We report a confirmed case of cannabis exposure in an Omani female child with developmental delay. Cannabis exposure in children can lead to many consequences; for example, chronic use can result in developmental delay, abnormal behaviour, and hyperactivity while there is a risk of coma with acute exposure. It is important for clinicians to consider substance abuse as a differential diagnosis for similar presentations in paediatric patients, noting that children are at risk of cannabis exposure if their parents/caregivers are cannabis users

Al-Shidhani, Thuraya A.

Arora, Vinita

PubMed

We report a confirmed case of cannabis exposure in an Omani female child with developmental delay. Cannabis exposure in children can lead to many consequences; for example, chronic use can result in developmental delay, abnormal behaviour, and hyperactivity while there is a risk of coma with acute exposure. It is important for clinicians to consider substance abuse as a differential diagnosis for similar presentations in paediatric patients, noting that children are at risk of cannabis exposure if their parents/caregivers are cannabis users. 

Sultan Qaboos University Scientific Journals

Cannabis is the most widely used illicit drug in many developed societies. It is estimated in the USA that the population incidence rates of marijuana use from late childhood to adolescence increase from 1.30% to 16.29% from age 11 to 16 years, and then appear to plateau. A sharp increase is noted during ages 13–15 years.1 There is a paucity of statistics about the prevalence of cannabis use in Oman; however, the government has recently established a new 50 bed psychiatric hospital specialised in the treatment of addiction. Absolute numbers from 1994 indicate that 150 people were addicted to cannabis (hashish) and, in 2009, 19 people died of drug abuse.2According to botanical classification, cannabis comes from family of Cannabaceae and species of stiva, indica and ruleralis.3 The common names for cannabis are: marijuana, marihuana, potweed, grass and Mary Jane.3 There are multiple risks from using cannabis, e.g. decreased ability to concentrate, decreased motivation, balance problems, increased heart rate and blood pressure, damage to fertility and increased risk of serious psychiatric illness.4 Behavioural problems were associated with early marijuana use specifically in those who started to use cannabis prior to 15 years of age.5 Recent cannabinoid research  discovered  an endocannabinoid system with specific genes coding for cannabinoid receptors (CBRs).6 The availability of these endocannabinoids in breast milk can affect the development of the newborn baby.6 Substance abuse includes the abuse of legal drugs as well as the use of illegal drugs. A caregiver's self-use and abuse of alcohol, cannabis (marijuana), SQU Med J, November 2011, Vol. 1, Iss. 4, pp. 511-514, Epub. 25th Oct 11Submitted 21st Mar 11Revision Req. 13th Jun 11, Revision recd. 2nd Jul 11Accepted 14th Sep 111Oman Medical Specialty Board, Muscat, Oman, and Academic Fellowship Program, University of Toronto, Canada; 2Leslie Dan Facul ty of Pharmacy, University of Toronto, Canada.*Corresponding Author email: shidhanitutu@gmail.comتعرض طفلة ُعمانية للحشيش )القّنب(تقرير ألول حالة من ُعمانثريا ال�ضيداين وفينيتا اأرورااأن ي�ؤدي تعر�ص  اأي�صا من تاأخر يف النم�. ميكن  امللخ�ص: هذا تقرير حلالة م�ؤكدة تبني تعر�ص طفلة ُعمانية للح�صي�ص، وهي تعاين الأطفال للح�صي�ص اإىل الكثري من التداعيات، على �صبيل املثال، ال�صتخدام املزمن ميكن اأن ي�ؤدي اإىل تاأخر يف النم�، وال�صل�ك ال�صاذ، وفرط الن�صاط، يف حني اأن هناك خماطر من ح�ص�ل غيب�بة يف حالة التعر�ص احلاد. من املهم بالن�صبة لالأطباء النظر يف تعاطي املخدرات ب��صفها الت�صخي�ص التفريقي لعرو�ص مماثلة عند الأطفال املر�صى، حيث املالحظ اأن يك�ن الأطفال عر�صة خلطر التعر�ص للح�صي�ص اإذا كان ال�الدان/مقدم� الرعاية يعان�ن من الإدمان عليه.مفتاح الكلمات: تعاطي احل�ضي�س، اإ�ضاءة معاملة الطفل، منو الطفل، ا�ضطرابات تاأخر النمو، تقرير حالة، ُعمان.abstract: We report a confirmed case of cannabis exposure in an Omani female child with developmental delay. Cannabis exposure in children can lead to many consequences; for example, chronic use can result in developmental delay, abnormal behaviour, and hyperactivity while there is a risk of coma with acute exposure. It is important for clinicians to consider substance abuse as a differential diagnosis for similar presentations in paediatric patients, noting that children are at risk of cannabis exposure if their parents/caregivers are cannabis users.Keywords: Cannabis abuse; Child abuse; Child development; Developmental delay disorders; Case report; Oman.Cannabis Exposure in an Omani ChildFirst case report from Oman*Thuraya A. Al-Shidhani1 and Vinita Arora2CASE REPORTCannabis Exposure in an Omani Child First case report from Oman512 | SQU Medical Journal, November 2011, Volume 11, Issue 4heroin, cocaine, methamphetamine, and other drugs expose children to risk in multiple ways. Members of the medical community need to understand these risks, and be aware of the consequences on children in the care of adult abusers. The misuse of drug substances by children may have far-reaching consequences, and may impact family unit functions. Many substance abusers are polysubstance users leading to a compounded negative effect which may be difficult to measure. Often, other interrelated social factors, such as untreated mental illness, alcoholism, trauma history