BACKGROUND AND OBJECTIVES

Marijuana use has increased nationally and is the most common federally illicit substance used during pregnancy. This study aimed to describe hospital practices and nursery director knowledge and attitudes regarding marijuana use and breastfeeding and assess the association between breastfeeding restrictions and provider knowledge, geographic region, and state marijuana legalization status. We hypothesized that there would be associations between geography and/or state legalization and hospital practices regarding breastfeeding with perinatal marijuana use.

METHODS

A cross-sectional, 31-question survey was sent electronically to the 110 US hospital members of the Academic Pediatric Association’s Better Outcomes through Research for Newborns (BORN) network. Survey responses were analyzed using descriptive statistics to report frequencies. For comparisons, χ2 and Fisher exact tests were used to determine statistical significance.

RESULTS

Sixty-nine (63%) BORN nursery directors across 38 states completed the survey. For mothers with a positive cannabinoid screen at delivery, 16% of hospitals universally or selectively restrict breastfeeding. Most (96%) nursery directors reported that marijuana use while breastfeeding is “somewhat” (70%) or “very harmful” (26%). The majority was aware of the potential negative impact of prenatal marijuana use on learning and behavior. There were no consistent statistical associations between breastfeeding restrictions and provider marijuana knowledge, geographic region, or state marijuana legalization status.

CONCLUSIONS

BORN newborn clinicians report highly variable and unpredictable breastfeeding support practices for mothers with perinatal marijuana use. Further studies are needed to establish evidence-based practices and to promote consistent, equitable care of newborns with perinatal marijuana exposure.

What’s Known on This Subject:

Marijuana is the most common federally illicit substance used during pregnancy. Little is known about hospital practices regarding breastfeeding in the setting of perinatal marijuana use in US states with varying marijuana legalization status.

What This Study Adds:

This cross-sectional survey study identifies opportunities for standardizing hospital practices regarding breastfeeding with perinatal marijuana use and explores potential drivers of practice variation including provider knowledge, geographic region, and marijuana legalization status.

Across the United States, increasing state legalization of marijuana use has been associated with increased public perception that marijuana use is safe, including among pregnant women.1  Some pregnant women view marijuana as a “safer alternative” to prescription medications for health symptom management.2  Marijuana use has increased nationally and is the most common federally illicit substance used during pregnancy, affecting up to 10% of births in some states.3,4  The psychoactive component of marijuana, tetrahydrocannabinol, is found in significant quantities in breastmilk5  after both inhalation6  and consumption of edibles,7  and persists for up to 6 weeks after use.8  The American College of Obstetricians and Gynecologists9  and the American Academy of Pediatrics (AAP) advise against marijuana use during pregnancy and lactation.10  Similarly, the Academy of Breastfeeding Medicine recommends counseling of breastfeeding mothers to reduce or eliminate marijuana use.11 

Recommendations against marijuana use during lactation are based on the available evidence for adverse neurodevelopmental outcomes and other safety risks among exposed children. Previous research has demonstrated that prenatal marijuana use increases the risk of low birth weight,12,13  sudden infant death syndrome,5  and cognitive and behavioral problems in childhood.14  Studies have found an association between prenatal marijuana use and reduced scores in verbal and memory domains on neuropsychological assessments at 4 years of age; decreased attention, increased hyperactivity, and greater impulsivity at 10 years of age; and lower scores in reading, math, and spelling at 14 years of age.15  Postnatally, exposure to marijuana via breastmilk has been shown by some to negatively affect infant motor development.15 17  Studies of older children suggest that marijuana use by preteens and adolescents is associated with lower intelligence quotients, impaired executive functioning, and slower cognitive function compared with healthy controls.18  More recently, functional magnetic resonance imaging studies found evidence of altered brain function among adolescents with cannabis use disorder.18  Collectively, these findings suggest that any marijuana use during pregnancy and while breastfeeding has the potential for short- and long-term adverse neurodevelopment among exposed children.

