Marijuana Use During Pregnancy and Breastfeeding: Is It Really A Big Deal?

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Introduction

Happy New Year! I cannot believe that it is 2024! I hope this finds you happy and healthy! And speaking of happiness and euphoria, today I am going to discuss marijuana use, how it relates to pregnancy, its effects on the growing fetus, as well as the implications of its use during breastfeeding. 

Who would have thought that in 2024, we would be living in a time where marijuana use is so prominent and that it would be legal in 24 states as of January of 2024?!?

But, nonetheless, here we are! Because marijuana has been legalized in so many states, there are now many false evolving perceptions on its general safety as well as its implications on the developing fetus and infant who are exposed to it either in utero or through breastmilk. In general, the perception of harm from marijuana is decreasing while the potency of marijuana is scarily increasing (AWHONN, 2019). In fact, marijuana is the most widely used illegal drug during pregnancy in the United States. And, its use in gaining speed amongst all adult age groups, in both sexes, and in pregnant women (SAMHSA, 2022). 

For our 56th episode, I reviewed the most up-to-date literature and share the findings from several studies that reveal both short and long-term negative effects on the pregnant mother and developing fetus if used during pregnancy, and its future implications on the growing infant, child, and their transition into the teenage years, and as an adult after prenatal exposure. I will also point out the general concentration of marijuana in breast milk if used by a nursing mother, as well as how long it stays in the breast milk, and how it may impact the exposed infant. 

This episode is packed full of useful information and will be ideal for any healthcare worker that works in obstetrics, labor and delivery, mother-baby units, or NICUs. Family members and friends who care about a pregnant woman or nursing mother who is currently using marijuana and want to ensure that she is fully educated on the implications of its use on her growing fetus or infant should definitely listen. And last, but actually, the most important, I encourage ALL women who are either considering becoming pregnant or who are currently pregnant and use marijuana on a regular basis, to listen. I will be honest, I do have a strong opinion about the use of marijuana during pregnancy and while nursing, but for this episode, I ONLY provide the research findings and facts from my review. So what you will hear is not skewed and it is crucial that you listen so you can hear how marijuana will impact your fetus and your child’s future development. Let’s get to it!

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Marijuana Use During Pregnancy and While Breastfeeding: Is It Really a Big Deal?

 

What exactly is marijuana?

Marijuana refers to the dry leaves, flowers, stems, and seeds from the Cannabis sativa or Cannabis indica plant (NIDA, 2019). Marijuana contains over 500 chemicals and varying levels of delta-9-tetrahydrocannabinol or (THC), which is the component that is responsible for the feelings of euphoria, relaxation, and the heightening of your senses (NIDA, 2019). I learned that there are actually hundreds of slang terms used for marijuana with grass, pot, and weed being the most common – but personally, my favorite was wacky tabacky (National Drug Intelligence Center, 2003).

Additionally, marijuana has changed over time. What is available today is much stronger than previous versions. The concentration of THC in cultivated marijuana plants has increased 3-fold between 1996 and 2014 or from 4% to 12% (HHS, 2019). The marijuana available in dispensaries has an average concentration of THC between 17.7% and 23.2% (HHS, 2019). And, some of the more concentrated products like the dabs or waxes contain between 23.7% and 75.9% (HHS, 2019). Holy smokes! And unfortunately, the risk of physical dependence and addiction also increases with exposure to higher concentrations of THC (NIDA, 2019). Additionally, the higher doses of THC are more likely to produce anxiety, agitation, paranoia, and psychosis (HHS, 2019). I also learned that edible marijuana takes longer to absorb and produce its effects, which increases the risk of unintentional overdose, since they do not feel the effects, they just eat more (HHS, 2019). Chronic users of marijuana with a high THC content are also at an increased risk for developing a condition known as cannabinoid hyperemesis syndrome, which involves cycles of nausea and vomiting. Sadly, I have seen pregnant patients get admitted for this several times.

