Which diseases support the use of cannabis in paediatrics?
The FDA has approved a CBD drug called Epidiolex for the treatment of Lennox-Gastaut Syndrome, Dravets Syndrome and tuberous sclerosis. CBD can help reduce seizure frequency and severity associated with these conditions.
What are some of the dangers of cannabis in paediatrics?
There is some evidence that adolescent cannabis use can interfere with normal neurocognitive brain function, but little is known about whether cannabinoids affect children or infants the same way. Another danger is that there is no robust evidence for cannabis treatment in diseases other than those mentioned in the takeaway above.
What's on the agenda for the future?
Cannabis is being investigated as a potential treatment for paediatric pain, sleep, and behavioural disorders, for paediatric palliative care, and for autism.
It sometimes feels that everyday, our knowledge about cannabis becomes more robust and we become more and more confident at using it. But the stark reality is that when it comes to medical science, we still know less about cannabis than any approved pharmaceutical drug. And that’s what makes cannabis in paediatrics still a contentious topic.
There is robust evidence for the use of cannabis in children with certain diseases, but certainly not all diseases. On top of this, there are important considerations about cannabinoids and brain development in children and adolescents.
The demand for cannabis in paediatrics is growing enormously in Canada but medical bodies have yet to develop guidance documents or standard protocols, leaving many paediatricians in the dark. The knowledge and understanding of paediatricians and paediatric medicine have essentially fallen behind the demand from parents.
But that still doesn’t answer the question — can children benefit from cannabis? What we’re doing to discover is that some children may benefit from cannabis while for others, it may hinder their development and recovery. Let’s have a look and see which is which.
The challenges of cannabis in paediatrics.
The main challenge that paediatricians face when deciding whether or not to administer cannabis to children is the caveat that cannabis may have detrimental effects on brain development in children and adolescents. It is thought to cause disadvantages in neurocognitive performance as a result of alterations to brain functioning. However, it’s not clear whether pre-existing differences (to the normal population) might lead adolescents to use cannabis, or whether cannabis is the cause of those differences.
The majority of the research surrounds cannabis use in adolescents, not cannabis in children. This creates another hurdle into the understanding of how cannabis affects pre-teens and children and their brain development.
All of this not knowing — but with potent potential risks (brain development) — is the reason that paediatricians hesitate when it comes to prescribing cannabis. Depending on the severity of the disease, it might just be better to choose something that doesn’t pose the risk of affecting brain development.
It’s important to recognise that all drugs come with side effects, and a doctor’s job is often to weigh up the pros and cons and then offer those to a patient — even if that patient is a child. For example, Dravets Syndrome can cause seizures so frequent and so severe, that a child can be left with developmental problems and even a crouched walk. In this kind of scenario, a paediatrician may choose cannabis as a treatment option as the alternative itself is much worse.
Another obvious challenge that paediatricians face is the lack of robust evidence of cannabis use in children for specific diseases. There is some evidence to support the use of cannabis for certain seizure disorders, for example, and for tuberous sclerosis (we’ll share some of this research with you later in the article). But there isn’t an overwhelming amount of evidence to support the use of cannabis in children with pain disorders, ADHD, anxiety, or depression — all of which are common reasons for parents to request cannabis treatment from paediatricians.
What treatments does the research support?
When it comes to cannabis in paediatrics, there are few diseases for which cannabis is fully supported by research as a treatment. These are Dravets Syndrome, tuberous sclerosis, and Lennox-Gastaut Syndrome. Let’s have a look at these conditions and the research that supports cannabis as a treatment.
Dravets Syndrome and treatment with cannabis.
As we mentioned earlier, Dravets Syndrome is a very rare disease affecting otherwise healthy infants. It’s thought to be caused by a gene mutation. Symptoms typically begin in the first year of life and are characterised by clonic seizures (jerking movements) and fever. The jerking often happens on one side of the body, and are long seizures.
Eventually, this can escalate into status epilepticus, which is when seizures occur very frequently with very little time in between. Intellectual impairment and brain abnormalities are complications of Dravets Syndrome because of how severe seizures are, their frequency and their duration. Up to 20% of children diagnosed with Dravets Syndrome will die before reaching adulthood.
In a clinical trial testing the efficacy of CBD on children with Dravets Syndrome in 2017, researchers found that the frequency and severity of all kinds of seizures were reduced in the subjects who took CBD. The percentage of those who experienced greater than 50% reduction in seizures was an astonishing 43%. In total, 5% of subjects using CBD became seizure free after treatment, while 0% of the placebo group became seizure free.
This research lead to the approval of Epidiolex, a drug created by GW Pharmaceuticals made of purified CBD. The FDA approved Epidiolex in 2018, and is approved in paediatrics for the treatment of Dravet Syndrome.