Clinicians caring for newborns and their families in the immediate postpartum period must navigate the complex intersection of clinical recommendations, cultural and political trends, and issues of patient autonomy and beneficence that surround breastfeeding with marijuana use. There are numerous health benefits of breastfeeding for mothers and infants, and breastfeeding during the birth hospitalization is an important milestone for bonding and promoting a beneficial family experience.19  Thus, more research is needed to determine how newborn care leaders and clinicians weigh the risks of marijuana exposure through breastmilk against the benefits of breastfeeding, and how these considerations are implemented as hospital practices in US states with varying marijuana legalization.

The goals of this study were to (1) describe hospital practices and nursery director knowledge and attitudes related to marijuana use and breastfeeding, (2) assess the association between provider knowledge about marijuana and breastfeeding restrictions, and (3) determine whether geographic region and/or state marijuana legalization status affected breastfeeding restrictions. We hypothesized that there would be associations between geographic region and/or state legalization status and hospital practices regarding breastfeeding with perinatal marijuana use.

This study was conducted through the Academic Pediatric Association’s Better Outcomes through Research for Newborns (BORN) network, a group of nursery directors and clinicians who care for late preterm and term newborns at academic and community hospitals. At the time of the survey, the network consisted of 110 nursery sites located in 38 states caring for a total of ∼400 000 newborns per year. Within each hospital, multiple clinicians may participate as BORN members although 1 individual (typically the nursery medical director) serves as the site representative and primary point of contact. For this study, only site representatives were recruited to participate. BORN receives support from an Academic Pediatric Association research manager and research assistant for meeting coordination, network membership management, listserv communications, and study proposal review and implementation.

This was a cross-sectional survey administered electronically using a REDCap link sent to each BORN representative, who received up to 4 monthly reminders between February and December 2021 during the SARS-CoV-2 pandemic. The 31-item survey was investigator-developed with collaboration from BORN members with expertise in newborn care and perinatal substance use. Survey items were derived or adapted from existing, validated instruments whenever possible (full survey in Supplemental Information). Responses were multiple choice with additional free text options, when applicable. The first section on hospital characteristics and practices included questions on hospital type and setting, number of births per year, availability of International Board Certified Lactation Consultants, Baby Friendly hospital designation, perceived state marijuana legalization status, the hospital’s drug screening practices for pregnant women, drugs tested on routine urine drug screening, and the hospital’s breastfeeding practices for mothers who test positive for cannabinoids at the time of delivery. Based on the institution for each site representative, actual state marijuana legalization status (not legal or unknown, legal for medical use only, or legal for medical plus recreational use) was determined. We confirmed legalization status at the time of survey completion based on the date of when legalization was signed into law and we considered marijuana to be legal for medical use if it was allowed for medical use in general (not just a single condition). The second section examined general and pediatric-specific knowledge and attitudes related to marijuana use. For knowledge, we asked questions regarding the known health effects of marijuana use in general and health effects for pregnant women, the fetus/newborn, and breastfed infants. For attitudes, we asked directors to describe the health effects of marijuana use on a 5-point Likert-like scale (ranging from “not very harmful” to “very harmful”). Because of our small sample size, we combined “somewhat” and “very harmful” for our data analyses. Finally, the third section on clinician sociodemographic characteristics included questions on the director’s specialty, highest degree completed, and number of years in practice. We compiled geographic location based on the site’s registration information with BORN and categorized states by US Census region (West, Midwest, Northeast, South). The study was approved by the University of Washington and Seattle Children’s institutional review boards.

Our primary outcome was hospital practice variation related to breastfeeding for mothers with perinatal marijuana use. We also examined whether resources for marijuana cessation were provided to mothers with a positive cannabinoid screen at the time of delivery. Bivariate comparisons tested for associations between our outcomes and US Census region as well as perceived and actual state legalization status. Finally, we tested the association between the primary outcome and clinician knowledge.

