Can children use cbd oil for pain

Should You Give Your Kid CBD?

More Americans are using the hemp (or marijuana) extract on their kids, but experts aren’t sold on its efficacy.

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Priscilla Batista is stuck at home in Charlotte, N.C., with a highly emotional 4-year-old.“Every toddler obviously is emotional, but she’s a pretty constant, volatile child,” she said. “It doesn’t allow her to focus. She’s just struggling.” Batista doesn’t yet have an official diagnosis for her daughter, but, suspecting an attention deficit disorder, she has turned to CBD (cannabidiol) for help.

CBD is one of the more well-known components of cannabis, along with THC (tetrahydrocannabinol). Both chemicals affect the brain, but while THC makes users feel high, CBD doesn’t, though it does make some users feel more relaxed. CBD products have become hugely popular around the world, from oils that can be eaten or rubbed on skin, to soaps, gummy candies and even pet treats.

A 2019 Gallup poll found 14 percent of more than 2,500 Americans surveyed use CBD products, mostly for pain, anxiety and sleep problems. Statistics for kids are much harder to come by, but there are Facebook groups with thousands of followers where parents discuss giving CBD to their kids for conditions including the autism spectrum and attention deficit hyperactivity disorder. In April, a cannabis-focused magazine published a survey of more than 500 parents and found that 40 percent had given CBD products to their children for behaviors related to the autism spectrum.

Very little controlled research has been done with CBD and kids. There is only one approved drug based on CBD for any age group, and that’s for rare kinds of epilepsy in children. There are promising hints — but little proof thus far — that the compound might work on some other conditions in children too, including other kinds of seizures, autism and anxiety.

“When you’re desperate, you want options,” said John Mitchell, clinician at Duke ADHD Clinic in Durham, N.C. “I’m a parent myself. I get it.” But, he cautioned, for now the enthusiasm is running ahead of the science. “I’m very hesitant to say anything promising about it. It’s an open question.”

The medical community considers pure CBD relatively safe: The World Health Organization, for example, has said there’s no evidence of anyone abusing CBD recreationally, or of any public health problems. But there are still some risks, especially for kids.

Last year, the Food and Drug Administration wrote that CBD has the potential to cause liver injury (in users of any age), and suggested it might affect the developing brains of children. No one knows the long-term effects of giving CBD to kids, said Arno Hazekamp, Ph.D., a pharmaceutical researcher and cannabis consultant in the Netherlands. “Those kids are still kids,” he said. Researchers will have to wait until they are older to assess long-term effects. Also, since most CBD products aren’t regulated, he added, they can be tainted with dangerous additives.

Hints of help

The only drug containing CBD that has been approved for adults or children is Epidiolex, which is currently the only known treatment for two rare and devastating forms of childhood epilepsy: Dravet syndrome and Lennox-Gastaut syndrome. Epidiolex, approved in 2018, was developed after the high-profile case of Charlotte Figi, whose desperate mother used CBD to dramatically control her debilitating seizures.

The way that CBD acts on the brain makes it a good candidate for controlling seizures caused by other conditions too. The Epilepsy Foundation said that early evidence from animal studies, anecdotal reports and small clinical trials suggest that CBD could potentially help with seizures. Dozens of trials are underway to test if, why and how CBD might work for kids and adults suffering from seizures of various kinds.

There are also hints CBD might work for some autistic kids. Dr. Gal Meiri, M.D., clinical director of the National Autism Research Center of Israel at Ben Gurion University of the Negev, has studied CBD oils and autism. In a study that Meiri co-authored in 2019, 155 autistic kids aged 18 years and younger tried CBD oil for at least six months. More than 80 percent of the parents reported significant or moderate improvement in their kids. “Some of the parents reported benefits not just with seizures but also behaviors, like self-harm,” he noted.

Most such studies are based on parents’ perceptions, rather than measured changes in comparison to placebo groups. The placebo effect can be strong, since parents typically want to see improvements. A placebo-controlled trial of CBD for autistic children has been completed at the Shaare Zedek Medical Center in Israel, but the results aren’t yet published. Another is underway at the University of California, San Diego.

“I’m trying to be very cautious about it,” said Meiri with regards to CBD and autism. “We still don’t have enough research about safety and efficacy.”

Similarly, many parents are trying CBD products for children with A.D.H.D., for which there are no reported controlled trials with kids. One small trial on 30 adults with a mouth spray containing both CBD and THC had inconclusive results.

With no scientific proof that CBD works and is safe for children, Mitchell said stimulant-based medications like Adderall are a better option than CBD. “We know much more about one than the other, so the choice is simple,” he said. But he understands why a parent might consider CBD as an alternative, he said, given that it is typically seen as a gentle drug with few side effects.

