Hot Seat #179: Denouement

Posted on: November 8, 2021, by :

This week’s Hot Seat case focused on an infant with an episode of unresponsiveness at home. And while infants presenting to the emergency department following BRUE-like events are common, the recurrent nature of this patient’s symptoms and association with vomiting warranted further workup.

With such a broad differential diagnosis in this case, polling showed a wide range of approaches to diagnosis. Most providers agreed that they would order an EKG with basic labs, slightly fewer chose to include a urine drug screen. Ultimately, the patient’s urine was positive for cannabinoids. The parent’s initial explanation, that she uses CBD supplements that could pass through the breastmilk, was not supported in consultation with our toxicologist, and ultimately the patient’s mother admitted to having THC-containing products in the home.

The era of legal adult recreational cannabis use has brought with it a risk that children will be exposed to these products. It has also made many of us reconsider how we approach such cases. Here, where a child’s clinical presentation is well explained by a cannabis exposure, we saw a lot of variability in how providers would proceed. About two-thirds of junior and senior clinicians surveyed would pursue our full non-accidental trauma evaluation, but a significant number would not. And while most agreed that involving social work and reporting to the DC Child and Family Services Agency hotline was warranted, there was less agreement on who else to involve. The polling here highlights the practice variability we see around cannabis exposures, where less then half of respondents would involve our child abuse pediatricians in the evaluation.

Ultimately, the patient was admitted to the hospitalist service.  Her EEG was normal, and neurology did not feel her history was explained by seizure activity.  Echocardiogram was subsequently normal, and the Q-wave abnormalities were favored to be an incidental finding.  CAPC was consulted, and NAT workup was initiated, and ultimately normal (including ophthalmology exam, skeletal survey, and trauma labs).  Comprehensive toxicology screen was sent to confirm THC-positivity.  Hematology was consulted regarding anemia, child diagnosed with iron deficiency in the setting of breastfeeding without iron supplementation. CPS report was filed, and the child was discharged home with her parents after 2-day admission. Although there is no consensus on how to interpret accidental cannabis exposures in young children from a child safety standpoint, we generally agreed in our discussion that the most important thing is to approach these cases in a uniform way to limit potential biases, while we continue to learn and adapt to the new landscape brought on by cannabis legalization.

Walter Palmer
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