Pediatricians are being asked by parents about treating their children with cannabidiol (CBD) products obtained via local shops, online sellers, and national pharmacy chains. As many parents are using CBD regularly, it is likely that children are being given these products without pediatricians’ endorsement, convinced by the national media and word of mouth that they are both safe and effective for conditions such as anxiety, sleep problems, and pain.
The purpose of this article is to examine the evidence relating to the safety and therapeutic benefit of CBD for pediatric patients, and to offer suggestions how pediatricians should respond to queries from parents regarding its use.
Cannabis: CBD and THC content
Cannabis contains over 100 different chemicals identified as cannabinoids. The major psychoactive component in cannabis is delta-9-tetrahydrocannabinol (THC), which produces euphoria, changes in perception and mood, as well as an increase in appetite. In contrast, CBD alone produces sedation, without the psychoactive effects associated with THC.1
Marijuana consists of the dried flowers, leaves, and stems of the female cannabis plant and contains between 3% to 20% THC. Different subspecies of cannabis contain different ratios of THC to CBD, with the highest ratios in Cannabis sativa and the lowest in Cannabis indica.2 “Hemp” is a term used to classify varieties of cannabis with 0.3% or less of THC and is the source of most CBD products available commercially. Cannabidiol is sold for inhalation by smoking or vaping; ingestion via a spray, pill, oil, or tincture; as a CBD-infused edible; or to be used topically as a cream or balm.
Delta-9-tetrahydrocannabinol exerts its effects by binding to 2 cell membrane receptors called the cannabinoid type 1 (CB1) receptor and type 2 (CB2) receptor. Cannabinoid type 1 receptors are mainly concentrated in brain tissues and CB2 receptors are found in immune and hematopoietic cells. Through its effects on these receptors, THC affects pain, perception, anxiety, learning, memory, and motor control.
In contrast, CBD has no effect on CB1 and CB2 receptors and exerts its sedative activity by affecting numerous other neurotransmitters. It also has been demonstrated to reduce the euphoric effects of THC by inhibiting its effects on the CB1 and CB2 receptors and modulating the metabolism of THC.2
To date, the US Food and Drug Administration (FDA) has approved only one CBD medication, Epidiolex, for treatment of refractory seizures in patients aged 2 years and older with Lennox-Gastaut syndrome or Dravet syndrome. Epidiolex, approved just last year, is synthetic CBD and contains no THC. Extensive clinical trials with this drug have been conducted and results provide significant insight regarding its benefits and adverse effects.3,4 More on this in a moment.
Medical cannabinoids in pediatric patients
Wong and Wilens published a systematic review of medical cannabinoids in pediatric patients in 2017. Of 2743 citations examined to identify the evidence base of cannabinoids for children and adolescent patients, they identified 22 studies meeting inclusion criteria. They found sufficient evidence that THC-derived products are effective for chemotherapy-induced nausea as well as CBD for epilepsy. They also reported insufficient evidence for cannabinoids for spasticity, Tourette syndrome, neuropathic pain, and posttraumatic stress disorder. They advocated for further research regarding CBD and THC, given that recreational cannabis has potential psychiatric and neurocognitive adverse effects, including lower intelligence quotient scores, deficits in memory, psychomotor performance, and attention.5
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