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Copyright MotherJourney/Laurel Wilson 2019 Should not be shared/duplicated without permission, [email protected] Handout – Top Takeaways Up In Smoke: The Potential Long Term Impact of Cannabis Use During Perinatal Period Laurel Wilson, IBCLC, RLC, BSc,CLE, CCCE, CLD www.motherjourney.com [email protected] For list of references/resources/additional information, please visit: http://motherjourney.com/marijuana-and-breastfeeding.html Objectives: • Identify the two active cannabinoids found in cannabis of potential concern during pregnancy and breastfeeding. • Identify two potential risks to the developing baby for prenatal and postpartum exposure to cannabis. • State at least two open ended questions to use when discussing marijuana use and breastfeeding with their clients/patients. Takeaways: Cannabis is the most commonly used illicit substance among pregnant women in Western societies. Legal use in 9 states, all but four states have some form of legalization. Use of Cannabis during Perinatal period: • 3.9% of pregnant women used in past month and 7.0% used in past 2-12 months marijuana* • Past year users 16.2% were daily users* • Self reported use 5.7% in pregnancy and 5% during lactation** Considered a Schedule 1 Substance Federally - A dangerous substance with a high potential for abuse and no valid medical purpose Schedule 1 Challenges • American Medical Institute • Institute of Medicine NOTES
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Handout–TopTakeawaysUpInSmoke:ThePotentialLongTermImpactofCannabisUseDuringPerinatalPeriodLaurelWilson,IBCLC,RLC,BSc,CLE,CCCE,CLDwww.motherjourney.cominfo@motherjourney.comForlistofreferences/resources/additionalinformation,pleasevisit:http://motherjourney.com/marijuana-and-breastfeeding.htmlObjectives:• Identifythetwoactivecannabinoidsfoundincannabisof
potentialconcernduringpregnancyandbreastfeeding.• Identifytwopotentialriskstothedevelopingbabyfor
prenatalandpostpartumexposuretocannabis.• Stateatleasttwoopenendedquestionstousewhen
discussingmarijuanauseandbreastfeedingwiththeirclients/patients.
Takeaways:
CannabisisthemostcommonlyusedillicitsubstanceamongpregnantwomeninWesternsocieties.Legalusein9states,allbutfourstateshavesomeformoflegalization.UseofCannabisduringPerinatalperiod:• 3.9%ofpregnantwomenusedinpastmonthand7.0%used
inpast2-12monthsmarijuana*• Pastyearusers16.2%weredailyusers*• Selfreporteduse5.7%inpregnancyand5%during
lactation**ConsideredaSchedule1SubstanceFederally-AdangeroussubstancewithahighpotentialforabuseandnovalidmedicalpurposeSchedule1Challenges• AmericanMedicalInstitute• InstituteofMedicine
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• DHHSwroteapatentonCannabinoids–antioxidantsandneuro-protectant• FDAapprovedmedicinesmadewithTHCandCBD• NASEMrecognizesmedicinaleffects
TheNationalAcademyofScience,EngineeringandMedicinefoundthat:• Thereisconclusiveorsubstantialevidencethatcannabis
orcannabinoidsareeffective:• Forchronicpaininadults• Antiemeticsinthetreatmentofchemotherapy-inducednausea
andvomiting• Multiplesclerosisspasticitysymptoms• Thereismoderateevidencethatcannabisor
cannabinoidsareeffectivefor:• Improvingshort-termsleepoutcomes• Thereislimitedevidencethatcannabisorcannabinoids