That matches Batista’s experience. “My daughter has a beautiful personality; she’s sweet, she’s spunky. I don’t want to medicate her with something that’s going to turn her into a zombie,” she said, referring to parent complaints that some stimulant-based drugs can make their kids seem spacey.

“I don’t want her to fall behind,” she said. Batista has seen other kids with A.D.H.D. struggle academically. “It can really swallow a kid whole; then you have a failure to launch.”

Mitchell added there are signs CBD might help with anxiety: a symptom that sometimes accompanies autism and A.D.H.D. In a 2018 study of CBD for kids with autism, for example, anxiety improved in more than a third of the 60 patients.

Surprisingly, there’s not much evidence that CBD helps with sleep — despite its reputation for causing drowsiness in recreational users. “Something can make you sleepy and have no effect on your sleep quality,” said Hazekamp.

No silver bullets

Even if CBD is someday approved for use against other kinds of seizures, autism or A.D.H.D., it is unlikely to work for everyone.

Kelly Cervantes, a mother and health activist in Chicago, gave CBD to her daughter Adelaide, who suffered from an unidentified neurodegenerative condition with severe infantile spasms. “We were desperate, and we wanted to try anything we could,” said Cervantes. That was when her daughter was about a year and a half old, and before Epidiolex, so she says she got the product online rather than though her doctor. Sadly, Adelaide’s symptoms got worse. “It entirely depends on the child. There is no one pill, one oil, one treatment that is going to cure everyone,” she said.

In addition, Adelaide’s doctors began to see signs of liver failure. Cervantes took her off the CBD. She said CBD, “does not come without side effects, which I think is a major misconception about it.” In trials of Epidiolex, a moderate dose caused side effects in at least 10 percent of the children, including elevated liver enzymes, decreased appetite, diarrhea, fatigue, sleep problems and malaise.

Furthermore, it’s impossible to know what’s in a CBD product without independent testing. One of Hazekamp’s studies in the Netherlands analyzed 46 cannabis oils made by patients or sold online. Only 21 products even advertised the ingredient concentrations and many of those were wildly wrong. Seven didn’t contain any cannabinoids at all. One of them had more than 50 percent more THC in it than the product claimed.

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“There can be pesticides, heavy metals and microbes in the plants,” said Hazekamp. It isn’t clear if those are making it into CBD oils, he said.

It’s impossible to overdose on pure CBD, but synthetic knock-offs can be poisonous. In 2019, the American Association of Poison Control Centers put out an alert noting “growing concern” about CBD products, with national calls about CBD rocketing from just over 100 in 2017 to more than 1,500 last year.

“The labels aren’t always right,” said Hazekamp. “If you try it, make sure it is what you think it is.”

Talk to your doctor

When Cervantes tried CBD, she bought it online from what she believed to be a reputable company, but she can’t be sure what was in it. It would help parents of suffering children, she said, if CBD products were more regulated and parents felt they could talk to their doctors about it, rather than worrying about its association with marijuana.

“I had a patient start taking CBD and I only found out a month in,” said Mitchell. “Parents may assume that a doctor will respond in a negative way.” It’s a doctor’s responsibility, he said, to be open to discussing options. “If you shut a patient down, it doesn’t mean you won the argument, it means they’re not going to talk about it.”

Batista said her daughter’s doctors told her to be careful with CBD and didn’t recommend it.

Still, she’s been using it for several months, getting it from a company that advertises independent testing to confirm their product’s contents, and starting with a low dose. She said she can’t tell if it’s doing anything, but holds out hope that a gentle drug with few side effects will be effective for her little girl. “I want to think that it’s helping.”

Cannabidiol (CBD) Use among children with juvenile idiopathic arthritis

Juvenile idiopathic arthritis (JIA) is common and difficult to treat. Cannabidiol (CBD) is now widely available, but no studies to date have investigated the use of CBD for JIA.

Methods

We performed a chart review to identify patients with JIA at a Midwestern medical institution between 2017 and 2019. We surveyed primary caregivers of JIA patients using an anonymous, online survey with questions on caregiver knowledge and attitudes towards CBD. We compared respondents with no interest in CBD use vs. those contemplating or currently using CBD using descriptive statistics.

