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Copyright MotherJourney/Laurel Wilson 2019
Handout – Top TakeawaysUp In Smoke: The Potential Long Term Impact of Cannabis Use During Perinatal Period
Laurel Wilson, IBCLC, RLC, BSc,CLE, CCCE, [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
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• DHHS wrote a patent on Cannabinoids – antioxidants and neuro-protectant• FDA approved medicines made with THC and CBD• NASEM recognizes medicinal effects
The National Academy of Science, Engineering and Medicine found that:• There is conclusive or substantial evidence that cannabis
or cannabinoids are effective:• For chronic pain in adults • Antiemetics in the treatment of chemotherapy-induced nausea
and vomiting• Multiple sclerosis spasticity symptoms • There is moderate evidence that cannabis or
cannabinoids are effective for:• Improving short-term sleep outcomes • There is limited evidence that cannabis or cannabinoids
are effective for:• Increasing appetite and decreasing weight loss associated
with HIV/AIDS• Symptoms of Tourette syndrome• Anxiety symptoms• PTSD
Two strains used for medicinal and recreational purposes:Cannabis Sativa and Cannabis Indica.
Forms of Use:Dried Herb, Hashish, Marijuana Oil, Concentrates, Edibles, Salves
Prescription Forms:Dronabinol (Synthetci THC), Marinol (Synthetic THC), Sativex (Synthetic THC and CBD)
Do Not Confuse Cannabis with K2 or Spice – very dangerous
Cannabis contains more than 400 chemicals and @ 60 Cannabinoids (phytocannabinoids) including THC, CBD, CBN, CBG and terpenes
THC ∆9 -tetrahydrocannabinol
• THC effects: Psychoactive, Euphoria, Analgesic, Antibacterial, Antiemetic, Anti-tumoral, Bronchodilator, Appetite Stimulant, Neuroprotective (medium doses), Sleep Inducing, Anticonvulsant, Muscle Relaxant, Immuno-modulating
• THC - First 11 Hydroxy THC (psychoactive) first main metabolite of THC
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• Then Nor-9-Carboxy THC (non active)(Nonpsychoactive)• Carboxy THC stays in the body, is lipophilic• THESE ARE THE NON ACTIVE METABOLITES.• Hangs out in body from days to up to 4 weeks• THC metabolized in blood, and Carboxy THC is excreted
through urine (20-35%) and feces (60-85%)• Elimination life 20-38 hours, chronic users up to 4 days
CBD- Cannabidiol• CBD Effects – Neuroprotection, Anticonvulsant, Analgesia,
Sedation, Antiemetic, Antispasmodic, Anti-inflamatory, Antianxiety
Molecules 101 handout from Elephant Circle www.elephantcircle.net
Major Concern- Pesticides• Many grow houses using pesticides approved only for outdoor
use on indoor • Because EPA can only regulate federally approved substances,
Cannabis is not included• Some states allow 75-200 pesticides• Five most common banned substances found in raids
• Myclobutanil - “Bad Actor”• Imidacloprid - “moderately hazardous• Abamectin and the avermectin chemical family - “Bad
Actor,”• Etoxazole• Spiromesifen
Endocannbinoid System – CB1 and CB2 receptors• Impacts: Learning and memory, Anxiety, Depression,
Addiction, Appetite, Neuro-protection
When using THC:• Hypocampus/Hypothalamus
• Hunger• Feelings of hunger
• Hippocampus• Short term memory• Lack of memory
• Cerebellum• Coordination• Lack of coordination
• Amygdala• Learn to fear• Become Paranoid
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• Limbic System• Dopamine• Feel pleasure
Perinatal Use in Animal Studies:• Disrupts EC Signaling• Alters dopamine, seratonin, and opiod receptors• Disrupts Synaptogenesis
Wang, 2004• 42 postmortem fetal brain samples (from saline induced
abortions)• Decrease in dopamine receptor (D2) mRNA expression in
amygdala• Significant prevalence in males• Chronic use association with low mRNA levels
Comparison of population studies:• OPPS
• 1978• Ottowa, CA• MJ and tobacco• Low Risk, Euro-Amer, Middle Class• Gest Age Red.• No diff in BW
• MHPCD• 1982• Pittsburg, PA• MJ and alcohol• High Risk, Mixed Ethnicity, Low socioeconomic• Birth length reduced after 1st tri exp• Inc. BW after 3rd Tri. Exp.
• Gen R• 2001• Netherlands• Many substances• Multiethnic, higher• socioeconomic class• Fetal growth reduced after from 2nd tri on• Reduced BW
Infant Behavior• OPPS
• Inc. startles and tremors• Red. habituation to light
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• 48 mo. Lower memory and verbal skills• MHPCD
• No diff. in neonatal beh.• 36 Mo. Lower short term memory and verbal skills
• Gen R• 2001• Netherlands• 36 mo. No differences
Child Behavior• OPPS
• More impulsivity and hyperactivity• Impaired visuo-perception func.
