Marijuana/Cannabis Use and Breastfeeding: A Clinical Dilemma

By last count, 29 U.S. states and the District of Columbia have legalized marijuana (cannabis) for medicinal use. ¹ More to the point of the concern regarding cannabis use while breastfeeding is the reality that by mid-2017, seven U.S. states and the District of Columbia have legalized cannabis for recreational use. ² This development is despite the fact that the U.S. Federal government continues to categorize cannabis as a “Schedule I controlled substance.” Such schedule categorization per the United States Drug Enforcement Administration defines cannabis as having “no currently accepted medical use in treatment in the United States, a lack of accepted safety for use under medical supervision, and a high potential for abuse.”

Clearly, there is a disconnect between the United States Federal authorities' legal and presumed scientific view point and the growing contrary wave of individual state authorizations for the legal use of cannabis. This, no doubt, reflects on the one hand the reality of the rapid U.S. societal and cultural changes that are taking place on the ground and on the other hand the lack of hard data about the effect of both the short- and long-term exposure to cannabis. Likewise is the recent recommendations from various medical organizations and experienced clinicians that differ in their emphasis, reflecting the lack of evidence-based scientific information.^3–5

Thus the two articles in this issue of Breastfeeding Medicine addressing this issue are both timely and more than welcome. Mourth and colleagues review the literature with an emphasis on the applicability of the published information for clinical management decisions and as an updated practical guide for the front-line physicians managing the maternal–infant dyad. Mourh's article is complemented by Anderson's Lact Med column that details the pharmokinetic aspects of maternal cannabis exposure and potential of infant “ingestion” either through secondary environmental exposure or primarily by the feeding of mother's breast milk.

By and large, the current recommendations are that nursing mothers not “indulge” at all in cannabis use. However, the reality is that there is an increasing ubiquitous and acceptable use of cannabis by nursing mothers on the one hand and increasing documentation of health and developmental benefits of breastfeeding on the other hand. Thus, the recommended trade off for mothers is to continue with the nursing while minimizing as much as possible their cannabis indulgence.

Of importance is Anderson's analysis of the pharmokinetics of cannabis use that precludes a recommendation of spacing the time of milk intake and cannabis use (in contrast to what is recommended regarding maternal alcohol ingestion). The increased use of recreational cannabis (both legal and tolerated by authorities) also raises the question of the quality of donor milk that is being provided, especially to high-risk preterm infants. The reality of the increasing indiscriminate use of cannabis by all segments of our society should serve as a warning call to the indiscriminate use of donor milk from nonregulated milk banks or from “friends and relatives” whose cannabis use is not known or documented. The recent article of Joya et al. ⁶ provides a review of the various analytical methods available to detect “drugs of abuse,” including cannabis, and should serve as a guide for those who wish provide appropriate drug-free quality human milk to these infants

The flip side to our concern regarding unwelcome chemical additions to breast milk is the reality that breastfeeding infants do need supplementation of specific nonmacronutrients. This subject is summarized in this issue by Cai and colleagues who reviewed the need for iron supplementation in exclusively breastfed infants and by Naik and colleague who addressed the issue of vitamin D supplementation. At least regarding these two issues, we have data as opposed to its absence or inadequacy of data regarding the subject of cannabis and thus their recommendations are evidence based and should be heeded.