For bivariate comparisons, we dichotomized breastfeeding practices in 2 ways: (1) as “no restrictions” or “restrictions” if there were universal or selective restrictions on breastfeeding for mothers who tested positive for cannabinoids at the time of delivery; and (2) as whether breastfeeding was “encouraged” or “discouraged” (but not restricted, or restricted selectively or universally) for mothers who tested positive for cannabinoids at the time of delivery. Data were analyzed using standard descriptive statistics, and χ2 and Fisher exact tests for bivariate comparisons. We performed analyses using Stata version 14 (Stata Corp, College Station, TX).

Of the 110 BORN nursery representatives, 69 (63%) across 38 US states completed the survey. This is a similar response rate as previously published BORN studies.14,15  Hospital and participant characteristics are shown in Table 1. All 4 Census regions were represented. Most sites were university-affiliated (72%) and teaching hospitals (94%). The majority of directors were general pediatricians and/or hospitalists (87%) who were >10 years posttraining (68%).

TABLE 1

Characteristics of Participating BORN Hospitals and Newborn Nursery Directors (N = 69)

Hospital CharacteristicsN (%)
Region 
 West 16 (23) 
 Midwest 14 (20) 
 Northeast 22 (32) 
 South 17 (25) 
State marijuana legalization 
 Not legal for any use 10 (15) 
 Legal for medical use only 27 (39) 
 Legal for recreational and medical use 29 (42) 
 Unable to determine 3 (4) 
Hospital toxicology screening 
 Cannabinoid 65 (94) 
 Amphetamine 69 (100) 
 Opiate 68 (99) 
 Benzodiazepine 68 (99) 
 Barbiturate 65 (94) 
 Phencyclidine 52 (75) 
 Methadone 51 (74) 
 Buprenorphine 25 (36) 
 Oxycodone 46 (66) 
 Propoxyphene 12 (17) 
Hospital description 
 Community 15 (22) 
 University 50 (72) 
 Other 4 (6) 
Hospital setting 
 Rural 6 (9) 
 Suburban 17 (25) 
 Urban/metropolitan 46 (66) 
Teaching hospital 65 (94) 
Annual number of deliveries 
 <1000 4 (6) 
 1000–1999 11 (16) 
 2000–4999 43 (62) 
 >5000 11 (16) 
IBCLC availability 
 7 d per week 52 (75) 
 3-6 d per week 17 (25) 
Baby Friendly hospital designation 
 Yes 40 (58) 
 No 22 (32) 
 In process 7 (10) 
Nursery director characteristics 
Years posttraining 
 <5 4 (6) 
 5–10 19 (28) 
 11–20 27 (39) 
 >20 19 (28) 
Gender 
 Female 56 (81) 
Specialty 
 General pediatrics 34 (49) 
 Hospital medicine 26 (38) 
 Neonatology 9 (13) 
Hospital CharacteristicsN (%)
Region 
 West 16 (23) 
 Midwest 14 (20) 
 Northeast 22 (32) 
 South 17 (25) 
State marijuana legalization 
 Not legal for any use 10 (15) 
 Legal for medical use only 27 (39) 
 Legal for recreational and medical use 29 (42) 
 Unable to determine 3 (4) 
Hospital toxicology screening 
 Cannabinoid 65 (94) 
 Amphetamine 69 (100) 
 Opiate 68 (99) 
 Benzodiazepine 68 (99) 
 Barbiturate 65 (94) 
 Phencyclidine 52 (75) 
 Methadone 51 (74) 
 Buprenorphine 25 (36) 
 Oxycodone 46 (66) 
 Propoxyphene 12 (17) 
Hospital description 
 Community 15 (22) 
 University 50 (72) 
 Other 4 (6) 
Hospital setting 
 Rural 6 (9) 
 Suburban 17 (25) 
 Urban/metropolitan 46 (66) 
Teaching hospital 65 (94) 
Annual number of deliveries 
 <1000 4 (6) 
 1000–1999 11 (16) 
 2000–4999 43 (62) 
 >5000 11 (16) 
IBCLC availability 
 7 d per week 52 (75) 
 3-6 d per week 17 (25) 
Baby Friendly hospital designation 
 Yes 40 (58) 
 No 22 (32) 
 In process 7 (10) 
Nursery director characteristics 
Years posttraining 
 <5 4 (6) 
 5–10 19 (28) 
 11–20 27 (39) 
 >20 19 (28) 
Gender 
 Female 56 (81) 
Specialty 
 General pediatrics 34 (49) 
 Hospital medicine 26 (38) 
 Neonatology 9 (13) 