areeffectivefor:• Increasingappetiteanddecreasingweightlossassociated
withHIV/AIDS• SymptomsofTourettesyndrome• Anxietysymptoms• PTSD
Twostrainsusedformedicinalandrecreationalpurposes:CannabisSativaandCannabisIndica.FormsofUse:DriedHerb,Hashish,MarijuanaOil,Concentrates,Edibles,SalvesPrescriptionForms:Dronabinol(SynthetciTHC),Marinol(SyntheticTHC),Sativex(SyntheticTHCandCBD)DoNotConfuseCannabiswithK2orSpice–verydangerousCannabiscontainsmorethan400chemicalsand@60Cannabinoids(phytocannabinoids)includingTHC,CBD,CBN,CBGandterpenesTHC∆9-tetrahydrocannabinol• THCeffects:Psychoactive,Euphoria,Analgesic,Antibacterial,
Antiemetic,Anti-tumoral,Bronchodilator,AppetiteStimulant,Neuroprotective(mediumdoses),SleepInducing,Anticonvulsant,MuscleRelaxant,Immuno-modulating
• THC-First11HydroxyTHC(psychoactive)firstmainmetaboliteofTHC
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• ThenNor-9-CarboxyTHC(nonactive)(Nonpsychoactive)• CarboxyTHCstaysinthebody,islipophilic• THESEARETHENONACTIVEMETABOLITES.• Hangsoutinbodyfromdaystoupto4weeks• THCmetabolizedinblood,andCarboxyTHCisexcreted
throughurine(20-35%)andfeces(60-85%)• Eliminationlife20-38hours,chronicusersupto4days
CBD-Cannabidiol• CBDEffects–Neuroprotection,Anticonvulsant,Analgesia,
Sedation,Antiemetic,Antispasmodic,Anti-inflamatory,Antianxiety
Molecules101handoutfromElephantCirclewww.elephantcircle.netMajorConcern-Pesticides• Manygrowhousesusingpesticidesapprovedonlyforoutdoor
useonindoor• BecauseEPAcanonlyregulatefederallyapprovedsubstances,
Cannabisisnotincluded• Somestatesallow75-200pesticides• Fivemostcommonbannedsubstancesfoundinraids
• Myclobutanil-“BadActor”• Imidacloprid-“moderatelyhazardous• Abamectinandtheavermectinchemicalfamily-“Bad
Actor,”• Etoxazole• Spiromesifen
EndocannbinoidSystem–CB1andCB2receptors• Impacts:Learningandmemory,Anxiety,Depression,
Addiction,Appetite,Neuro-protectionWhenusingTHC:• Hypocampus/Hypothalamus
• Hunger• Feelingsofhunger
• Hippocampus• Shorttermmemory• Lackofmemory
• Cerebellum• Coordination• Lackofcoordination
• Amygdala• Learntofear• BecomeParanoid
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• LimbicSystem• Dopamine• Feelpleasure
PerinatalUseinAnimalStudies:• DisruptsECSignaling• Altersdopamine,seratonin,andopiodreceptors• DisruptsSynaptogenesis
Wang,2004• 42postmortemfetalbrainsamples(fromsalineinduced
abortions)• Decreaseindopaminereceptor(D2)mRNAexpressionin
amygdala• Significantprevalenceinmales• ChronicuseassociationwithlowmRNAlevels
Comparisonofpopulationstudies:• OPPS
• 1978• Ottowa,CA• MJandtobacco• LowRisk,Euro-Amer,MiddleClass• GestAgeRed.• NodiffinBW
• MHPCD• 1982• Pittsburg,PA• MJandalcohol• HighRisk,MixedEthnicity,Lowsocioeconomic• Birthlengthreducedafter1sttriexp• Inc.BWafter3rdTri.Exp.
• GenR• 2001• Netherlands• Manysubstances• Multiethnic,higher• socioeconomicclass• Fetalgrowthreducedafterfrom2ndtrion• ReducedBW
InfantBehavior• OPPS
• Inc.startlesandtremors• Red.habituationtolight
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• 48mo.Lowermemoryandverbalskills• MHPCD
• Nodiff.inneonatalbeh.• 36Mo.Lowershorttermmemoryandverbalskills
• GenR• 2001• Netherlands• 36mo.Nodifferences
ChildBehavior• OPPS
• Moreimpulsivityandhyperactivity• Impairedvisuo-perceptionfunc.
