Ingestion of Illicit Substances by Young Children Before and During the COVID-19 Pandemic

Cannabis Legalization and Resource Use for Ingestions by Young Children

OBJECTIVE

In conjunction with widening legalization, there has been a rapid rise in unintentional cannabis ingestions in young children. We sought to determine if the legal status of recreational cannabis was associated with resource use in young children with cannabis poisoning.

METHODS

This retrospective cross-sectional study of the Pediatric Health Information System included emergency department encounters between January 2016 and April 2023 for children <6 years of age with a diagnosis indicating cannabis ingestion. The primary exposure was recreational cannabis legalization status in the state in which the encounter occurred. We used logistic regression models to determine the association of recreational cannabis legality with resource utilization outcomes, adjusting for demographic covariates.

RESULTS

We included 3649 children from 47 hospitals; 29% of encounters occurred in places in which recreational cannabis was legal. Compared with environments in which recreational cannabis was illegal, cannabis-legal locations had lower uses of advanced neuroimaging (24% vs 35%; adjusted odds ratio [aOR], 0.65; 95% confidence interval [CI]: 0.55-0.77), lumbar puncture (1.6% vs 3.8%; aOR, 0.42; 95% CI: 0.24-0.70), ICU admission (7.9% vs 11%; aOR, 0.71; 95% CI: 0.54-0.93), and mechanical ventilation (0.8% vs 2.9%; aOR, 0.30; 95% CI: 0.14-0.58). Urine testing was more common in places in which recreational cannabis was legal (71% vs 58%; aOR, 1.87; 95% CI: 1.59-2.20).

CONCLUSIONS

State-level legalization of recreational cannabis was associated with a significant decrease in the utilization of advanced medical resources in cases of cannabis intoxication in children. These findings suggest the need for a focus on policies and procedures to minimize invasive testing in cases of cannabis intoxication in children.

Presentation, Management, and Child Protective Service Reporting of Children Who Test Positive for Cannabis in an Emergency Room Setting

OBJECTIVES

Rates of cannabis ingestion among young children are increasing. Small studies have evaluated symptomatology of these children. The literature lacks research regarding factors influencing medical management. Our goal was to 1) understand circumstances leading to exposure over time and 2) gain insight into factors that may influence emergency room management and Child Protective Services reporting over time.

METHODS

Retrospective cross-sectional study on children younger than 10 years with cannabis-positive urine drug screens in the emergency room setting. Single-factor analysis of variance and Fisher exact tests were used to assess for trends. Two-tailed t tests and Fisher exact tests were used to compare management of children presenting to the emergency room with chief complaint (CC) "ingestion" versus those without.

RESULTS

Of the 179 children, the mean age was 3.7 years and 48% were boys. We observed a significant increase over time in cannabis-positive children. The most common location of exposure was the primary residence (54%), with parents as the most frequent users (46%). In the emergency department, the most common CC was ingestion followed by altered mental status and fatigue. Children with an "ingestion" CC were managed with less testing than those with other CCs. They received fewer needle sticks (43% vs 91%), less imaging (5% vs 56% computed tomography heads), and fewer procedures (0% vs 8% lumbar punctures). Children with "ingestion" CC were less likely to be reported to Child Protective Services.

CONCLUSIONS

Pediatric cannabis exposures are increasing and have a wide array of clinical presentations that complicate emergency room management. Parental report of cannabis ingestion seems to impact and reduce potentially unnecessary testing.

Impact of COVID-19 on Acute Care Hospitalizations for Suicidality

BACKGROUND AND OBJECTIVES

The coronavirus disease 2019 (COVID-19) pandemic contributed to the public health crisis for pediatric mental health. We characterized our local patient population presenting with suicidality or suicide attempts before and after the pandemic by examining: 1. frequencies of hospitalizations for suicidality to determine whether they differed by age, legal sex, race and ethnicity, or socioeconomic status; 2. average length of stay and discharge disposition; 3. 7-, 30-, and 365-day reutilization rates; and 4. admission trends during COVID-19 surges.

METHODS

Retrospective data between March 2018 and March 2022 was analyzed, including patients ages 10 to 17 years hospitalized for either suicidality or a suicide attempt at 1 freestanding tertiary care pediatric medical hospital in the Midwest. Encounters were divided into 2 categories on the basis of the COVID-19 pandemic: "Prelockdown" (March 1, 2018-March 12, 2020) and "postlockdown" (March 13, 2020-March 31, 2022). Patients were limited to 1 presentation pre- and postlockdown. We analyzed frequencies using means and SDs, categorical data using χ2 and Fisher's exact tests, and continuous data with t tests.