• MHPCD• More impulsivity and hyperactivity• Inattention, delinquency
• Gen R• Not yet examined
Adult Behavior• OPPS
• Response Inhibition• Alters neural
functioning during visuo-spatial working memory processing
• MHPCD• Not yet examined
• Gen R• Not yet examined
Ottowa Prenatal Prospective Study, OPPSMaternal Health Practices and Child Development Study, MHPCDGeneration R Study, GEN R
Gunn, 2016• Infants were more likely to be anemic, have lower birth
weight, and require placement in NICU • HOWEVER, insufficient evidence to support or refute a
statistical association between maternal cannabis smoking and later outcomes in the offspring
• Women used alcohol and/or tobacco during pregnancy. Thus it is not clear to what extent outcomes were related to marijuana use alone, or a combination of marijuana, alcohol, and tobacco
Crume, 2018
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50% increased risk of low birth weight (also tobacco users) No increased risk for SGA, preterm birth, and NICU stay
2014 Colorado TriCounty Survey• 5.9% WIC participants were Cannabis users
• Depression/Anxiety/Stress 63%• Pain relief 60%• Nausea/Vomiting 48%• Fun and recreation 40%• Other 14%
Dr. Baker and Hale Study 2018 Transfer of Inhaled Cannabis into Breastmilk 2018
• Abstained 24 hours• 0.1 g of containing 23.18% THC – with a new glass pipe
Prezidential Kush Sativa• Smoked (3-4 hits over 10-20 minutes) and pumped at 20
minutes and 1, 2, and 4 hours • Relative infant dose 2.5% of maternal dose• Peaked at 1 hour, with a peak of 94 ng/mL (range 12.2–
420.3 ng/mL), and receded slowly over the subsequent 4 hours.
Questions after study:• What is the plasma level in the breastfeeding infant?• What effect would repeated and continuous doses have on
breast milk concentrations? • What about transfer with use of oral cannabis products? • What do cannabis products do to the endocannabinoid
system? • What is the lasting effect of exposing developing infants to
cannabis?
Potential concerns for babies:• Increase risk SIDS if smoking• Positive urine screens (up to two weeks after exposure)• Potential double exposure• May cause epigenetic damage• Potential for exposure to other drugs. Marijuana not always
“clean”
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Pediatrics – Bertrand Study Marijuana Use by Breastfeeding Mothers and Cannabinoid Concentrations in Breast Milk• 54 Samples - exposure in past 14 days• 88% daily use• 64% primarily inhaled• Lower detection rate >1 ng/ml (Baker > 5 ng/ml)• Date not based on dosing, but self reporting• 20/54 no THC• Median THC conc. = 9.47 ng/mL (range = 1.01 – 323)• 11-OH-THC was detected in 5 samples• CBD was detected in 5 samples• RID 2.5 (1000 lower than adult dose)
What do we know from these two studies:• RID 2.5 (1000 lower than adult dose)• (Oral Bioavailablity is still 1-5%)• Peak levels seem to be 60-120 minutes post use• Half life of THC in milk is about 1 day• Metabolism can vary dramatically
What do Experts/Orgs/Journals Say?
Academy of Breastfeeding Medicine Statement #9, 2015• Counsel those who admit use• Strongly advise those with positive urine screen
• Avoid or reduce use• Advise on long-term neurobehavioral risks
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• Avoid direct exposure of smoke to infant• Take into careful consideration and counsel on the
potential risks of exposure of marijuana and benefits of breastfeeding to the infant.
• Careful consideration of the risks versus benefits of breastfeeding in the setting of moderate or chronic marijuana use
• At this time, although the data are not strong enough to recommend not breastfeeding with any marijuana use, we urge caution.
Obstet Gynecol 2013• Due to the potential for breastfeeding to mitigate some of
the effects of smoking and little evidence of serious infant harm, it appears preferable to encourage mothers who use marijuana to continue breastfeeding, but minimize infant exposure to marijuana smoke and reducing marijuana use. (Hill, 2013)
Hill Reed 2017• If a woman is going to smoke tobacco, she should be
encouraged to continue breastfeeding. There is a lack of evidence to suggest that the recommendation to a mother who uses marijuana should be any different.
Infant Risk Site
Healthy Children AAP 2018• American Academy of Pediatrics (AAP) clinical report,
"Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes" recommends women who are pregnant or breastfeeding avoid marijuana use. The American College of Obstetricians and Gynecologists (ACOG) also recommends that obstetrician-gynecologists counsel
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women against using marijuana while trying to get pregnant, during pregnancy, and while they are breastfeeding.
ACOG Committee Opinion #722 10/2017 “Obstetrician–gynecologists should be discouraged from prescribing or suggesting the use of marijuana for medicinal purposes during preconception, pregnancy, and lactation. Pregnant women or women contemplating pregnancy should be encouraged to discontinue use of marijuana for medicinal purposes in favor of an alternative therapy for which there are better pregnancy-specific safety data. There are insufficient data to evaluate the effects of marijuana use on infants during lactation and breastfeeding, and in the absence of such data, marijuana use is discouraged.”
LactMed/NIH• “…it appears preferable to encourage mothers who use
marijuana to continue breastfeeding while minimizing infant exposure to marijuana smoke and reducing or abstaining from marijuana use...”
Clinical Considerations• Benefit of drug for mother • Impact of not taking med for mother and infant• Impact of drug on milk supply • Quantity of drug infant receives • Impact of drug exposure on infant • Risk of NOT breastfeeding
Open Ended Questions/CounselingASK - Open Ended Questions• Ask about Marijuana use with non-judgmental approach.• Ask about freq and amount of use.• Ask why she is using?• Ask about care for child when use occurs.• Ask if mother is open to alternative forms of medicationAFFIRM• Let the mother know she is not alone in her feelings.• Let the mother know that her reasons for using are
understood, but there are other options.• Validate the mothers feelings without validating her choice
of substance use.
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COUNSEL• Educate on potential risks of use• Talk to mother about alternatives during breastfeeding• Offer services/counseling/cognitive behavior therapy• Suggest specific screening for developmental milestone• Depending on chronic or occasional use – advise appropriately
Families Need Help?• Family Law and Cannabis Alliance flcalliance.org• National Advocates for Pregnant Women advocatesforpregnantwomen.org • Elephant Circle elephantcircle.net
References and Resources:www.motherjourney.com
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