• MHPCD• Moreimpulsivityandhyperactivity• Inattention,delinquency
• GenR• Notyetexamined
AdultBehavior• OPPS
• ResponseInhibition• Altersneural
functioningduringvisuo-spatialworkingmemoryprocessing
• MHPCD• Notyetexamined
• GenR• Notyetexamined
OttowaPrenatalProspectiveStudy,OPPSMaternalHealthPracticesandChildDevelopmentStudy,MHPCDGenerationRStudy,GENRGunn,2016• Infantsweremorelikelytobeanemic,havelowerbirth
weight,andrequireplacementinNICU• HOWEVER,insufficientevidencetosupportorrefutea
statisticalassociationbetweenmaternalcannabissmokingandlateroutcomesintheoffspring
• Womenusedalcoholand/ortobaccoduringpregnancy.Thusitisnotcleartowhatextentoutcomeswererelatedtomarijuanausealone,oracombinationofmarijuana,alcohol,andtobacco
Crume,2018
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• 50%increasedriskoflowbirthweight(alsotobaccousers)• NoincreasedriskforSGA,pretermbirth,andNICUstay
2014ColoradoTriCountySurvey• 5.9%WICparticipantswereCannabisusers
• Depression/Anxiety/Stress63%• Painrelief60%• Nausea/Vomiting48%• Funandrecreation40%• Other14%
Dr.BakerandHaleStudy2018TransferofInhaledCannabisintoBreastmilk2018• Abstained24hours• 0.1gofcontaining23.18%THC–withanewglasspipe
PrezidentialKushSativa• Smoked(3-4hitsover10-20minutes)andpumpedat20
minutesand1,2,and4hours• Relativeinfantdose2.5%ofmaternaldose• Peakedat1hour,withapeakof94ng/mL(range12.2–
420.3ng/mL),andrecededslowlyoverthesubsequent4hours.
Questionsafterstudy:• Whatistheplasmalevelinthebreastfeedinginfant?• Whateffectwouldrepeatedandcontinuousdoseshaveon
breastmilkconcentrations?• Whatabouttransferwithuseoforalcannabisproducts?• Whatdocannabisproductsdototheendocannabinoid
system?• Whatisthelastingeffectofexposingdevelopinginfantsto
cannabis?Potentialconcernsforbabies:• IncreaseriskSIDSifsmoking• Positiveurinescreens(uptotwoweeksafterexposure)• Potentialdoubleexposure• Maycauseepigeneticdamage• Potentialforexposuretootherdrugs.Marijuananotalways
“clean”
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Pediatrics–BertrandStudyMarijuanaUsebyBreastfeedingMothersandCannabinoidConcentrationsinBreastMilk• 54Samples-exposureinpast14days• 88%dailyuse• 64%primarilyinhaled• Lowerdetectionrate>1ng/ml(Baker>5ng/ml)• Datenotbasedondosing,butselfreporting• 20/54noTHC• MedianTHCconc.=9.47ng/mL(range=1.01–323)• 11-OH-THCwasdetectedin5samples• CBDwasdetectedin5samples• RID2.5(1000lowerthanadultdose)
Whatdoweknowfromthesetwostudies:• RID2.5(1000lowerthanadultdose)• (OralBioavailablityisstill1-5%)• Peaklevelsseemtobe60-120minutespostuse• HalflifeofTHCinmilkisabout1day• Metabolismcanvarydramatically
WhatdoExperts/Orgs/JournalsSay?AcademyofBreastfeedingMedicineStatement#9,2015• Counselthosewhoadmituse• Stronglyadvisethosewithpositiveurinescreen
• Avoidorreduceuse• Adviseonlong-termneurobehavioralrisks
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• Avoiddirectexposureofsmoketoinfant• Takeintocarefulconsiderationandcounselonthe
potentialrisksofexposureofmarijuanaandbenefitsofbreastfeedingtotheinfant.