Views of marijuana from pregnant women

Marijuana is the most commonly used illicit drug in the United States. And as I said, it is the illicit drug most commonly used during pregnancy as well. Cannabis use among pregnant women in the United States has actually increased in recent years from an estimated 3.4% in 2002 to 7.0% in 2017 (Young-Wolff et al., 2021). With the recent legalization of medical and recreational marijuana use across the United States and the increased use of other cannabinoid derivatives, there is this evolving false perception of its safety (Gross et al., 2022). And unfortunately, pregnancy and breastfeeding populations are no exception with many women who view it as a safe, natural way to treat nausea, vomiting, or “morning sickness.”  Dickson et. al., said that 69% of dispensaries and 83% of those with a medical license to dispense actually recommended marijuana use to help with nausea during pregnancy.

A 2017 study looked at pregnant women’s beliefs and confirmed the growing false perception that smoking marijuana did not pose a risk to their infant with rates increasing from 3.5% to 16.5% over a 7-year study (Davis, 2020). Therefore, it has been shown that 34-60% of marijuana users continue to use during pregnancy because they believe it is safe and less expensive than tobacco (Committee on Obstetric Practice). 

Ambiguity of reporting marijuana use amongst healthcare providers

Healthcare providers are mandated to report any suspected cases of child abuse or neglect to child protective services. With marijuana use, federal legislation to protect fetuses and newborns from exposure to dangerous substances is quite ambiguous. Despite marijuana use being illegal at the federal level in the United States, it has been legalized for medical and/or recreational use in half of the states.

The Keeping Children and Families Safe Act of 2003 and the Child Abuse Prevention and Treatment Act of 1973 direct states to require medical personnel to report substance-exposed newborns and to create plans for interventions with each individual state’s Child Protective Services (CPS). Unfortunately, the act did not set specific standards to be able to assess, test, and report newborns exposed to substances in utero. This has left each individual state to interpret the legislation which has resulted in a wide variability in how intrauterine exposed infants are identified and what exactly is required by healthcare professionals (Ryan et al., 2018). The controversy is in part due to the lack of evidence to determine at what point the parents’ recreational or medical use of marijuana begins to pose a risk to their ability to care for their children or can be coined as “child abuse” since it does alter the senses and likely impacts their ability to care for their children (Jacob’s Institute of Women’s Health, 2017; Stott & Gustavsson, 2016).  

The ability for social workers, case managers, and/or CPS staff to assess all of the factors in play is difficult when you consider the limited time frame they are given and the workloads of the investigators (Stott & Gustavsson, 2016). But, despite the ambivalence of the federal law and the variation of each state’s regulation, marijuana remains a Schedule 1 drug on the United States Drug Enforcement Administration’s list of controlled substances. All healthcare providers must be aware of the state’s specific reporting requirements where they provide care.    

 So how does marijuana act on the body?

THC is a small and highly lipophilic molecule – meaning that it tends to combine with or dissolve in lipids or fats. Once inhaled or ingested, it is distributed rapidly to the brain and fat in the body. It binds to the cannabinoid receptors in the brain to produce a variety of effects including the euphoria that I mentioned, as well as intoxication, memory, and motor impairments. THC is metabolized by the liver and the half-life (or the length of time required for the concentration in the body to decrease to half of its starting dose) varies between 20-36 hours in occasional users to 4-5 days in heavy users sometimes taking up to 30 days for the body to completely excrete the drug (Committe on Obstetric Practice, 2017). 

So, how exactly does marijuana use by a pregnant woman impact her, the growing fetus, and the future of the child? 

Using marijuana during pregnancy can affect the baby’s development and place the mother at an increased risk for pregnancy complications whether it is with smoking, vaping, dabbing, eating, drinking, or by applying creams or lotions to the skin (CDC, 2020).  THC has been shown to rapidly cross the placenta. From there, it is distributed rapidly to the fetal brain and the fat of the fetus. After maternal ingestion, concentrations of THC in the fetal blood are approximately one-third to one-tenth of maternal concentrations (Ryan et al., 2018). 

Marijuana binds to the cannabinoid receptors, type 1 and 2 that are part of the endocannabinoid system (ESC) (Raypole, 2019). The endocannabinoid system consists of the endogenous cannabinoids (endocannabinoids) or molecules made by your body that are similar to cannabinoids, but they’re produced by your body (Raypole, 2019). During fetal development, marijuana binds to endocannabinoids and cannabinoids which are the same receptors critical for fetal brain development (Lo J et al., 2022).

