My near-and-dear colleague Nikki Lee challenges us not to over-react to
concerns about marijuana use and BFg, reminding us that "testing positive"
and "being high" are two different things.  We have "skewed attitudes about
this herb" because of films like 1936's Reefer Madness  (which ought,
honestly, to be declared something of a cult classic by now:
https://en.wikipedia.org/wiki/Reefer_Madness)

But families aren't smoking my grandma's weed any more than they are
watching (and believing) her over-the-top cult classic movies.  The stuff
that is out there today -- on the streets, or "craft-farmed" with
agricultural specificity in states that permit marijuana purchase and use
within their borders -- is way different and stronger than the stuff my
1970's college classmates were smoking.  Colorado has seen a 121% increase
in potency in the last 15 years.

My thinking about marijuana use during pregnancy and BFg has changed in
recent years. My interest was first piqued when I heard Tom Hale cautioning
so strongly against its use. He does not use L5 lightly.  So I figured I
better learn more.

(1) I listened to an excellent session at a conference by LLL-Mountain
Plains (Colorado) in Sept 2014, a state that has decriminalized marijuana
within its borders. The speaker was Kathryn Wells MD, who was part of that
state's multi-disciplinary gubernatorial panel established to do a survey
review of the literature, and to provide recommendations healthcare
providers could use when working with patients or clients using or exposed
to marijuana.

Their Guidance Document is now out (March 2015) and the CO Dept of Public
Health and the Environment (CODPHE) has a *hugely* helpful page, chock full
of links including a recorded webinar about marijuana use (see min. 14 for
BFg and marijuana use), handouts for patient use, one-pager of guidance for
HCPs to use in patient discusssion, a list of all the research they
reviewed.

They offered analysis of how "sound" the research was and the clinical
implications ... including their conclusion that there is no slam-dunk
evidence to indict marijuana, they are loathe to overstate any of the
evidence, and there are research gaps (including for BFg users).

However, enough is known ... with implications about what is not known ...
that CO says there is no safe level of marijuana use by pregnant or
breastfeeding parents. They are conducting research now that will look
specifically to BFg and marijuana use; should be available late 2015.

Their guidelines are excellent in that they encourage an early, thoughtful
risk-benefit discussion, with each individual patient/client .... rather
than relying on blanket Reefer Madness-type No messaging.  The idea is that
HCPs (should) do this with all patients who engage in any risky health
behavior ... marijuana use is no different.

Everyone should bookmark the CODPHE page, and freely surf their many useful
links: https://www.colorado.gov/pacific/cdphe/marijuana-clinical-guidelines

(2)  I listened to an excellent USLCA webinar by Laura Borgelt PharmD
(doctor of pharmacology): http://uslca.org/webinar/weed-n-feed. I was
firstly stunned to learn, cuz I had no idea, that our bodies have an
"endocannibinoid" system just like we have a lymph system and a central
nervous system.  It is a system seeking equilibrium, or homeostasis, with
receptors and "keys" that fit the receptor.

The endocannabinoid system develops at 14-19 weeks gestation; the fetal
brain has more CB1 receptors than an adult brain.  Exogenous cannabinoids
(like THC, found in marijuana) can stimulate our internal cannabinoid
receptors (CB1) ... and the idea is that the THC in marijuana -- which is
many-fold times stronger than the cannabinoids our bodies naturally produce
-- will hit those receptors like a sledgehammer (her term).  Cannabis
exposure during ppregnancy could interfere with the development of
"synaptogenesis" (synapses in the central nervous system).  And THC from
marijuana loves the fats in human milk, human cells and human brains --
accumulating because it takes so long to metabolize out.

The research on long-term effects of marijuana use by BFg parents is all
over the place, and often inherently unreliable since many studies rely on
self-reported use to define "amounts" smoked.  One decent one is the Ottawa
Prenatal Prospective Study, which defined "heavy use" as one joint a day.
They found there *may* be some memory function loss in babies of heavy
marijuana users. But they had better confidence of deficits in 6 y.o and 10
y.o. and young teen offspring of users ... who scored higher on
"impulsivity", poor spelling performance, imparied optical function and
hyper-reactivity.

Her conclusion, given THC's lipophilic nature (being 8X higher in mom's
milk over her blood, according to one early study), and the impact on brain
and nerve development that research is just hinting at, is that she "is not
comfortable with any marijuana use in pregnancy."

There are no easy answers here.  I encourage us not to assume, however,
that lack of evidence means no evidence.


Liz Brooks, JD, IBCLC, FILCA
Wyndmoor, PA, USA

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