Given the complications of Dravets Syndrome and the high morbidity associated with it, treatment is absolutely vital. However, Dravets Syndrome is highly resistant to seizure medication, and CBD is an appropriate intervention to control seizures and minimise complications.
Lennox-Gastaut Syndrome and cannabis treatment.
Like Dravets Syndrome, Lennox-Gastaut Syndrome is a rare kind of epilepsy that causes severe and frequent seizures. However, Lennox-Gastaut Syndrome is characterised, not only by multiple seizure types, but also by abnormal EEG readings and cognitive impairment. This triad of symptoms is the main framework by which Lennox-Gastaut Syndrome is diagnosed.
Mortality with Lennox-Gastaut Syndrome is less than Dravets Syndrome, with early fatalities only occurring in 4-7% of diagnoses. These usually occur because of accidents associated with seizures. In this way, Lennox-Gastaut Syndrome is considered less severe than Dravets, and it’s also less rare.
At the same time, Lennox-Gastaut Syndrome is morbid and symptoms are stressful for both children and parents. It happens to be another condition for which cannabis in paediatrics is generally accepted. The same drug, Epidiolex, has shown great promise for Lennox-Gastaut Syndrome and the FDA has approved Epidiolex for this condition too.
Tuberous sclerosis and how cannabis helps.
Tuberous sclerosis (TS) is completely unlike Lennox-Gastaut and Dravets Syndromes in that it’s not a seizure disorder. TS is another rare disease (total prevalence of 1 in 20,000) that causes benign tumours (noncancerous) to grow on the body, skin, brain, kidneys, and other parts of the body. Though the tumours are noncancerous, they can cause a host of symptoms depending on where they are in the body.
For example, a person with TS might experience seizures if their tumour is located in the brain. Others might experience lung or eye-related issues, again because the lesions occur in those areas. TS is usually diagnosed at birth, but in some cases doesn’t get diagnosed until adulthood.
TS is not associated with high morbidity or mortality statistics like Dravets or Lennox-Gastaut, but because seizures are a factor in TS, treatment is very important. Up to 90% of patients with TS experience seizures. And as you might have guessed, treating intractable seizures caused by TS is where cannabis comes into the picture.
As the writers of this study conclude, CBD is a highly effective treatment for seizure reduction in those with intractable seizures caused by TS — but it’s not a miracle. And it’s not a miracle because with TS, tumours recur, and it doesn’t seem like CBD intervention can stop that. However, CBD helps to reduce seizures — and that’s a very important aspect for sufferers of TS.
Those born with TS go on to live fruitful, productive lives, and so a paediatrician may not choose cannabis as a first line of treatment for a child with TS. They may first choose to explore other therapies that have been better researched.
Other paediatric conditions considered for cannabis treatment.
Though the evidence is only robust for these specific types of epilepsy and TS, there is ongoing research and investigation into cannabis treatment for spasticity, motor disorders, and Tourette syndrome.
In one open-label study including 25 children, a CBD-rich preparation was given to children with complex motor disorder. The children that received CBD showed improvements in sleep, muscle spasticity, dystonia, and quality of life.
In this feasibility study, researchers demonstrated a possible connection between the endocannabinoid system and Autism Spectrum Disorder (ASD). The rationale is that many ASD sufferers experience seizures (up to 33%), and that this suggests a connection between ASD and the endocannabinoid system. Researchers declared improvements of a range of different kinds in 61% of patients.
There are a lot of other paediatric diseases on the agenda when it comes to cannabis research including neuropathic pain, neurological diseases, sleep disorders and behavioural problems. Paediatric palliative care is also another context in which it’s important to consider cannabinoid treatments. We don’t often think of palliative care or hospice as being relevant to children, but children also experience very painful and sometimes fatal diseases that simply require palliation. In palliative care, the only objective is comfort, and therefore it may not matter that cannabinoids may hinder a child’s brain development.
Cannabis in paediatrics; controversial, but let’s talk about it.
There’s absolutely no doubt that stigma plays a role in how we feel about giving cannabis to children. Some parents choose it as a final resort but still feel like they are drugging their child. It’s interesting that some parents might feel this way about giving cannabis to their children but not Ritalin.
At the same time, children are delicate and they can’t make health decisions for themselves. And so it’s very important not to give medications that can have risks for the future of their health. It has to be completely safe before we can openly encourage the use of cannabinoids in children.
It’s important to be having the conversation openly because despite stigma, some children can benefit from cannabis treatment. Parents who want to explore the options of cannabis treatment with their children should find a cannabis-friendly medical practitioner for honest, up-to-date medical advice.
What’s your experience with paediatrics? Do you or anyone you know have a child eligible for treatment with cannabis? We’d love to hear your stories. Drop them in the comments!