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11 cannapatientcare.com october 2022 | cannabis patient care doctor focus Cannabis for Children with Cancer D U S T I N S U L A K , D . O . C ANNABIS is a well-known and broadly accepted treat- ment for chemotherapy-induced nausea and vomiting, but this is just one fraction of the many potential ther- apeutic benefits that cannabis can provide to patients with cancer. On the basis of my clinical experience, nearly any- one with cancer can benefit from appropriately-dosed cannabis, regardless of their age. It's invaluable in treating cancer-relat- ed symptoms like pain, mitigating the adverse effects of con- ventional treatments, supporting emotional and spiritual ad- justment to the challenging diagnosis, prognosis, and clinical course, and, when needed, as a tool in end-of-life care. Among medical specialties, oncologists are some of the most comfortable in recommending cannabis for patients, largely due to the observed benefits and published clinical trial data. Oncol- ogy patients are also typically curious about or open-minded to the potential benefits of cannabis. Many clinicians and parents, however, are less likely to consider cannabis for pediatric pa- tients with cancer, often to the child's detriment. The thought of a child taking cannabis may, for some, con- jure images of teenage illicit cannabis smoking, which clearly has potential risks. More recently, with the approval of a can- nabidiol (CBD)-based medication in the United States for two rare seizure disorders, the medical community is beginning to accept the idea that CBD can be helpful for some children, yet tetrahydrocannabinol (THC) is still frequently considered for- bidden territory. It's essential that we set aside these notions and consider the therapeutic and palliative potential of can- nabis without bias. What do we know about the safety and ef- ficacy of THC in children? Read on to learn more. Is it Safe for Children to Use Cannabis and Do They Get High? In my clinical experience, and that of several colleagues, we have found that children are less likely than adults to expe- rience adverse psychoactive effects from THC. The late Ester Fride, PhD, who pioneered exploration of the endocannabinoid system (ECS) in early development, reported that the grad- ual postnatal increase of CB1 receptors and anandamide is accompanied by a gradual maturing response to the psycho- active potential of THC in postnatal mice between birth and weaning (1). This observation in rodent studies is supported by frequent mentions in the 19th-century literature that children often tolerated heroic doses of cannabis medicines that would produce incapacitation in an adult (2). Examples are also found in the modern literature: in a pediatric clinical trial with sub- lingual Δ 8 -THC for chemotherapy-induced nausea or vomiting, up to 0.64 mg/kg/dose was virtually totally effective and free of side effects (3). This is a dose that would produce pronounced impairment in most non-cannabis tolerant adults. In my practice, the most common and often only adverse effects of THC-dominant cannabis in children are giggling, bloodshot eyes, and sleepiness; when these occur, a minor dosage reduction usually resolves them all. What about the risks in the developing brain? First, it's im- portant to distinguish the adverse effects of a medically-su- pervised, judiciously-dosed pediatric trial from the known detrimental effects of adolescent illicit cannabis smoking. The latter has been associated with adverse neuropsychiatric out- comes in adulthood, though the association has not proven to be causal (4). A recent review and meta-analysis of longitu- dinal studies that evaluated frequent or dependent cannabis use in young people did indeed find a decrease in intelligence quotient (IQ) over time, but that decrease was just under 2 points (5). The authors thought this decrease was not clini- cally significant and "alone is unlikely to completely explain a range of psychosocial problems linked to cannabis use in this cohort." In other words, even under the worst circumstances (heavy adolescent use, not medically-supervised), the nega- tive impact on cognition is minimal. In controlled pediatric trials, THC most commonly led to side effects of drowsiness and dizziness, with severity asso- ciated with higher doses; no major side effects were report- ed after dose reduction. The most common side effects with high-dose CBD are somnolence, diarrhea, and decreased ap- petite (6). In comparison with the adverse effect profiles of most treatments being considered for pediatric patients with cancer, cannabis is almost always the safest. Most pediatric patients with cancer will not remain on can- nabis indefinitely, but some may require ongoing treatment for cancers that don't resolve or for symptoms that persist af- ter treatment, such as chemotherapy-induced peripheral neu- ropathy (CIPN). Unfortunately, there is limited data that sheds