and domestic violence also affect these families.7There are several paediatric case reports found in the literature regarding cannabis abuse/exposure leading to effects on cognitive function/behavior and coma, but none specifically on cannabis exposure in children in Oman.8,9 This case report describes illicit cannabis exposure in an Omani female child with developmental delay.Case ReportAn Omani female child, aged 2 years and 10 months, was brought by her parents to the Accident and Emergency Department of Sultan Qaboos University Hospital, Muscat, Oman. The patient presented with drowsiness, abnormal eye movements, was lethargic and had been unable to sit or stand for the previous 4 hours. The history was reluctantly provided, so the physician on call documented the unconfirmed information given by the parents, noting that it was somewhat inconsistent in nature. The father made little eye contact with medical personnel, and seemed uncomfortable. His verbal and non-verbal expressions and cues to his wife indicated that she was not to offer any information. Apparently, the patient had ingested an unknown blackish substance mixed with sand, followed by vomiting, further lethargy and drowsiness, with nystagmus. The parents sought medical assistance approximately 4 hours after the onset of symptoms. Of note, the child’s chart indicated that she had been a full term baby. However, there had been a delay in gross motor skill and language development noted to have begun at approximately 2 years of age. The parents indicated that the patient was a hyperactive child who occasionally ate her own hair. The physician noted that the family as a unit presented with psychosocial and alcoholism/substance issues, and loss of income. It was noted that two older siblings were “normal” as indicated by the mother of the patient.On initial examination, the following parameters were significant: lethargy, drowsiness, Glasgow coma scale of 12/15, tachycardia, nystagmus, and pupils dilated (4 mm), but reactive to light. A gastric lavage was performed, producing gastric aspirate mixed with food particles. During this procedure, the child vomited a blackish sticky substance, with subsequent clinical improvement over the ensuing hours. The samples were sent for analysis, and she was hydrated intravenously. Investigations revealed microcytic hypochromic anaemia while all other investigations were normal. The patient rested through the night, and continued to improve. The subsequent plan was to involve social work and perform an HIV test, but the patient’s father discharged her against medical advice. An incident report indicating suspected child abuse was filed. Five days later, tetracannabinoid substance was confirmed in the child’s vomit.DiscussionChildren exposed to maternal addiction have increased rates of cognitive, socio-emotional, and behavioural problems.10 This case report illustrates an Omani female child who was exposed to cannabis. The child was noted to have developmental delay and hyperactivity to which prenatal/chronic cannabis exposure may have been a contributing factor. A prospective investigation showed that there is a significant association between substance use disorder in parents and cannabis use disorder and behavioural disinhibition in their sons.11 The Generation R study showed that multiple demographic, emotional and social characteristics were associated with maternal cannabis use. These characteristics should be considered when investigating offspring exposed to cannabis in utero as they may be important in mother-child interaction and child development.12 There is indirect evidence of post-pregnancy resumption of substance use. Pregnant and parenting women, regardless of race or ethnicity, benefit from prevention efforts focusing on cessation rather than temporary abstinence from substance use.13Thuraya A. Al-Shidhani and Vinita AroraCase Report | 513This patient demonstrated speech delays and hyperactivity, which were also found in one case report in which a Californian teacher of a 7 year-old boy, who had been exposed prenatal to cannabis, noted that he demonstrated frequent fidgety behaviour, hyperactivity, and trouble focusing on learning tasks. Noted by family to be a "sweet and happy" child at home, his parents still expressed concern about his repetitive behaviours, fear of leaving the house, and insistence on a certain order of his toys. He also displayed "meltdowns" and tantrums at non-compliance with his wishes. A receptive and expressive language disorder had previously been diagnosed at 4 years of age, and been followed by speech therapy and a social skills language group programme.14 Survival analysis in another study revealed that aggressive, co-morbid, and inattentive/hyperactive schoolchildren had a significantly earlier onset of drinking, drunkenness, marijuana and overall illicit drug use compared to healthy schoolchildren.15 The conclusions of this study were as follows: three levels of behavioural risk of substance abuse exist: 1) the highest level has trajectories of increased aggressive and inattentive/hyperactive problems throughout childhood; 2) the next level involves only an increased inattentive/hyperactive behavioural trajectory, and 3) the lowest level involves those with neither type of problem.15 Children with both inattention/hyperactivity and aggression have the greatest need for childhood intervention to