Editor’s Note: Dr. Earl Chism (he/him/his) is a first-year resident physician in pediatrics at the University of California, San Francisco. He is a member of the Pediatric Leaders Advancing Health Equity (PLUS) Program, and his interests include medical education and improving health outcomes by increasing representation in healthcare. - Rachel Y. Moon, MD, Associate Editor, Digital Media, Pediatrics
With the increase in the number of states legalizing marijuana for medical and/or recreational use, healthcare providers are getting many more questions regarding its use. In order to avoid any additional haziness, clinicians must continue to do our due diligence to provide well-researched recommendations and establish equitable practices for our patients who are using marijuana.
One common question that comes up is surrounding the use of marijuana while breastfeeding.
Drs. Pearl Chang, Neera Goyal, and Esther Chung from the University of Washington and Nemours duPont Pediatrics, in their article entitled “Marijuana Use and Breastfeeding: A Survey of Newborn Nurseries,” which is being early released in Pediatrics this week (10.1542/peds.2023-063682), discuss this question and offer important insight into some of the existing sentiments and practices in place today.
The authors collected information using a cross-sectional survey that was sent to nursery medical directors across the US who were members of the Academic Pediatric Association’s Better Outcomes through Research for Newborns (BORN) network.
The study focused on two outcome measures:
- Hospital practices involving breastfeeding mothers with known perinatal marijuana use.
- Hospital practices aimed at providing information about marijuana cessation to mothers who had a positive screen for cannabinoids.
The survey also collected data about the following: hospital data such as setting, resources, and practices; general sentiments and knowledge related to marijuana use; and sociodemographic information about the respondents.
The authors then examined whether there was any association between general demographic data and hospital practices.
In this analysis, there were, of course, some unsurprising associations, such as the association between legalization of marijuana and region (the highest proportion of responses where medical and recreational use of marijuana was legal was from the West).
Regarding the primary outcome measures:
- Most hospitals do not restrict breastfeeding for mothers with a positive cannabinoid screen.
- A lower proportion of hospitals located in urban settings had the practice of encouraging breastfeeding in mothers with known marijuana use, compared with those in rural and suburban settings.
- There was a surprisingly low percentage of survey respondents who mentioned hospital practices focused on providing information about marijuana cessation to mothers with positive cannabinoid screens.
Other study findings were also quite telling. The authors found that there was “substantial variation” in how and when clinicians decide to encourage or restrict breastfeeding for mothers with known perinatal marijuana use, and they challenge us as readers to think about why these variations exist and how they may contribute to the existing inequalities related to breastfeeding in the US.
For example, in August 2023, Cohen et al. described how young, non-White, poorer individuals are disproportionately tested for peripartum substance use If these groups are receiving a different standard of care that makes breastfeeding more difficult, it is not surprising that non-Hispanic Black children have been found to have significantly lower rates of breastfeeding initiation and maintenance than their peers.
In their discussion, the authors examine these structures upholding these inequities. The idea of intersectionality helps us think about the overlapping layers (for example, race + poverty + prenatal marijuana use) of a person’s identity that can make them more likely to face marginalization in the form of varying practices surrounding breastfeeding. We’ve seen how a person of a particular race or class may be more likely to face bias in the form of variable hospital practices, and, more often than not, a person holds more than one of these identities.
The authors don’t have one simple fix for the variable practices that exist, but they do offer a number of potential tools for harm reduction, such as:
- Developing standardized information sheets about marijuana use for pregnant patients
- Employing people from the population served by the hospital to help reduce bias
- Providing clinicians more information about marijuana and lactation to be able to give more balanced counseling
- Creating policies based on the well-known data about the benefits of breastfeeding
- Re-examining existing policies that restrict mothers who test positive for marijuana from breastfeeding
As clinicians, we must continue to be cognizant of variations in practice that can exacerbate health inequities. This article offers an important perspective and encourages us to be intentional and take action rather than blow smoke.