Animal studies have shown that endocannabinoids play key roles in normal fetal brain development which involves neurotransmitter systems and neuronal development (Committee on Obstetric Practice, 2017). The neurons in our body are important information messengers that use electrical and chemical signals to send different information between areas of the brain, spinal cord, and our entire body. Neuronal development in the brain begins around the 5th week of gestation which includes neuronal proliferation, migration, differentiation and survival (Ackerman, 1992). To simply break it down, neurons have rapid growth followed by migration of the cells toward their predetermined location. The process of differentiation or specification programs the cells for their future course of development. To give you an idea of how rapidly the nerve cells proliferate, in a 12- to 14- week embryo, nerve cells proliferate at a rate of about 15 million per hour (Ackerman, 1992). The process continues even after the infant is born, then around 18 months of age, neurons are not added anymore and the grouping of cell types into their specific regions is essentially complete (Ackerman, 1992). The receptors in the fetus that are impacted by marijuana use during pregnancy are part of the endocannabinoid system, which impacts the formation of brain circuits that are crucial for decision-making, mood, and how someone responds to stress (HHS, 2019). Therefore, cannabinoids do affect the developing fetal brain and impact the important process of neuronal development in the brain.  

What has the evidence shown regarding the use of marijuana during pregnancy and its future implications on the growing infant, child, and their transition into the teenage years, and as an adult after prenatal exposure?

The Colorado Pregnancy Risk Assessment Monitoring System reported that maternal marijuana use was associated with a 50% increased risk of low birth weight or a weight less than 2,500 grams regardless of maternal age, race, ethnicity, education, and tobacco use (Crume et al., 2018). Therefore, half of the women who use marijuana will have a low birth weight infant. This in turn brings on a whole other slew of complications that also increase the infant’s risk of requiring a NICU admission as they may struggle with low oxygen levels, respiratory distress, difficulties with feedings, trouble gaining weight, and maintaining blood sugars and body temperature. Low birth weight infants are also at an increased risk for infection, nervous system complications, digestive problems, and sadly SIDS.

The Avon Longitudinal Study also found an association between prenatal marijuana use and lower birth weights, smaller birth lengths and head circumferences when compared to women in the control group who did not report use (Fergusson et al., 2017). 

Impact of marijuana use on the pregnant woman

In other studies they found that women who used any marijuana during pregnancy had a higher likelihood of developing anemia, or a low red blood cell count which can lead to a reduction in oxygen flow to the rest of the organs (Ryan et al., 2018). Additionally, its use increases the risk of preterm labor. A recent study that was published in 2019 by Corsi et al., found that reported use of cannabis during pregnancy significantly increases the risk of preterm birth at 12% versus 6% for nonusers. Obviously with a preterm birth, it will likely require admission to the NICU and the infant is at an increased risk of developing an infection, breathing problems, feeding difficulties, developmental delays, cerebral palsy, vision problems, learning disabilities, hearing problems, growth, and so much more.  

Literature review of how prenatal marijuana exposure impacts the child’s future development.

There are two longitudinal studies, the Ottawa Prenatal Prospective Study (OPPS) and the Maternal Health Practices and Child Development Study (MHPCD) that have observed children who were prenatally exposed to marijuana from infancy through adolescence and early adulthood. 

Fried, P. (1995), reviewed the findings from the OPPS study where they observed infants since 1978 and found that prenatally exposed children had lower scores in verbal reasoning and memory tasks at the age of 4. Children have also shown deficits in global measures of language comprehension, memory, visual and/or perceptual function, and reading tasks that require sustained attention at 6 years of age. The exposed children also had lower scores on tests of visual problem-solving, visual-motor coordination, and visual analysis when compared to children who were not exposed in utero. Additionally, children that were exposed to higher amounts of marijuana prenatally have shown a higher level of dysfunction on impulsive and hyperactive scales. Children in the study between the ages of 9-12 who were prenatally exposed to marijuana had deficits in executive function tasks including impulse control and visual problem-solving. At the age of 13-16 years, problems were seen in attention, problem-solving, visual integration, and analytic skills requiring sustained attention if they were exposed to marijuana in utero. Participants also had higher rates of depressive symptoms at the ages of 16-21. A functional MRI study of this sample at ages 18 through 22 revealed changes in neural activity with working memory tasks that were not observed in matched children who were not exposed. 

