Marijuana and Breastfeeding

Ryan, Ammerman, and O’Connor’s Clinical Report on “Marijuana Use During Pregnancy and Breastfeeding: Implications for Neonatal and Childhood Outcomes” was published recently in Pediatrics.  The report, co-authored by the American Academy of Pediatrics (AAP) Committee on Substance Use and Prevention and the AAP Section on Breastfeeding, summarizes data on the prevalence of marijuana use in women of childbearing age.  Overall, rates of marijuana use have increased in recent years, according to the National Survey on Drug Use and Health.  Pregnant women use marijuana less frequently than do nonpregnant women in the same age range.

Legalization of marijuana has made both inhaled and edible forms of marijuana more widely available and have decriminalized its use in certain US states.  Medical marijuana is available in an even larger number of states. Some women report using marijuana during pregnancy to combat nausea and vomiting, and this has been advocated in certain social media postings. Federal laws in the US still prohibit the use of marijuana. 

US Public Health guildelines should reflect evidence, not anecdote

In 2008, the United States Preventive Services Task Force issued the following recommendation with Grade B Evidence: “The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding.” Since that time, breastfeeding initiation, continuation, and exclusivity rates have continued to rise, and the number of hospitals designated as Baby Friendly has increased by almost 5-fold.  The ABM Position on Breastfeeding–Revised 2015 indicates that “breastfeeding is, and should be considered, normative infant and young child feeding” and “a human rights issue for both mother and child.”  ABM further states that “children have the right to the highest attainable standard of health,” and “as breastfeeding is both a woman’s and a child’s right, it is therefore the responsibility of the healthcare system . . . to inspire, prepare, and empower as well as support and enable each woman to fulfill her breastfeeding goals and to eliminate obstacles and constraints to initiating and sustaining optimal breastfeeding practices.” ABM calls for an improvement in breastfeeding promotion, protection and support and states that medical professionals have a responsibility to promote, protect, and support breastfeeding as a basic ethical principle.

The American Academy of Pediatrics, in its 2012 Policy Statement on Breastfeeding and the Use of Human Milk concludes that, “research and practice in the 5 years since publication of the last AAP policy statement have reinforced the conclusion that breastfeeding and the use of human milk confer unique nutritional and nonnutritional benefits to the infant and the mother and, in turn, optimize infant, child, and adult health as well as child growth and development. Recently, published evidence-based studies have confirmed and quantitated the risks of not breastfeeding. Thus, infant feeding should not be considered as a lifestyle choice but rather as a basic health issue. As such, the pediatrician’s role in advocating and supporting proper breastfeeding practices is essential and vital for the achievement of this preferred public health goal.”

Recently, the USPSTF proposed a new recommendation: “The USPSTF recommends providing interventions during pregnancy and after birth to support breastfeeding.”  Note that this statement does not state “promote and support,” but just “support.” The task force made a deliberate decision to delete the “promote” from the previous “promote and support.” The evidence review, however, does not support the proposed change. In explanations about this change, a member of the Task Force, Dr. Alex Kemper, as quoted in MedPage Today, stated that “the reason the Task Force made this slight word change is to recognize the importance of a mother doing what she feels is best for her and her baby and not wanting to, for example, make mothers feel guilty or bad if they decide not to breastfeed,” he said. “It’s really a personal choice that needs to be made based on her own personal situation.”

Should You Sleep Train Your Baby at 2 Months?

A Wall Street Journal article from May 2, 2016, “Can You Sleep Train Your Baby at 2 Months?, by Sumathi Reddi, a weekly consumer health column writer, quotes a pediatrician who routinely teaches parents to train babies to sleep through the night beginning at age 2 months. Dr. Michel Cohen bases his advice on the experience of training his own children a decade ago.  He encourages other pediatricians in his practice to follow the same advice. Dr. Cohen states that, “It actually works better at 2 months than at 4 months.”

Can you sleep train your baby at 2 months?  Perhaps.  Should you sleep train your baby at 2 months might be the better question.  Evidence on infant sleep and development does not support the practice.  A systematic review conducted in the UK showed that sleep training in the first 6 months of life did not prevent sleep or behavioral problems later on, nor did it protect against postnatal depression. It may even worsen maternal anxiety and lead to further problem crying after 6 months of age. J Dev Behav Pediatr. 2013 Sep;34(7):497-507  Sleep training at 2 months involves a significant increase in infant crying, which is stressful not only for babies, but for the whole family. Middlemiss and colleagues showed that when babies were allowed to “cry it out” at night, this resulted in babies having very high levels of stress hormones, such as cortisol, increasing heart rate and blood pressure. Early Hum Dev. 2012 Apr;88(4):227-32.  Alternatively, babies who learn early on that a caring adult will respond to their crying by feeding and holding are less likely to experience stress and isolation, especially during those early months of life, when brain development and connections between brain cells are occurring in rapid fashion.  Young babies and mothers are hard wired to be together frequently.

