CLINICAL OBSERVATION Decriminalization of Cannabis – potential risks for children? Israel Amirav (amirav@012.net.il) 1,2 , Anthony Luder 1,2 , Yuri Viner 1,2 , Martin Finkel 3 1.Paediatric Department, Ziv Medical Centre, Safed, Israel 2.Faculty of Medicine, Technion, Haifa, Israel 3.Child Abuse Research Education & Service Institute, School of Osteopathic Medicine, University of Medicine and Dentistry of New Jersey, Stratford, NJ, USA Keywords Cannabis, Coma, Infants, Legalization Correspondence Israel Amirav, Paediatric Department, Ziv Medical Centre, Safed, Israel. Tel: +972 46828712 | Fax: +972 46828746| Email: amirav@012.net.il Received 7 September 2010; revised 28 September 2010; accepted 2 November 2010. DOI:10.1111/j.1651-2227.2010.02081.x ABSTRACT The legalization of cannabis for medicinal purposes is becoming increasingly widespread worldwide. The anticipated growing ease of access to cannabis may create an increased risk for passive and ⁄ or active ingestion by children. We report a case of a 1.5-year-old infant who presented with unexplained coma that was later proved to be associated with the ingestion of cannabis. This case highlights the importance of considering cannabis ingestion in the differential diagnosis of infantile and toddler coma and the need for public education regarding the risks of childhood exposure in the light of the legalization of cannabis for medical purposes and its greater availability. INTRODUCTION Cannabis is a mild habit-forming drug containing cannabi- noid (particularly delta-9-tetrahydrocannabinol THC), which has medicinal and social uses. Children exposed to cannabis are vulnerable to severe effects, as the case reported here demonstrates. Recently, the medicinal and limited personal use of cannabis has been proposed and in some cases legalized in various jurisdictions. This may lead to unintended consequences such as easier access to medic- inal cannabis, which could increase accidental or inappro- priate administration to children. Whereas some officials believe that revenue generated from regulating and taxing cannabis could allow for the reallocation of public funds, improving public education and reprioritizing law enforcement (1), others believe that the social cost of legalizing cannabis will outweigh the eco- nomic benefits (2). Insufficient attention has been given to the unintended consequences of readily available access to medicinal mari- juana, which could increase accidental ingestion or inap- propriate administration to children. CASE REPORT A previously healthy 1.5-year-old boy presented to the emergency department (ED) with the sudden onset of ataxia and increasing lethargy. The mother reported that she had given her son some nonalcoholic malt beer, following which he had appeared happier than usual and then had become increasingly lethargic. She suspected that the symptoms were related to the beer. There was no indication of an infectious process, history of ingestion of toxic sub- stance ⁄ drugs or head or other trauma. Pregnancy, delivery and early development were normal. He lived at home with his mother and maternal grandfather. The mother was a sin- gle parent who was being treated with an antidepressant medication (oxazepam) following a lymphoma 2 years pre- viously. The mother denied that her son had had access to her medications. The mother had had previous contacts with social workers because of reported violence by a for- mer partner who had had a history of substance abuse. Examination revealed stupor with a Glasgow Coma Scale of 11; cranial nerves, muscle tone and deep tendon reflexes were normal; pupils were 3.5 mm in diameter, constricting to 2.0 mm with light, temperature 37.8°C, blood pressure 87 ⁄ 37 mmHg, pulse 140 beats ⁄ min, respiratory rate 20 breaths ⁄ min and oxygen saturation 90% in room air. There was no evidence of head trauma. The rest of the examination was unremarkable. Laboratory evaluation revealed normal blood count, glucose and electrolytes and chest X-ray. An initial urine screen was positive for canna- bis. This was confirmed in a second analysis by immuno- chemistry as well as by GC-MS at the central toxicology laboratory. Serum THC concentrations of 207 and 113 ng ⁄ ml were detected. He was admitted to the paediatric intensive care unit, where he received supportive treatment limited to intravenous fluids and nasal oxygen. His symp- toms resolved rapidly. The case was reported to child protective services for investigation. High-risk classification of the family has led to close follow-up and some administrative assistance par- ticularly regarding day care. DISCUSSION In this case, a positive cannabinoid urine test, which the caretaker was unable to explain, led to the suspicion of can- nabis use and child abuse or neglect by the caretaker. Acta Pædiatrica ISSN 0803–5253 618 ª2010 The Author(s)/Acta Pædiatrica ª2010 Foundation Acta Pædiatrica 2011 100, pp. 618–619