RESULTS

A total of 1017 encounters were included, stratified into pre- and postlockdown groups for analysis (909 encounters, 889 unique patients). There was a significant difference in 365-day reutilization pre- and postlockdown when analyzing re-presentation to the emergency department (P = .025) and hospital readmission (P = .006). Admissions incrementally increased after the COVID-19 alpha variants in September 2020 and again after the delta variant in August 2021.

CONCLUSIONS

The COVID-19 pandemic further intensified the already critical issue of pediatric mental health, demonstrating increased reutilization in the year after their initial presentation and an increase in admissions after the alpha variant.

Child Protection System Interactions for Children With Positive Urine Screens for Illicit Drugs

Importance

Young children are ingesting illicit drugs at increased rates, but it is unknown what the associated child protection system (CPS) responses are when a child tests positive.

Objective

To document the child protection system involvement and the characteristics of children who test positive for illicit substances.

Design, Setting, and Participants

This retrospective cross-sectional study linked medical discharge and child protection system administrative data. The setting was Rady Children's Hospital San Diego, a free-standing pediatric hospital in California. Participants included all emergency department and inpatient medical encounters involving children aged 12 years or younger with a positive urine drug test between 2016 and 2021. Statistical analysis was performed from February 2023 to January 2024.

Exposure

Drug type, including amphetamines, barbiturates, benzodiazepines, cannabis, cocaine, fentanyl, opiates, and phencyclidine.

Main Measures and Outcomes

CPS responses associated with the medical encounter including reports, substantiations, case openings, and out-of-home placements.

Results

A total of 511 emergency department and inpatient medical encounters involving children had a positive drug test (262 [51.3%] were female; 309 [60.5%] were age 6 years or younger; fewer than 10 [<3.0%] were American Indian or Alaska Native; 252 [49.3%] were Hispanic [any race], 20 [3.9%] were non-Hispanic Asian, 56 [11.0%] were non-Hispanic Black, 143 [28.0%] were non-Hispanic White, 36 [7.0%] had other or unknown race and ethnicity; 233 [43.6%] had a CPS report prior to the medical encounter). Following the positive screen, 244 (47.7%) were reported to child protection, and 61 (11.9%) were placed out-of-home within 30 days. Mean (SD) quarterly counts of encounters with positive drug tests doubled after the COVID-19 pandemic onset (32.9 [9.8]) compared with prior to the pandemic onset (16.5 [4.7]); for encounters positive for cannabis, mean (SD) quarterly counts were 3 times as high after the pandemic onset than prior (16.6 [4.7] vs 5.7 [2.9]). Encounters for children under age 1 were significantly more likely to have associated child protection reports (relative risk [RR], 2.91 [95% CI, 2.21-3.83]) and child protection case openings (RR, 1.71 [95% CI, 1.07-2.72]) than encounters involving older children.

Conclusions and Relevance

In this cross-sectional study of emergency department and inpatient medical encounters, less than half of children with positive urine drug screens were reported to CPS; out-of-home placements were uncommon. With increased encounters for positive drug tests, it is unclear what services these children and families are receiving.

Unintentional pediatric poisonings before and during the COVID-19 pandemic: A population-based study

OBJECTIVES

The impact of coronavirus disease 2019 (COVID-19) on unintentional pediatric poisonings is unclear. We examined changes in emergency department (ED) visits and hospitalizations for poisonings before and during the COVID-19 pandemic. We compared changes in cannabis vs non-cannabis poisoning events given the recent legalization of cannabis in October 2018 and cannabis edibles in January 2020.

STUDY DESIGN

Interrupted time-series (ITS) analyses of changes in population-level ED visits and hospitalizations for poisonings in children aged 0-9 years in Ontario, Canada (annual population of 1.4 million children), over two time periods: pre-pandemic (January 2010-March 2020) and pandemic (April 2020-December 2021).

RESULTS

Overall, there were 28,292 ED visits and 2641 hospitalizations for unintentional poisonings. During the pandemic, poisonings per 100,000 person-years decreased by 14.6% for ED visits (40.15 pre- vs. 34.29 during) and increased by 35.9% for hospitalizations (3.48 pre- vs. 4.73 during). ED visits dropped immediately (Incidence Rate Ratio [IRR], 0.76; 95% CI, 0.70-0.82) at the onset of the pandemic, followed by a gradual return to baseline (quarterly change, IRR 1.04, 95%CI 1.03-1.06), while hospitalizations had an immediate increase (IRR 1.34; 95% CI, 1.08-1.66) and no gradual change. The only increase in poisonings was for cannabis which had a 10.7-fold for ED visits (0.45 to 4.83 per 100,000 person-years) and a 12.1-fold increase for hospitalizations (0.16 to 1.91 per 100,000 person-years). Excluding cannabis, there was no overall increase in poisoning hospitalizations.

