Cannabinoids in Pediatric Care

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Cannabis for pediatric care? What initially may sound like a shocking and perhaps controversial subject is already a reality. In 2020, cannabis and the plant’s derivatives are well into preclinical and clinical trials for the treatment of several pediatric conditions, including intractable forms of childhood epilepsy. In fact, a pharmaceutical preparation of cannabidiol (CBD) made history in 2018 as the first Food and Drug Administration (FDA)-approved cannabis-derived medicine, and it’s approved for children.

 

The new wave of support for medical cannabis, and especially for cannabidiol (CBD), is thanks to the efficacy of cannabis in pediatric care. Parents of children fighting catastrophic diseases were some of the original advocates for medical cannabis. The social acceptance and reenvisioning of cannabis for pediatric care came in 2013 when the remarkable story of Charlotte Figi made national headlines. 

 

Charlotte’s family (now of Charlotte’s Web fame) were some of the first to publicly break the taboo around medical cannabis for chronic pediatric conditions. Her parent’s fight to get her the life-saving plant-based medicine she needed is what convinced many policymakers about the power of this plant.   

 

So while it may sound controversial to talk about cannabis-based medicines in pediatrics, it’s one of the most established areas of medical cannabis today. 

 

The State of Cannabinoids in Pediatrics 

 

Federally, cannabis remains classified as Schedule I under the Controlled Substances Act (CSA). Yet, a single pharmaceutical preparation of the plant is now available for the treatment of Lennox-Gastaut syndrome and Dravet syndrome. Epidiolex, by GW Pharmaceuticals, consists of CBD and now falls under a Schedule V regulation. It is approved for use among children as young as two. Of course, the state-level situation varies significantly from the federal approach.

 

In a 2019 publication for Contemporary Pediatrics, author Mary Beth Nierengarten discusses the state of cannabinoid-based therapies in US pediatrics today. Colorado, Florida, and California are only a few examples of states with medical cannabis programs allowing for recommendations for children under the age of 18. In many of these states, the list of approved qualifying conditions for medical cannabis includes pediatric ailments like cancer, epilepsy, nausea, muscle spasms, and end of life care. 

 

Still, state-based programs may require special protocols before a child receives a recommendation, including the requirement to try other federally regulated pharmaceutical options first. More than one doctor may also have to sign off before a child can receive a legal recommendation.

 

For parents, medical cannabis is often a medicine of last resort. When all other conventional pharmaceuticals have failed, parents turn to alternative options in a desperate attempt to fix their child’s life-threatening or life-debilitating condition. 

 

The desperation to cure a child has uprooted entire families from their homes to move into cannabis-friendly states. It has also created advocacy groups fighting to allow children to take medical cannabis in school. In some cases, parents begin seeking medical cannabis for their child without approved recommendations, sourcing suspect products and treating their child outside the system entirely. A lack of consistency, regulation, and information has been challenging for parents, pediatricians, and school boards.

 

The American Academy of Pediatrics (AAP) released an updated policy for cannabis in pediatrics in 2015. Their updated policy is conservative, stating, “The AAP opposes ‘medical marijuana’ outside the regulatory process of the US Food and Drug Administration.” However, they also tentatively acknowledge a place for cannabis in pediatric care: “Notwithstanding this opposition to use, the AAP recognizes that marijuana may currently be an option for cannabinoid administration for children with life-limiting or severely debilitating conditions and for whom current therapies are inadequate.”

 

Notably, since the release of this policy, there have been several developments about the potential of cannabis use for the treatment of medical conditions in children, including the approval of Epidiolex and new preclinical and clinical trials.

 

The Growing Potential Behind Cannabinoid Therapy in Pediatric Care

 

In only a few short years, medical cannabis has gone from an alternative fringe therapy for the treatment of intractable childhood epilepsy to making history as the first cannabis-derived FDA-approved drug of its kind in the US. Seizure disorders are often the first qualifying conditions approved under state medical cannabis programs. As in the case of Charlotte Figi, families often report near-miraculous improvement to intractable epilepsy following treatment with cannabis and cannabis derivatives.

 

Beyond straight CBD therapies for seizure disorders, there is growing scientific support for mixtures of THC and CBD, including a recent Canadian study. Yet, seizures and epilepsy are not the only areas of pediatric care getting a cannabinoid treatment.

 

In 2017, the Journal of Pediatrics published “Medical Cannabinoids in Children and Adolescents: A Systematic Review.” The researchers repeated the necessary but common refrain that “additional research is needed to evaluate the potential role of medical cannabinoids in children and adolescents,” but they also found evidence supporting its use for nausea and vomiting associated with chemotherapy among children. 

 

Numerous studies have demonstrated that THC (or synthetic preparations of THC) effectively decreased chemotherapy-induced nausea and vomiting, with a high degree of tolerability. The systematic review above detailed several case reports identifying pediatric applications of dronabinol (a synthetic cannabinoid) for chronic pain, neuropathic pain, depression, and muscle spasticity as well as anxiety and sleep. Many of these case reports have opened the door for current preclinical studies.

 

An Introduction to Transdermal Cannabinoids in Pediatrics

 

Among adults, smoking is consistently the most popular route of administration, but it is an unacceptable delivery method within pediatrics. Not only does it go against all social conventions, but it is also poorly suited for physician-directed delivery or consistency between treatments. 

 

Transdermal routes of administration are uniquely suited to pediatric care. There are already many approved patch-based medicines used in pediatrics today, including fentanyl, buprenorphine, clonidine, scopolamine, methylphenidate, oestrogens, nicotine, and tulobuterol. 

 

Transdermal cannabinoids make sense because they are non-invasive, convenient, consistent, and, most importantly, remove the need for inhaled routes of administration. With the advances made in RYAH’s Smart Patch, which allows for slow-release and precise dose control, the future of a transdermal cannabinoid application in pediatrics is apparent. 

 

Considerations for Future Applications

 

As with all types of medicine, special conditions apply for pediatric therapy—and cannabis is no different. As the AAP made clear in their 2015 policy update, there are still serious concerns about the long-term impact of chronic cannabis exposure among adolescents. 

 

Smart transdermal applications naturally lower the risk of over-ingestion and potential for abuse. But, finding the balance between therapeutic benefit and long-term outcomes is the next frontier of research into cannabinoids in pediatric medicine.