prevent substance abuse in adolescence.11 Emerging evidence from human studies and animal research demonstrates that an early onset of cannabis consumption might have lasting consequences on cognition; may increase the risk of neuropsychiatric disorders, promote further illegal drug use, and increase the likelihood of cannabis dependence. These findings suggest that young people represent a highly vulnerable cannabis consumer group, carrying a higher risk than adult consumers of suffering adverse consequences from cannabinoid exposure.16There are four independent factors in early or middle childhood that predict early initiation of use of substances and subsequent substance use disorders by early adulthood: 1) Disrupted families or drug-using parents 2) Problem behaviours; 3) Poor parental monitoring, and 4) Poor parental supervision.17 The father of this patient had no consistent employment, possibly partly due to cannabis abuse. High levels of cannabis abuse are related to poorer educational outcomes, lower income, greater welfare dependence and unemployment, and lower relationship and life satisfaction.18ConclusionIt is important for clinicians to consider substance abuse as a differential diagnosis for presentations similar to this case in other paediatric patients. Emergency medicine clinicians should be able to detect suspicious behaviour as described above, supported by inconsistent information/history given by family members in order to provide appropriate immediate treatment, and also initiate follow-up care for the patient and possibly also for the family.acknowledgementsThe authors gratefully acknowledge the great support and motivation to publish this case of the following physicians: Dr. Hashim Javad and Dr. Alexander P Chacko of the Department of Child Health, Sultan Qaboos University Hospital, Muscat, Oman, and Dr Kamlesh Bhargava of the Department of Family Medicine and Public Health, Sultan Qaboos University Hospital and Program Director for Family Medicine at the Oman Medical Specialty BoardReferences1. Tang Z, Orwin RG. Marijuana initiation among American youth and its risks as dynamic processes: Prospective findings from a national longitudinal study. Subst Use Misuse 2009; 44:195–211.2. Oman Drug Addiction. Narcinon International. From: www.narconon.org/drug-information/oman-drug-addiction.html.  Accessed: Jun 2011.3. The Vaults of Erowid. Cannabis. From: www.erowid.org/plants/cannabis/cannabis.shtml Accessed Sep 2011.4. BBC Health. What is cannabis? From: www.bbc.co.uk/health/emotional_health/addictions/cannabis.shtml Accessed: Sep 2011. 5. Falls BJ, Wish ED, Garnier LM, Caldeira KM, O'Grady KE, Vincent KB, et al. The association between early conduct problems and early marijuana use in college students. J Child Adolesc Subst Abuse 2011; 20:221–36.Cannabis Exposure in an Omani Child First case report from Oman514 | SQU Medical Journal, November 2011, Volume 11, Issue 46. Onaivi ES. Commentary: functional neuronal CB2 cannabinoid receptors in the CNS. Curr Neuropharmacol 2011; 9:205–8.7. Wells K. Substance abuse and child maltreatment. Pediatr Clin North Am 2009; 56:345–62.8. Bonkowsky JL, Sarco D, Pomeroy SL. Ataxia and shaking in a 2-year-old girl: Acute marijuana intoxication presenting as seizure. Pediatr Emerg Care 2005; 21:527–8.9. Shukla PC, Moore UB. Marijuana-induced transient global amnesia. South Med J 2004; 97:782–4.10. Simmons LA, Havens JR, Whiting JB, Holz JL, Bada H. Illicit drug use among women with children in the United States: 2002-2003. Ann Epidemiol 2009; 19:187–93.11. Ridenour TA, Tarter RE, Reynolds M, Mezzich A, Kirisci L, Vanyukov M. Neurobehavior disinhibition, parental substance use disorder, neighborhood quality and development of cannabis use disorder in boys. Drug Alcohol Depend 2009; 102:71–7.12. El Marroun H, Tiemeier H, Jaddoe VW, Hofman A, Mackenbach JP, Steegers EA, et al. Demographic, emotional and social determinants of cannabis use in early pregnancy: The Generation R study. Drug Alcohol Depend 2008; 98:218–26.13. Muhuri PK, Gfroerer JC. Substance use among women: Associations with pregnancy, parenting, and race/ethnicity. Matern Child Health J 2009; 13:376–85. 14. Stein MT, Drahota A, Chavira DA. Ian: A 7-year old with prenatal drug exposure and early exposure to family violence. J Dev Behav Pediatr 2008; 29:512–5.15. Jester JM, Nigg JT, Buu A, Puttler LI, Glass JM, Heitzeg MM, et al. Trajectories of childhood aggression and inattention/hyperactivity: Differential effects on substance abuse in adolescence. J Am Acad Child Adolesc Psychiatry 2008; 47:1158–65.16. Schneider M. Puberty as a highly vulnerable developmental period for the consequences of cannabis exposure. Addict Biol 2008; 13:253–63.17. Hayatbakhsh MR, Mamun AA, Najman JM, O'Callaghan MJ, Bor W, Alati R. Early childhood predictors of early substance use and substance use disorders: Prospective study. Aust N Z J Psychiatry 2008; 42:720–31.18. Fergusson DM, Boden JM. Cannabis use and later life outcomes. In: Addiction, Wiley Online Library. From:www.onlinelibrary.wiley.com/doi/10.1111/j.1360-0443.2008.02221.x/abstract .Accessed: Mar 2011.

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Cannabis Exposure in an Omani Child : First case report from Oman

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Cannabis Exposure in an Omani Child: First case report from Oman

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