CONCLUSIONS

The COVID-19 pandemic was not associated with increases in any type of unintentional pediatric poisonings, with the exception of cannabis poisonings. Increased cannabis poisonings may be explained by the legalization of non-medical cannabis edibles in Canada in January 2020.

Evaluation of COVID-19 Effect on Mental Health, Self-Harm, and Suicidal Behaviors in Children and Adolescents Population

OBJECTIVES

The impact of the COVID-19 pandemic on the psychological state of the under-18 population includes an increased risk of psychopathological symptoms development and exacerbation of already present psychiatric disorders. This study aimed to assess the prevalence of mental health problems in Polish children and adolescents with a focus on suicidal and self-harm behavior with the impact of the pandemic.

METHODS

The questionnaire collected demographic data, information regarding mental states and psychopathological symptoms, history of self-harm and suicidal behaviors, as well as the experience of psychological, and physical violence, and suicidal self-harm behaviors before and during the COVID-19 pandemic.

RESULTS

In the final analysis, 782 responses were included. Self-evaluation of general and mental health scores was significantly lower during the pandemic among children (both p < 0.001) and adolescents (both p < 0.001). Moreover, general and mental health scores were lower among adolescents compared to children before (both p < 0.001) and during (both p < 0.001) the pandemic. The frequency of seeking help because of mental health problems increased during the pandemic among children and adolescents, while no changes were observed in the prevalence of psychiatric hospitalizations in either of the populations (p = 0.317 and p = 1.00, respectively). Out of autoregressive behaviors among children during the pandemic period, only the frequency of thinking about death increased (p = 0.038). No suicidal attempts were undertaken by children in either of the evaluated time periods. The presence of all autoaggressive behaviors was greater among adolescents compared to children both before and during the COVID-19 pandemic (all p<0.05).

CONCLUSIONS

A subjective decrease in psychophysical well-being, an increase in the frequency of seeking mental health help during the pandemic, as well as an increased prevalence of depressive and anxiety symptoms were observed in the under-18 population as a potential consequence of the COVID-19 pandemic and related socioeconomic changes. The marked increase in self-harm behavior in the adolescent population (age > 12) and the marked increase in the frequency of death thinking in children (age ≤ 12) suggests the need for greater awareness and easier access to professional help from mental health specialists, particularly in a time of unprecedented stress and social isolation.

The trend of poisonings before and after the COVID-19 pandemic

The COVID-19 pandemic has substantially affected people and healthcare systems. One of the main challenges was the reduction and change in the pattern of non-COVID-19 diseases and conditions. Moreover, due to the mental burden of the pandemic, the trend of poisonings and abuses changed. In this study, we aimed to assess the trends of poisonings from different agents before and during the COVID-19 pandemic using the interrupted time series method. This study was conducted at one of the main Tehran referral centers for poisoning, Baharloo Hospital. Pre-COVID-19 period was defined as April 2018 to January 2020 while the COVID-19 time was from February 2020 to March 2022. The total number of monthly poisoning cases in addition to eight categories of drugs/substances/agents were identified, including drugs (such as psychiatric drugs, cardiovascular drugs, and analgesics), opioids, stimulants, methanol, ethanol, cannabis, pesticides, and carbon monoxide. Interrupted time series analysis was performed to compare the pre-pandemic trend of total monthly cases from each category in addition to the proportion (%) of each one. In total, 13,020 cases were poisoned during the study period, among which 6088 belonged to the pre-pandemic period and 6932 were admitted during the COVID-19 era. There was no significant difference in terms of demographic characteristics of patients before and during the pandemic (p-value > 0.05). At the beginning of the pandemic, there was a sudden fall in the number of poisoning patients (- 77.2 cases/month, p-value = 0.003), however, there was a significant increasing trend during the COVID time (3.9 cases/month, p-value = 0.006). Most of the categories had a sharp decrease at the beginning of the pandemic except for methanol and ethanol which had increases, although not significant. Cannabis also had a significant change in slope (- 0.6 cases/month, p-value = 0.016), in addition to the sudden decrease at the beginning of the pandemic (- 10 cases/month, p-value = 0.007). Regarding the proportion of each category from total monthly poisoning cases, methanol, and ethanol had immediate rises of 4.2% per month and 10.1% per month, respectively (both significant). The pandemic had significant effects on the pattern of poisonings from different agents in Iran, the most important of which were alcohol (ethanol and methanol). These differences had policy implications that can be helpful for policymakers and healthcare systems in combating similar situations in the future.