Results

Of 900 reviewed charts, 422 met inclusion criteria. Of these, 236 consented to be sent a survey link, and n=136 (58%) completed surveys. Overall, 34.5% (n=47) of respondents reported no interest in using a CBD product for their child’s JIA, while 54% (n=79) reported contemplating using CBD and 7% (n=10) reported currently giving their child CBD. Only 2% of respondents contemplating or actively using a CBD product learned about CBD from their child’s rheumatologist, compared with television (70%) or a friend (50%). Most respondents had not talked to their child’s rheumatologist about using CBD. Of those currently using CBD, most used oral or topical products, and only 10% of respondents (n=1) knew what dose they were giving their child.

Conclusions

Our results show infrequent use but a large interest in CBD among caregivers of children with JIA. Given CBD’s unknown safety profile in children with JIA, this study highlights a need for better studies and education around CBD for pediatric rheumatologists.

Background

Juvenile idiopathic arthritis (JIA) is the most common type of chronic arthritis in children, affecting 1 in 1000 children. It is an important cause of short and long-term disability and causes significant financial burden with annual direct medical costs ranging $400-$7,000 [1]. Effective treatments for JIA include non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, disease modifying anti-rheumatic drugs (DMARDs), and biologic agents, but each carries potential adverse effects [2]. Indeed, parents and children frequently worry about side effects and the long-term safety of medications prescribed for JIA [3, 4]. As a result, many parents and children (34-92%) use complementary and integrative medicine (CIM) separately or in conjunction with standard treatment of JIA [5,6,7,8,9,10].

CBD’s safety profile has only been characterized among individuals with Dravet and Lennox Gastaut syndrome, so whether CBD is safe for use in healthy children or other pediatric populations remains unknown. Complicating matters, CBD is a promiscuous molecule that interacts with numerous systems in the body (e.g., serotonergic 5HT1A, endocannabinoid system as cannabinoid receptor 1 antagonist) [19, 20], and may interact with the metabolism of drugs commonly taken by children with JIA including prednisone and naproxen [21]. Further, testing of safety and potency of CBD products is not governed by a strong regulatory apparatus, [22, 23] and a recent JAMA study revealed that only 31% of CBD products sold online are accurately labeled for potency with 21% of samples containing THC [24]. As such, there are safety concerns about use in children, especially those with JIA.

As pediatric rheumatologists, the authors (C.F., M. R.) have been frequently asked about using CBD products to treat JIA symptoms, but to date, there is no literature available regarding the use of CBD in children with JIA. The objective of this study was to determine the frequency of CBD use among children with JIA and investigate caregiver knowledge and opinions about CBD use for their children.

Methods

All study procedures and protocols were approved by the Institutional Review Board (IRB) at the University of Michigan (HUM00169198). We first conducted an administrative data query at the University of Michigan to identify all children ages 0-17 years of age at the time of a visit associated with the ICD-10 code for JIA between 1/1/2017 and 12/31/2019. That administrative data query identified 900 patients with ICD-10 codes for JIA.

Participant eligibility

The charts of those 900 patients were then reviewed by C.F. Parents or guardians of patients were invited to participate in the study if the patient was younger than 18 years of age at the time of survey, had a diagnosis of JIA, had more than 1 visit to Pediatric Rheumatology clinic, and had been evaluated by a Pediatric Rheumatologist within the last 18 months. N=422 eligible participants were contacted by phone and invited to take an anonymous online survey created by the authors using a unique link through Qualtrics between December of 2019 and February of 2020. Only respondents interested in the survey were sent the unique link. Respondents were not compensated for completing the survey.

Survey

The survey consisted of 83 items, some of which were variably displayed depending on participant’s responses. Questions addressed parent/guardian demographics (age, gender, ethnicity, education level, annual household income), use of complementary and integrative medicine (CIM) over lifetime (no use, 1 CIM, 2-4 CIMs, > 4 CIM), history of parent/guardian CBD product and cannabis use, child demographics and disease characteristics (age, gender, subtype of JIA, disease duration, parent/guardian report of disease activity at last rheumatology appointment, current rheumatologic medications used, co-morbid health conditions), and total number of CIM therapies used over child’s lifetime.

Respondents using CBD or contemplating CBD use for treatment of their child’s arthritis answered questions about sources of CBD information, perceptions of how CBD might improve their child’s arthritis, perceptions of the safety of CBD, and whether they had discussed CBD with their child’s provider. If respondents had not discussed CBD with their child’s healthcare provider, they were asked for the reasons why.

If parent/guardian reported using CBD product for child’s arthritis, they were asked questions about their CBD product(s), route of CBD administration, frequency of CBD use, parental perception of child’s disease activity pre and post-CBD use (using a 0-10 visual analogue scale), and total daily dosage of CBD (if known).

