • Other infections
      • Streptococcus
      • Trypanosomiasis

  • Non-infectious causes
    • Idiopathic
    • Drug-induced hypersensitivity
    • Eosinophilic myocarditis
    • Giant cell myocarditis
    • Sarcoidosis
    • Systemic lupus erythematosus

** = most common viruses identified

Myocarditis is divided into 3 phases: acute (where muscle fibers can be lysed), subacute (where viral cell damage occurs including apoptosis, and inflammatory processes), and chronic (where antibody production and cross-reactivity can cause myocyte damage). Myocarditis can be difficult to detect as patients may be asymptomatic but can also present with fulminant heart failure. Patient often have a preceding viral illness and then present with respiratory distress, dyspnea, edema or weakness especially around 7-14 days (subacute phase). Common physical examination findings are abnormal respiratory examination, cyanosis/hypoxia, tachycardia, new murmur, hypotension, fever, hepatomegaly, lethargy, and/or pallor. Evaluation includes looking for various causes of myocarditis including viral infections, cardiac enzymes, chest radiographs and potentially cardiac magnetic resonance imaging, electrocardiogram and/or echocardiogram. Treatment is supportive with treatment for dysrhythmias, and heart failure along with any treatment for the specific cause. Prognosis is usually good for most patients but it depends on the particular circumstances.

Learning Point

Cardiomyopathy (CM) is a disease of the myocardium where the heart is abnormally enlarged, thickened, and/or stiffened. The heart then is ineffective in pumping blood and may lead to heart failure.
CM caused by some of the following:

  • Genetic factors
    • Dilated cardiomyopathy
    • Hypertrophic CM
    • Conduction defects
    • Glycogen storage diseases
    • Ion channel defects
    • Left ventricular noncompaction
    • Mitochondrial myopathies
    • Neuromuscular syndrome
  • Mixed
    • Dilated CM
    • Restricted CM
  • Acquired
    • Myocarditis
    • Infants of diabetic mothers
    • Peripartum
    • Tachycardia or arrhythmia induced

Dilated cardiomyopathy (DCM) is the most common type of CM; up to 60% of cases. The differential diagnosis is extremely broad especially for acquired cases with viruses felt to be the most common cause and are the most common cause identified. Although for many patients no identifiable cause is found. A history of first degree relative with DCM or sudden death under age 30-35 increases the risk of DCM by a genetic cause. Presentation is similar to myocarditis but heart failure is more common along with respiratory problems, tachycardia, tachypnea, and feeding difficulties. Physical examination can show abnormal apical pulse, distant heart sounds, murmurs, and third heart sounds on cardiac examination. Pulmonary congestion on auscultation can be heart. Hepatomegaly and peripheral edema can occur but are less common in infants. Findings from specific causes can be seen such as hypotonia, muscle weakness or dysmorphic features.

Questions for Further Discussion
1. What are causes of sudden cardiac death in young patients? A review can be found here
2. What causes restrictive cardiomyopathy?
3. What causes hypertrophic cardiomyopathy?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.
Information prescriptions for patients can be found at MedlinePlus for these topics: Cardiomyopathy and Congenital Heart Defects.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Soares P, Rocha G, Pissarra S, Soares H, Flor-de-Lima F, Costa S, Moura C, Doria S, Guimaraes H. Neonatal dilated cardiomyopathy. Rev Port Cardiol. 2017 Mar;36(3):201-214.

Ware SM, Genetics of paediatric cardiomyopathies. Curr Opin Pediatr. 2017 Oct;29(5):534-540.

Pettit MA, Koyfman A, Foran M. Myocarditis. Pediatr Emerg Care. 2014 Nov;30(11):832-5.

Buggey J, ElAmm CA. Myocarditis and cardiomyopathy. Curr Opin Cardiol. 2018 May;33(3):341-346.

Barth Syndrome. Genetics Home Reference
Available from the Internet at https://ghr.nlm.nih.gov/condition/barth-syndrome (rev. 11/27/18, cited 11/28/18).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa