Cocaine Toxicity in Children

Little ones explore their environments by putting things into their mouths.  How many times have you been examining an infant, only to walk away with a highjacked slobbery stethoscope?  This doesn’t cause a problem until the things that make it into their mouths are not meant for pediatric consumption.  Consider some ingestions we have talked about previously with Iron Toxicity, Ethanol Poisoning, Calcium Channel Blocker overdose, and Liquid Nicotine.  These are all scary ingestions, but one that is even scarier, for many reasons, is cocaine.  I was reminded of this concerning exposure a few weeks ago with an infant who came to our ED with altered mental status who ended up with a positive urine drug screen.  Ignoring the social concerns for now, let’s review the medical issues associated with cocaine toxicity in children:

Cocaine Toxicity – Basics

• It is plant-based and vegan friendly! 
  • Alkyloid derived from the coca plant Erythroxylon coca, which has been used as a stimulant in South America for over 4000 years. [Richards and Le 2022]

• Cocaine started being manufactured in the mid 1800’s, and had many uses. [Richards and Le 2022]
  • Toothache drops
  • Energy tonics
  • Nausea pills

• Even the original Coca Cola beverage had a touch of this energy juice. [Richards and Le 2022]

• Effects last between 15-60 minutes, depending on route of administration [Richards and Laurin 2022]

• Can be snorted, swallowed, ingested, or smoked [Richards and Le 2022]

• It blocks monoamine synaptic reuptake of dopamine, norepinephrine, and serotonin. [Richards and Le 2022]
  • Prolongs a sympathetic response
  • Half life 1 hour

Cocaine Toxicity – Presentation and Exam 

• In teenagers and young adults, presentations can include: [Richards and Le 2022]
  • Tachycardia or other dysrhythmia, 
  • Hypertension, 
  • Coronary vasospasm,
  • Stroke, 
  • Death

• Seizures were the most common presenting neurologic symptom for children in several studies. [Dinnies 1990, Mott 1994, Armenian 2017]

• Other symptoms and presentations for younger children include [Armenian 2017, Mott 1994]:
  • Tachycardia
  • Altered/depressed mental status
  • Agitation, delirium
  • GI symptoms
  • Fever
  • Hypertension
  • Respiratory depression
  • Cyanosis
  • Mydriasis
  • Ataxia, dizziness
  • Drooling 

• Toxicity presentation can be very nonspecific, so must consider toxic and drug exposures in a child with undifferentiated seizures or altered mentation. [Edell 1993]

Cocaine Toxicity – Diagnosis 

• Urine drug screen tests for cocaine metabolite benzoylecgonine or 11- or delta-9-tetrahydrocannabinol-9 carboxylic acid. [Rosenberg 1991]

• Positive drug screen is very specific. No cross-reactivity with other medications.  If it’s positive for cocaine, it’s positive for cocaine.

• A study from Detroit Michigan from 1989-90 found 5.4% positive occult cocaine exposure in urine samples of children 1-60 months. [Rosenberg 1991]
  • Urine samples were initially obtained for other medical reasons and the cocaine screen was secondary.

Cocaine Toxicity – Treatment 

• Many children will only need observation and supportive care if relatively mild symptoms, no seizures or respiratory depression, and no hemodynamic instability [Armenian 2017]

• Treatment based on presenting symptoms is often warranted [Armenian 2017]:
  • Anticonvulsants for seizures
  • Activated charcoal if large ingestion or recent known ingestion
  • Whole bowel irrigation if large ingestion
  • Intubation for respiratory failure

• Agitation can be treated with benzodiazepines [Richards and Le 2022]

• Armenian 2017 reported a series where 67% of children with unintentional cocaine exposure needed some sort of medical treatment.
  • 39% admitted to ICU
  • 36% admitted to non-monitored acute care bed
  • 27.8% of 36 patients had a “major adverse outcome”, ie seizure, intubation for respiratory failure, rhabdomyolysis, or renal failure
  • Reported higher rate of serious complications from unintentional cocaine exposure compared to other unintentional drug/medication exposures. 

Cocaine Toxicity – Complications

• Unfortunately, if the child’s toxicity is not recognized right away, complications can arise, including [Armenian 2017]:
  • Rhabdomyolysis
  • Respiratory depression and failure
  • Aspiration
  • Cardiac arrest

Moral of the Morsel

• BE VIGILANT!! (Fox’s favorite!) Consider unintentional cocaine exposure/ingestion in a child with first time seizure, prolonged seizure, or undifferentiated altered mentation.  
• Urine drug screen does not lie!  The cocaine metabolite test is VERY specific.  If it is positive for cocaine, it is positive for cocaine.
• High alert for adverse events! Cocaine exposures can present with more frequent and serious outcomes compared to other exposures.

References:

1. Richards, J. and Le, J., 2022. Cocaine Toxicity. [online] Ncbi.nlm.nih.gov. Available at: <https://www.ncbi.nlm.nih.gov/books/NBK430976/> [Accessed 23 September 2022].
2. Richards JR, Laurin EG. Cocaine. [Updated 2022 May 23]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430769/
3. Dinnies JD, Darr CD, Saulys AJ. Cocaine toxicity in toddlers. Am J Dis Child. 1990;144(7):743-744. doi:10.1001/archpedi.1990.02150310009002 
4. Mott SH, Packer RJ, Soldin SJ. Neurologic manifestations of cocaine exposure in childhood. Pediatrics. 1994;93(4):557-560. 
5. Armenian P, Fleurat M, Mittendorf G, Olson KR. Unintentional Pediatric Cocaine Exposures Result in Worse Outcomes than Other Unintentional Pediatric Poisonings. J Emerg Med. 2017;52(6):825-832. doi:10.1016/j.jemermed.2017.03.017
6. Edell DS, McSwain M. Cocaine poisoning: an easily missed diagnosis in an infant. Clin Pediatr (Phila). 1993;32(12):746-747. doi:10.1177/000992289303201208 
7. Rosenberg NM, Meert KL, Knazik SR, Yee H, Kauffman RE. Occult cocaine exposure in children. Am J Dis Child. 1991;145(12):1430-1432. doi:10.1001/archpedi.1991.02160120098027