Statistical analysis

We performed descriptive analyses, and present results as frequency, n (%) and mean +/- standard deviation for categorical and continuous variables, respectively. We used Fisher’s chi-square test to assess differences in categorical variables. Participants were divided into 2 comparison groups for analyses: currently using or contemplating starting a CBD product for their child and no interest in starting a CBD product. Participants using CBD for treatment of their child’s arthritis were not used for standalone comparison due to small sample size (n=10). All statistical analysis was performed using Microsoft Excel (2016, Microsoft Corporation).

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Results

Participation

Overall, 422 JIA patients met inclusion criteria. Of those, 236 parent/guardians agreed to be sent the survey link and 136 participants completed the survey (58% response rate, Fig. 1). 10 respondents (7%) reported using a CBD product to treat their child’s JIA, 79 respondents (58%) reported contemplating use of a CBD product to treat their child’s JIA, and 47 respondents (34.5%) reported no interest in starting a CBD product. Demographic characteristics of the survey respondents are shown in Table 1. The study population was largely white, had a bachelor’s degree or higher, and had an annual income of more than 50,000 dollars per year. A large majority of respondents in both groups reported using one or more CIM therapies in their lifetime. There was no significant difference in the specific types or number of CIM therapies used across groups. Report of high disease activity was more frequent among those currently using or contemplating CBD use than those not contemplating use.

Flow diagram of study

A majority of those using CBD or contemplating using CBD for their child learned about it from TV (66%), a friend/relative (34%) or JIA online blog/support group (35%). Very few obtained information from a scientific journal article (17%) or their child’s rheumatologist (2%). Around half (52%) used 2 or more sources to learn about CBD. A majority of parents/guardians (75%) reported believing that CBD would reduce their child’s joint pain (Fig. 2 A), while only 15% of respondents reported believing that CBD has side effects. More than half of respondents reported thinking that CBD is safe because it is a natural product (Fig. 2 C). Nearly two-thirds (63%, n = 56) of respondents had not discussed using CBD with their child’s rheumatologist and over half (61%) of those did not plan on discussing with their child’s rheumatologist for the following reasons: scared of what provider may think (35%), felt they wouldn’t be taken seriously (29%), and believed rheumatologist would have no knowledge about CBD (18%).

Parent/gaurdian perceptions of those using CBD for their child’s arthritis and those contemplating use of CBD (n=89) on how they percieve CBD will help their child’s arthritis (A), how they learned about CBD (B), perception of safety fo CBD (C). 56 respondents haven’t told their child’s rheumatologist for the following reasons (D)

Contemplating CBD use

Respondents contemplating starting a CBD product for their child’s JIA (n=79) were interested in the following CBD products: CBD oil balm (30%), oil drops (25%), gummies (15%), soft gels/capsules (6.5%), and oil roll on (23%). Around a third (32%) of respondents were unsure what products they were interested in. Of those respondents (n=52) who were interested in starting a CBD product, 32.6% were interested in only oral CBD, 36.5% in a combination of oral and topical CBD, and 30.7% were interested only in topical CBD.

Current CBD use

Respondents using CBD products for their child’s JIA (n=10) reported administering CBD orally (50%) or topically (50%). The majority (60%) reported using CBD on an as needed basis, while 40% reported using CBD on a scheduled basis. Overall, 40% reported administering CBD once per day, 20% twice per day and 40% at least three times per day. Respondents who reported administering CBD as needed (n=6) gave it for joint pain (66%), joint swelling (50%), joint stiffness (66%), and/or when their child requested it (33%). Respondents reported their child’s overall wellbeing to be an average 3.6 prior to starting CBD (0 = very poor, 10 = very good) and 5.3 after taking a CBD product. Half (50%, n=5) of parents reported improvement of their child’s wellbeing after they started CBD while 30% reported no change in their child’s wellbeing and 20% reported decreased well-being. Respondents used the following CBD products: oil drops (40%), lotion (10%), soft gels (10%) and oil balm (40%). Only one respondent knew the total dose of CBD administered per day (20 mg daily) while 70% (n=7) were unsure and 20% (n=2) reported they believed that the dose of CBD was irrelevant.

Discussion

To our knowledge, this is the first study exploring parent/guardian knowledge and opinions regarding CBD use for their children with JIA. We found that while CBD use is infrequent, there is a strong parent/guardian interest in using CBD for treating JIA, especially among respondents reporting more active disease and a longer disease course. Use of stronger medications such as biologics, on the other hand, was not associated with a significant difference in CBD interest. These findings are consistent with other studies showing that children with JIA use CIM more frequently if they have more active disease and longer disease duration, and that use of immunosuppressive or biologic medications is not a factor related to CIM use among children with JIA [6, 25].

The majority of the survey respondents learned about CBD from television, the internet (JIA online blog/support group), or friend or family member with only a small percentage of respondents learned from a health care provider or scientific study, mirroring results from other studies of adults using CBD oil or cannabis [26, 27]. Our study further showed that many parent/guardians are not discussing CBD with their child’s rheumatologist. This is because they expressed worry that their child’s rheumatologist would negatively judge them and or not take them seriously if they discussed their experience with or interest in CBD. This finding is similar to a recent study in which only 9.6% of young adults reported discussing CBD usage with their healthcare provider [27]. Previous studies evaluating CIM use in adolescents with JIA have demonstrated similarly low rates of discussions with their health care provider, [10] and parents of children with other chronic health conditions have reported similar reasons for not discussing CIM with their child’s health provider. These results suggest that providers need CBD and CIM-related education to better serve individuals with JIA, and also that providers need to specifically ask about use of CBD and other CIM modalities.

As CBD becomes increasingly more popular, parental interest in using CBD to treat their child’s health conditions continues to grow. The use of the search terms for “CBD for children” and “CBD for kids” have increased since 2018, [22] and numerous blog posts and other forms of media report positive results from giving CBD to children [22]. These forms of media do often mention preclinical CBD research conducted in mice, which demonstrate that CBD has potent anti-inflammatory and analgesic effects in induced inflammatory arthritis [14, 15]. Further, some small clinical trials of CBD in adults do show that CBD may have analgesic activity (in neuropathy and temporomandibular joint disorder [28, 29]) and short-term anxiolytic effects, [30,31,32] and several clinical trials of CBD in arthritis are ongoing (for example, in rheumatoid arthritis) [33]. However, what is often not communicated is that studies on safety and efficacy of CBD among children with those symptoms (e.g., pain, inflammation) have not yet been conducted. As such, additional rigorous research is needed to investigate whether these preliminary therapeutic findings translate to the JIA context.

Consistent with prior reports about CBD administration among young adults, [12, 27] a majority of those using CBD for their child’s arthritis are administering CBD orally (60%) on an as needed basis as often as several times per day for joint pain and/or stiffness. In addition, 69% of those contemplating CBD expressed interest in an oral CBD product (alone or in combination with topical CBD). This strong interest in oral CBD is important to note, as CBD has been suggested to interact with the liver enzyme cytochrome P450 and could interfere with the metabolism of several commonly prescribed rheumatologic medications, including prednisone, naproxen, and tofacitinib, potentially leading to increased drug levels and increased risk of toxicity.

The large majority of respondents believed CBD is safe because it is a natural product and did not believe there were adverse effects of CBD. Surprisingly, only 1 of 10 participants currently giving their child CBD knew what dose they were administering. The overall safety of CBD for healthy children or other clinical populations remains unknown but the Epidiolex trials, [16, 34] which used high doses of CBD, reported non-serious adverse effects in children including dry mouth, sedation, and/or decreased appetite. Other studies have reported similar adverse effects in young adults or adults taking CBD [13, 27].

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Limitations

Respondents of both panels were similar in terms of race/ethnicity; education, age, and gender, however, > 95% of respondents were white/Caucasian which is not representative of the JIA patient population at our institution or in the US. Survey links were only generated for parents or guardians who expressed interest in participating in the study, so selection bias was likely present. In addition, respondents may have interpreted survey questions differently than we intended and wording of questions may have introduced bias. Finally, we only queried the parents/guardians of individuals with JIA rather than directly asking individuals with JIA about their experiences with or interest in CBD.

Conclusions

As CBD continues to gain popularity, parental interest in CBD for treating their child’s health condition(s) will likely increase. In this study, we show that while CBD use is currently infrequent for JIA, many parents/guardians are interested in using CBD to help with JIA symptoms. As such, is important that pediatric rheumatologists and other pediatric providers educate themselves about CBD to increase their comfort in discussing CBD and its potential safety issues with their patients and/or parents. Such efforts should focus on harm-reduction, communicating uncertainty without harming the patient-physician relationship, and guiding interested parties to reliable sources on CBD (e.g. the Arthritis Foundation)[35] to ensure that they are obtaining information based on scientific evidence. In addition, rigorous clinical studies are warranted to investigate both safety and efficacy of CBD in JIA to bridge the gap in knowledge.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

juvenile idiopathic arthritis

Non-steroidal anti-inflammatory drugs

Disease modifying anti-rheumatic drugs

Complementary and integrative medicine

Food and Drug Administration

Institutional Review Board

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