Do young children with known cannabis intoxication benefit from further neurological-based testing or imaging?

BACKGROUND

Recent work has demonstrated that children with unintentional cannabis ingestions often undergo extensive ancillary testing such as head imaging or lumbar puncture. To better understand the yield of these tests, our objective was to describe the frequency of additional significant diagnoses in children with cannabis ingestion.

METHODS

We performed a retrospective cross-sectional study of the Pediatric Health Information System (PHIS) database, including ED encounters from January 2016 to April 2023 with a diagnosis indicating cannabis exposure in children <6 years of age. We assessed the frequency of co-diagnoses that would be found on head imaging, lumbar puncture, or toxicology testing.

RESULTS

We included 4132 ED encounters for cannabis ingestion from 47 hospitals. Of these, 1243 (30%) received head imaging and 130 (3.1%) underwent lumbar puncture. There were 23 children (0.6%) with diagnosis of skull fracture or intracranial hemorrhage, 4 (<0.1%) with intracranial neoplasm, and 0 (0%) with a diagnosis for meningitis or intracranial abscess. Presence of discharge diagnosis for other drugs was also uncommon. The most frequent drug ingestion co-diagnoses were cocaine in 43 (1.0%) and opioids in 22 (0.5%) encounters.

CONCLUSION

In children with cannabis intoxication, high rates of head imaging and lumbar puncture are likely driven by the signs of altered mental status at presentation. These data suggest that if cannabis ingestion is considered early and identified quickly with testing, neuroimaging, particularly that with ionizing radiation, may be low yield.

Hand and Oral Hygiene Practices of South Korean Adolescents Before and During the COVID-19 Pandemic

Importance

Only a few studies have examined the long-term trends of hand and oral hygiene, especially among adolescents.

Objective

To investigate the 15-year trends in frequency of handwashing and toothbrushing and examine the factors associated with hand and oral hygiene, particularly during the COVID-19 pandemic.

Design, Setting, and Participants

This cross-sectional study, performed from January 1, 2008, to December 31, 2022, used general population-based data from 963 644 individuals in a national representative survey (Korea Youth Risk Behavior Web-based Survey [KYRBS]).

Exposure

COVID-19 pandemic.

Main Outcomes and Measures

Trends in hand and oral hygiene practices were measured by how frequently adolescents washed their hands and whether they fulfilled the recommended guidelines for toothbrushing. An interrupted time series analysis using linear and logistic regression models was performed to assess any associations with the COVID-19 pandemic. Hand and oral hygiene behaviors before and during the pandemic in each sociodemographic subgroup were also compared.

Results

In the 963 644 adolescents (495 697 [51.4%] male; mean [range] age, 15.01 [12-18] years) who participated in the KYRBS from 2008 to 2022, a 73.3% (95% CI, 59.4%-97.4%; P < .001) immediate increase was seen in overall hand hygiene behavior at the onset of the COVID-19 pandemic compared with the prepandemic period, with a sustained decrease thereafter (β = -0.018; 95% CI, -0.022 to -0.015; P < .001). Meanwhile, no immediate increase was observed in terms of overall oral hygiene behavior (0.1%; 95% CI, -0.9% to 1.1%; P = .82); however, there was a sustained decrease during the pandemic (β = -0.018; 95% CI, -0.020 to -0.016; P < .001). Older age, female sex, nonsmoking status, alcohol use, low household economic level, and poor school performance were significantly associated with poor hand hygiene during the pandemic.

Conclusions and Relevance

In this cross-sectional study of South Korean adolescents, an increase in the prevalence of hand hygiene was observed during the early pandemic; however, this prevalence decreased over time. Meanwhile, the decrease in the prevalence of oral hygiene was more pronounced during the pandemic. This study recommends stronger guidelines for adolescent health coaches, such as teachers or public health advisers, regarding hygiene behaviors, even after the COVID-19 pandemic ends.

Unintentional Pediatric Ingestion of Cannabis-Addressing a Growing Public Health Risk

This Viewpoint discusses the growing unintentional ingestion of cannabis and copycat products by children and urges clinicians, legitimate cannabis companies, large consumer brands, state attorneys general, and national legislators to provide solutions and education to adult users.