• Carefulconsiderationoftherisksversusbenefitsofbreastfeedinginthesettingofmoderateorchronicmarijuanause
• Atthistime,althoughthedataarenotstrongenoughtorecommendnotbreastfeedingwithanymarijuanause,weurgecaution.
ObstetGynecol2013• Duetothepotentialforbreastfeedingtomitigatesomeof
theeffectsofsmokingandlittleevidenceofseriousinfantharm,itappearspreferabletoencouragemotherswhousemarijuanatocontinuebreastfeeding,butminimizeinfantexposuretomarijuanasmokeandreducingmarijuanause.(Hill,2013)
HillReed2017• Ifawomanisgoingtosmoketobacco,sheshouldbe
encouragedtocontinuebreastfeeding.Thereisalackofevidencetosuggestthattherecommendationtoamotherwhousesmarijuanashouldbeanydifferent.
InfantRiskSite
HealthyChildrenAAP2018• AmericanAcademyofPediatrics(AAP)clinicalreport,
"MarijuanaUseDuringPregnancyandBreastfeeding:ImplicationsforNeonatalandChildhoodOutcomes"recommendswomenwhoarepregnantorbreastfeedingavoidmarijuanause.TheAmericanCollegeofObstetriciansandGynecologists(ACOG)alsorecommendsthatobstetrician-gynecologistscounsel
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womenagainstusingmarijuanawhiletryingtogetpregnant,duringpregnancy,andwhiletheyarebreastfeeding.
ACOGCommitteeOpinion#72210/2017“Obstetrician–gynecologistsshouldbediscouragedfromprescribingorsuggestingtheuseofmarijuanaformedicinalpurposesduringpreconception,pregnancy,andlactation.Pregnantwomenorwomencontemplatingpregnancyshouldbeencouragedtodiscontinueuseofmarijuanaformedicinalpurposesinfavorofanalternativetherapyforwhichtherearebetterpregnancy-specificsafetydata.Thereareinsufficientdatatoevaluatetheeffectsofmarijuanauseoninfantsduringlactationandbreastfeeding,andintheabsenceofsuchdata,marijuanauseisdiscouraged.”LactMed/NIH• “…itappearspreferabletoencouragemotherswhouse
marijuanatocontinuebreastfeedingwhileminimizinginfantexposuretomarijuanasmokeandreducingorabstainingfrommarijuanause...”
ClinicalConsiderations• Benefitofdrugformother• Impactofnottakingmedformotherandinfant• Impactofdrugonmilksupply• Quantityofdruginfantreceives• Impactofdrugexposureoninfant• RiskofNOTbreastfeeding
OpenEndedQuestions/Counseling
ASK-OpenEndedQuestions• AskaboutMarijuanausewithnon-judgmentalapproach.• Askaboutfreqandamountofuse.• Askwhysheisusing?• Askaboutcareforchildwhenuseoccurs.• AskifmotherisopentoalternativeformsofmedicationAFFIRM• Letthemotherknowsheisnotaloneinherfeelings.• Letthemotherknowthatherreasonsforusingare
understood,butthereareotheroptions.• Validatethemothersfeelingswithoutvalidatingherchoice
ofsubstanceuse.
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COUNSEL• Educateonpotentialrisksofuse• Talktomotheraboutalternativesduringbreastfeeding• Offerservices/counseling/cognitivebehaviortherapy• Suggestspecificscreeningfordevelopmentalmilestone• Dependingonchronicoroccasionaluse–adviseappropriately
FamiliesNeedHelp?• FamilyLawandCannabisAllianceflcalliance.org• NationalAdvocatesforPregnantWomenadvocatesforpregnantwomen.org• ElephantCircleelephantcircle.net
ReferencesandResources:[email protected]