Day et al., (2011), reviewed the Maternal Health Practices and Child Development Study (MHPCD) where they observed exposed infants since 1982 and reported similar findings. Additionally this study found that the children had deficits in intellectual abilities and on measurements of standardized academic tests at ages 6-9 and 13-16 years. They found lower reading and spelling scores in 10-year old children whose mothers reported smoking at least one joint per day during the first trimester. This study also found an increased risk of psychosis in young adults. 

Both studies found problem behaviors, mental health symptoms, and sadly higher rates of future substance use. So as you can see, cannabinoid exposure during early fetal developmental stages can result in negative, long-term neurobehavioral problems. 

Recommendations from professional organizations

The American Academy of Pediatrics (AAP), the American College of Obstetrics and Gynecology (ACOG), and the American Society of Addiction Medicine all recommend that all women considering pregnancy or those who are pregnant should be screened routinely for alcohol and other drug use, including marijuana throughout their pregnancy (Ryan et al., 2018). 

ACOG advises against the use of marijuana during preconception, pregnancy, and lactation “because of concerns regarding impaired neurodevelopment, as well as maternal and fetal exposure to the adverse effects of smoking.” They have a great website page that specifically addresses marijuana and pregnancy and why they advise against its use.

There is concern, though, that the laws that criminalize drug use during pregnancy have the potential to deter women from seeking prenatal and maternity care. Because of this, the Association of Women’s Health, Obstetrics and Neonatal Nurses (AWHONN) supports the implementation of legislation, policies, and public health initiatives that help to expand research, raise awareness, remove stigma, discourage use, and facilitate access to prenatal and maternity care for women who use marijuana so they continue to seek care.  

The American Academy of Pediatrics (AAP) also discourages the use of cannabis during breastfeeding because of concerns with short- and long-term neurobehavioral development in the infant (Ryan et al., 2018). 

Marijuana and breastfeeding: Does it cross into the milk?

So, you may be wondering, with marijuana use by breastfeeding mothers, does it cross into the milk, can it impact the infant? If so, what are the short and long-term outcomes for children exposed to breastmilk from a mother who smokes marijuana? 

However, as you likely know, providing human milk is recommended and one of the best ways to improve outcomes for all children. The AAP recommends breastfeeding and human milk as the standard of care for infant feeding given the substantial evidence of health and psychosocial benefits. Infants who receive human milk, especially if they are born premature, have a decreased risk of infections, gastroenteritis, ear infections, severe respiratory diseases plus so much more (Ryan et al., 2018). 

For much more information on breastfeeding, milk expression, and the barriers that are common for NICU Mothers please go back and listen to our 47th episode: 

Episode #47: Breaking Down the Milk Expression and Breastfeeding Barriers Common to NICU Mothers

Or if you’d like to learn more about the AMAZING composition of breastmilk and how preterm, term, and donor breast milk varies, you will love episode 48.

Episode #48: The Composition of Human Breast Milk: How Does Preterm, Term, and Donor Milk Vary?

But, we know that the main psychoactive component of cannabis, THC is excreted into breast milk. It is evident that depending on the chronicity of the mother’s cannabis use, breast milk can actually have up to 8 times the THC concentration of the mother’s plasma (Davis et al., 2020). The concentration of THC in breast milk is variable and ranges between 0.4% and 8.7% of the maternal dose (Davis et al., 2020). 

THC is stored in body fat and slowly released over time, meaning an infant could be exposed to an unknown amount and for an extended period of time (CDC, 2023). Various studies have shown that the length of time that THC can be detected in human milk has ranged from 6 days to greater than 6 weeks. A pharmacokinetic model which looks at the movement of drugs in the body predicted a half-life of 39 hours, which is consistent with a clearance of THC from the body in 8 days (U.S. National Library of Medicine, 2023).

In a study published in 2018 by Bertrand et al., THC was measurable in the majority of breast milk samples up to ~ 6 days after maternal marijuana use. Therefore, the theory of pumping and dumping after cannabis use in an attempt to minimize the infant’s exposure is not effective.  

Just as when the fetus was exposed in utero, with THC in the breast milk, it may affect the infant’s brain development and negatively affect a variety of neurodevelopmental processes resulting in hyperactivity, poor cognitive function, and additional long-term consequences. A systematic review of 6 studies found marijuana exposure in breast milk to be associated with decreased motor development in infants at 1 year of age (Seabrook, 2017).

