What are the guidelines for using marijuana (cannabis) in pediatric treatment?

Guidelines for Marijuana Use in Pediatric Treatment

Current guidelines strongly recommend against the use of marijuana or cannabis products for pediatric treatment except in very specific circumstances such as FDA-approved CBD for certain forms of epilepsy. 1

Current Evidence and Recommendations

General Recommendations

• The Canadian Association of Gastroenterology explicitly recommends against cannabis or derivatives to induce or maintain remission in pediatric Crohn's disease (Strong recommendation, very-low-quality evidence) 1
• The Canadian Paediatric Society recommends that sales of all cannabis products to children and adolescents be prohibited due to potential harms associated with cannabis use 1
• Pediatricians should include tobacco and cannabis use prevention as part of anticipatory guidance (Strong recommendation) 1

Documented Risks in Pediatric Populations

Cannabis use during adolescence has been linked to:

• Changes to the developing brain 1
• Substance use disorders 1
• Increased rates of psychiatric illness 1
• Cognitive decline 1
• Diminished school performance and lifetime achievement 1
• Impairments in attention, learning, memory, planning, and psychomotor speed 1

Limited Therapeutic Applications

The only well-established therapeutic use in pediatrics:

• CBD for specific forms of epilepsy (FDA-approved)
• Even in this context, CBD presents risks for hepatotoxicity with a nearly 6-fold increase in liver enzyme elevation 1

Clinical Management Algorithm

1. Assessment of Potential Indications

• Epilepsy: Consider pure CBD (not CBD-enriched cannabis extracts) only for refractory epilepsy not responding to conventional treatments 2
• Crohn's Disease: Do not use cannabis or derivatives for treatment 1
• Cancer-Related Symptoms: While ASCO provides guidance for adults, there are no established guidelines supporting cannabis use in pediatric oncology patients 1

2. Risk Assessment

Before considering any cannabis-based treatment:

• Evaluate developmental stage (younger age associated with higher risk) 1
• Screen for personal or family history of psychiatric disorders 1
• Assess risk for substance use disorders 1
• Consider potential drug-drug interactions with other medications 1

3. Monitoring for Adverse Effects

If a cannabis-based treatment is being used (e.g., FDA-approved CBD for epilepsy):

• Monitor liver enzymes regularly, particularly in the first 2 months 1
• Watch for neuropsychiatric effects 1
• Monitor for cardiovascular effects including tachycardia and orthostatic hypotension 3
• Be alert for cannabinoid hyperemesis syndrome with long-standing use 1

Special Considerations

Accidental Ingestion

• Marijuana ingestion can cause dangerous and potentially life-threatening toxicity in children 4
• Primary symptom is excessive drowsiness, potentially progressing to an unarousable state 5
• Consider marijuana exposure in children presenting with unexplained drowsiness 5
• Marijuana products have potential to provoke seizures in children 5

Adolescent Cancer Patients

• NCCN guidelines note that adolescent and young adult cancer patients may use cannabis to feel normal and part of their peer group 1
• If an adolescent cancer patient chooses to continue cannabis use, education on harm reduction is recommended:
  • Avoid high THC-content products
  • Avoid synthetic cannabinoids
  • Choose routes of administration other than inhalation
  • Limit frequency of use
  • Never drive while impaired 1

Pitfalls and Caveats

1. Lack of pediatric data: Most cannabis research has been conducted in adults, with very limited data in pediatric populations 1

2. Variable product composition: Cannabis products vary widely in composition, making it impossible to extrapolate findings from one preparation to another 1

3. Increasing THC potency: Average THC concentration has increased from 9% in 2008 to 17% in 2017, with concentrates reaching up to 70% THC, increasing risk of adverse effects 3

4. Long-term neurodevelopmental effects: Insufficient information exists on possible long-term changes in the central nervous system caused by cannabinoid treatments during early childhood 2

5. Self-medication risks: Self-medication with marijuana products should be discouraged, particularly in households with young children 5

In conclusion, current medical guidelines strongly caution against the use of marijuana in pediatric treatment outside of very specific FDA-approved indications, with emphasis on the potential for harm to the developing brain and long-term adverse outcomes.