Watch your baby, not the clock

Dr. Jon Matthew Farber published the final installment of pearls reflecting on his practice in the January 1, 2016 edition of Contemporary Pediatrics. (Farber, Pearls from the trenches: Part 4, Contemporary Pediatrics. ) As Dr. Farber noted in the introduction, “I have heard it said that half of what we practice now will be out-of-date in 10 years, but the trick is to know which half.” Many of his clinical observations are quite valid and helpful for the practitioner. Unfortunately, one of the tips in that edition is out-of-date and could be counterproductive.

Under “Words to Live By,” item #10 addresses breastfeeding routines and states that “After 10 minutes, if not sooner, a breast is mostly empty. Having a child feed for 20 to 30 minutes at the first breast will exhaust both the mother and the child (and can lead to very sore nipples). Particularly for newborns, I recommend 10 minutes at the first breast, switching breasts for another 10, and then “topping off” for another 5 to 10 minutes at each breast if the baby is still hungry.” This statement includes the Lancet reference. ( Lancet. 1979 Jul 14;2(8133):57-8. )

Indeed, as Dr. Farber has noted, in the more than 35 years since that publication, our understanding of breast milk production and transfer, as well as the composition of milk, has improved significantly. We also know that each baby is different, as he or she masters the skills of feeding from the breast with continued practice. While some babies may indeed consume a substantial volume of milk in 10 minutes, others, and especially newborns, may take significantly longer. (Breastfeed Med. 2013 Dec;8(6):469-73. )In addition, the greatest proportion of fat is consumed towards the end of a feeding. Frequent “switching” from side to side may result in relatively higher water and sugar intake, with proportionately less fat intake, tending to make babies more fussy and gassy, with frequent frothy, green stools. In some circumstances, these babies may suffer from growth faltering. (J Am Board Fam Med. 2016 Jan-Feb;29(1):139-42. ) Therefore, it is no longer recommended that parents follow the clock when feeding, but instead observe the baby for signs of satiety, such as, relaxing of the posture or falling asleep. A full feeding (no specific time, but noted by less frequent swallowing or the baby drifting off to sleep) on the first breast offered, followed by as much feeding as desired on the second breast, if requested by a baby, works well for most babies, especially during the newborn period. (Breastfeed Med. 2010 Aug;5(4):173-7.) The breast never completely empties, because production continues throughout the feeding. Soreness of nipples does not correlate with the time spent nursing, but with the adequacy of latch.

If the mother is experiencing sore nipples (J Obstet Gynecol Neonatal Nurs. 2005 Jul-Aug;34(4):428-37), the latch should be carefully evaluated by someone skilled in breastfeeding assessment, whether that be a doctor, nurse, lactation consultant, or other helping professional. Fellows, or members, of the Academy of Breastfeeding Medicine, an organization of physicians dedicated to the promotion, protection and support of breastfeeding and human lactation, are excellent resources. ( Academy of Breastfeeding Medicine) Good breastfeeding routines are especially important in the early days and weeks in order to establish and maintain a good milk supply. Timed feedings may actually increase the risk of insufficient milk supply, which can be challenging to resolve.

While the pearls gleaned from practical experience can be very useful in our clinical decision making tool kit, they must be combined with current knowledge of clinical practice. The majority of mothers initiate breastfeeding, however, 60% do not meet their own breastfeeding goals. (Pediatrics. 2012 Jul; 130(1): 54–60. )
. Evidence-based medicine combines careful review of the medical literature with clinical experience and judgment. In order to support breastfeeding families optimally and achieve the improved health outcomes for both mothers and children, it is critical that physicians and other health care providers communicate current information and recommendations to colleagues, instead of relying only on our own observations and dated references.

Joan Meek is a Associate Dean for Graduate Medical Education and Professor of Clinical Sciences
Florida State University College of Medicine. She has served as president of the Academy of Breastfeeding Medicine, Chair of the American Academy of Pediatrics Section on Breastfeeding, and Chair of the United States Breastfeeding Commitee. 

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.