Background: We report two cases of seizure-like activity after accidental pediatric cannabis ingestion. As states continue to alter laws regarding sale and formulation of cannabis products, pediatric ingestion of these products remains a dynamic public health concern. Expansion of marijuana legalization has been paralleled by increasing availability of edible THC products, including ones that may be mistaken by children for snack foods like cookies and gummies. Diagnosis of cannabis intoxication in children has proven a difficult and costly endeavor. Many caregivers are reluctant to admit that a child could have been exposed to marijuana due to stigmas and fear of liability. On the other hand, physicians may fail to consider cannabis in children due to nonspecific symptoms (drowsiness, tremors, palpitations, numbness) and fear of a missed, more serious diagnosis.

Case Presentation: The first patient is an 8-year-old male who presented with focal shaking and abnormal behavior that progressed to generalized full body shaking. He reported muscle pain as well as auditory and visual hallucinations, a constellation of symptoms that have not been reported in the setting of pediatric cannabis ingestion. Presenting vitals were stable and bloodwork and head CT were negative, resulting in discharge home. Urine drug testing was positive for cannabinoids with a THC of 504 ng/mL. The second patient, a 2-year-old female, presented with agitation and neck and limb stiffening followed by multiple episodes of rhythmic truncal flexion without extremity shaking. Her vital signs were stable with normal blood work, blood cultures, urinalysis, viral testing, x-rays and head CT. Her urine drug testing was positive for cannabinoids with a THC level of 820 ng/mL.

Discussion: Both patients’ presentations led to extensive, expensive workups, placing patients at risk of harm. The only necessary interventions for either patient were intravenous normal saline, social services, and observation. Public health efforts must be taken to decrease pediatric exposures to cannabis, including, but not limited to, regulations on snack-food-like packaging. Additionally, more timely identification of cannabis intoxication through history and drug screening may decrease invasive and costly testing in pediatric populations. One such recommendation incudes delaying all testing other than urine drug screening in children who are stable and have bilaterally reactive pupils. Rapid, more specific urine toxin immunoassay may also facilitate more efficient diagnosis. Physician education regarding atypical case presentation, such as those addressed in this case report, may aid in more streamlined diagnosis as well as decreased cost and patient risk.