Additionally, studies have shown that marijuana exposure can reduce breast milk production due to its possible direct effects on the mammary glands and through a decrease in prolactin (Davis et al., 2020). 

Unfortunately, the long-term implications of children who receive breast milk from THC positive women is unknown and we hope that future research provides more clarity. 

Due to the lack of studies on the long-term effects on infant’s exposed to marijuana through breastmilk, the professional guidelines recommend that the use of cannabis should be avoided by nursing mothers. The National Guidelines for breastfeeding in the setting of marijuana includes recommendations from the Centers for Disease Control (CDC), ACOG, AAP, and the Academy of Breastfeeding Medicine which all endorse that nursing mothers should abstain from or significantly reduce marijuana use. 

Additionally, marijuana should not be smoked by anyone in the vicinity of the baby. Marijuana smoke contains many of the same harmful chemicals as tobacco smoke (CDC, 2020). If the infant is exposed to the smoke, they are at an increased risk of sudden infant death syndrome (SIDS). Also, a parent or caregiver who is under the influence of marijuana while caring for the baby may miss hunger cues and not pay sufficient attention to the baby and other children. The effects of cannabis products can last for several hours potentially impairing a caregiver’s ability to react appropriately to situations with children.  

Overall recommendations

Overall, it is recommended that women who are considering becoming pregnant to be fully educated on the potential adverse effects of marijuana use on the woman herself, fetal, infant, and child development. Pregnant women who are using marijuana or other cannabinoid products should be counseled on the possible adverse effects, be encouraged to abstain during the pregnancy, and supported through that process.

And although marijuana is legal in some states, pregnant women who use marijuana may be subject to child welfare investigations if they have a positive marijuana screening – but, it is with the intent to provide supportive treatment for the mother and her child rather than to punish or prosecute her (Ryan et al., 2018). Additionally, marijuana use while breastfeeding is not recommended due to the potential risks to the infant. Parents should also not smoke marijuana around the infant due to the risk of smoke exposure.  

Closing

I truly hope that you found this episode helpful! I know that after my research, I definitely learned new information! Although marijuana is legal in so many states, we must not forget its potency and impact on those that use it, but especially on the growing fetus’ neuronal and brain development. Additionally, a fetus exposed to marijuana has a higher risk as a child and teenager of developing some of the long-term implications including, but not limited to decreased attention span, persistent behavioral problems and cognitive deficits.

Please consider stopping or minimizing your marijuana use if you are either pregnant or considering becoming pregnant. Marijuana is not a benign drug – its use may negatively impact you and the future of your child. So talk to your healthcare provider about your marijuana use so you can get additional support and help throughout your pregnancy and during the postpartum period if you plan to breastfeed your infant. 

And please, if you are caring for an infant or other children, abstain from marijuana use as it can negatively affect your ability to react to their needs in a timely and efficient manner. Because the effects from marijuana can last for several hours, your child’s safety, development, and overall well-being can be negatively impacted. 

For healthcare providers, it is essential that you know the state’s legislation and policies where you provide care. The information is ambiguous and always changing, so it is important to stay up-to-date so you know how to proceed with the care you provide and your responsibilities for reporting. 

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References

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Associations of Women’s Health, Obstetric and Neonatal Nurses. (2018). Marijuana use during pregnancy. Journal of Obstetric, Gynecology, and Neonatal Nursing, 47(5), P719-721. 

Associations of Women’s Health, Obstetric and Neonatal Nurses. (2019, August 30). AWHONN’s response to surgeon general health advisory on marijuana use by pregnant women. Retrieved from https://www.awhonn.org/awhonns-response-to-surgeon-general-health-advisory-on-marijuana-use-by-pregnant-women/

Bertrand, K., Hanan, N., Honerkamp-Smith, G., Best, B., & Chambers, C. (2018). Marijuana use by breastfeeding mother and cannabinoid concentrations in breast milk. Pediatrics, 142(3). 

Bishop, D., Borkowski, L., Couillard, M., Allina, A., Baruch, S., & Wood, S. (2017). Bridging the Divide White Paper: Pregnant Women and Substance Use: Overview of Research & Policy in the United States. Jacobs Institute of Women’s Health, https://hsrc.himmelfarb.gwu.edu/sphhs_centers_jacobs/5/

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Remember, once empowered with knowledge, you have the ability to change the course.