A committee of physicians and researchers from the Canadian Pediatric Society has issued recommendations for the use of medical cannabis in children.
The organization's Drug Therapy Committee reviewed more than 100 sources to assess the use of cannabis as part of a treatment plan for various conditions, including neurological conditions, cancer, and palliative care. The authors recommended open conversations with families about the benefits and risks of medical cannabis and called for additional rigorous research.
"When we talk about medical cannabis, it's a very complex issue," study author Yaron Finkelstein, MD, a professor of pediatrics, pharmacology, and toxicology at the University of Toronto and staff physician at the Hospital for Sick Children in Toronto, Canada, told Medscape Medical News. Unlike other medications, cannabis comes in a wide range of forms that contain different concentrations of substances from the plant.
The recommendations were published on April 5, 2024, in Paediatrics & Child Health.
Benefits and Risks
The cannabis plant contains roughly 150 pharmacologically active substances. Medical uses have primarily focused on cannabidiol (CBD), which has anti-inflammatory, analgesic, antiemetic, and other properties. Tetrahydrocannabinol, which produces a euphoric effect, has also been investigated for use in palliative care, for example. While adult consumption of cannabis for recreational use was legalized in Canada in 2018, the purchase of cannabis for medical use in children requires authorization from a physician. Three cannabis-based pharmaceuticals, Sativex, Nabilone, and Epidiolex are available in Canada.
"Over the past several years, there has been a lot of interest [in pediatric medical cannabis] that is mostly driven by patients and their families," said Finkelstein. Parents of children with severe conditions, such as drug-resistant epilepsy, may consider turning to cannabis when conventional medicine does not seem to help their child, he explained.
Currently, the evidence supporting the use of cannabis in children is most promising for drug-resistant epilepsy and chemotherapy-induced nausea and vomiting, Finkelstein said. Evidence also suggests that cannabis may be useful in palliative care for dying children. Other research has provided a lower level of evidence that cannabis may be beneficial for autism spectrum disorder.
It's also important to remember that cannabis comes with side effects and can be involved in drug-drug interactions, particularly at higher doses, said Finkelstein. For example, some antibiotics and antifungal medications are known to inhibit the metabolism of cannabis and can nearly double its effects. Furthermore, high doses of CBD may increase the blood levels of several drugs such as warfarin and tacrolimus. The long-term side effects of CBD use are largely unknown.
"We should always make sure that the benefits outweigh the risks, and there are very few areas where we know that there is a proven benefit," Finkelstein said.
Research Deficits
Often, findings and evidence from clinical trials "trickle down" from adult studies to use in pediatrics, said Finkelstein, and that trend is pronounced in cannabis research. This development may partly result from the fact that some previous studies have used methods of consumption such as smoking that are not appropriate in children. It also means that there is a dearth of high-quality studies.
In addition, a few of the studies reviewed were randomized clinical trials. Much of the current evidence is obtained from less rigorous work, such as case series. The randomized clinical trials that have been conducted primarily focused on drug-resistant epilepsy and chemotherapy-induced nausea and vomiting.
As with any medication, patients and their physicians must weigh the potential benefits of cannabis use against any safety concerns. But "in this field, the benefits and the risks are not fully elucidated," said Finkelstein. "We're really in dire need of more research that is properly planned on pharmacological principles." This research will help uncover which indications cannabis may be helpful for.
An Important Summary
Commenting on the document for Medscape Medical News, Deepa Kattail, MD, pediatric anesthesiologist and pain physician at the Hospital for Sick Children and associate professor of anesthesiology and pain medicine at the University of Toronto, said the recommendations are a great summary of the current evidence and gaps. While there have not been many changes since the last recommendations were issued in 2016, "it is an important update to summarize what we know at this time," particularly given the widespread availability of cannabis in Canada, said Kattail. She did not participate in drafting the document.
Kattail, who works with patients with acute and chronic pain, also emphasized the importance of weighing the balance between risks and benefits in the long term. For example, studies indicate that cannabis use in adolescents may increase the risk for developing mental health concerns such as depression later in life. "If the evidence for using cannabis is weak for the treatment of chronic pain, is it worth the possible mental health risks in the future?" she asked. "This is a conversation that must occur between patients, their families, and their healthcare professionals."
While conducting randomized control trials would be ideal, "realistically, this is a challenge," said Kattail. Because strong evidence of efficacy in adult studies is lacking, and cannabis is not available in a hospital formulary, it is difficult to receive ethics approval for a trial to assess whether cannabis can alleviate pain in children, she said. "The hope is that robust studies in the adult population may be used for guidance, and at this point, we are still awaiting such data."
No outside funding for the study was reported. Finkelstein and Kattail reported no relevant financial relationships.
Gwendolyn Rak is a health reporter for Medscape based in Brooklyn, New York.