West: Arizona, California, Colorado, Idaho, Oregon, Utah, Washington. Midwest: Illinois, Iowa, Kansas, Kentucky, Michigan, Minnesota, Montana, Ohio, Wisconsin. Northeast: Connecticut, Massachusetts, Maryland, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont. South: Alabama, Arkansas, Florida, Louisiana, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia, West Virginia. BORN, Better Outcomes through Research for Newborns; IBCLC, International Board Certified Lactation Consultant.

Based on the date that legalization was signed into law, most participating sites at the time of the study were located in states with legal marijuana use (39% for medical use only; 42% for medical and recreational use). Most respondents correctly identified the legal status of marijuana use in their state (83% correct, 13% incorrect, 4% unknown). As expected, there was a strong association between US Census region and state legalization of marijuana (P < .001): the highest percentage of respondents from states with both medical and recreational legalization were in the West (n = 16/16, 100%), and the highest percentage without any legalization was in the South (n = 9/17, 53%). Nearly all hospitals (94%) include cannabinoids in their routine urine toxicology panel. Further details of routine toxicology screening practices are shown in Table 1.

The majority (n = 63, 91%) of hospitals reported a risk-based approach to maternal toxicology testing; of these, 63% (n = 40) cited a history of marijuana use as an indication for testing. For mothers with a positive cannabinoid screen at time of delivery, 16% (n = 12) of hospitals either universally or selectively restrict breastfeeding (Table 2). Most hospitals consult social work (n = 52, 76%) and more than one-third (n = 25, 36%) refer to child welfare services. A minority of hospitals (n = 20, 29%) provide resources for marijuana cessation (Table 2).

TABLE 2

Hospital Practices Regarding Mothers with Positive Marijuana Drug Screen at Time of Delivery (N = 69)

Hospital PracticesN (%)
Breastfeeding policy 
 Encouraged to breastfeed 41 (59) 
 Discouraged but not restricted from breastfeeding 16 (23) 
 Restricted from breastfeeding 4 (6) 
 Depends on extent of marijuana use 3 (4) 
 Varies by provider or unknown 5 (8) 
Social work consult 52 (76) 
Automatic referral to child welfare 25 (36) 
Resources for marijuana cessation provided 20 (29) 
Hospital PracticesN (%)
Breastfeeding policy 
 Encouraged to breastfeed 41 (59) 
 Discouraged but not restricted from breastfeeding 16 (23) 
 Restricted from breastfeeding 4 (6) 
 Depends on extent of marijuana use 3 (4) 
 Varies by provider or unknown 5 (8) 
Social work consult 52 (76) 
Automatic referral to child welfare 25 (36) 
Resources for marijuana cessation provided 20 (29) 

The majority of directors (81%) were “confident” in their knowledge of marijuana’s effects on health. The large majority of directors knew that marijuana use can cause poor judgment (96%), impaired driving (96%), is stored in fat tissue (90%), and can be found in the breastmilk of mothers who use (97%). Most (96%) directors reported that marijuana use while breastfeeding is “somewhat” (70%) or “very harmful” (26%), compared with daily alcohol use, for which only 65% of respondents felt use was somewhat (43%) or very harmful (22%; Table 3). Overall, knowledge was high, with the majority aware of the potential negative impact of prenatal marijuana use on learning and behavior among exposed offspring (Fig 1). However, many did not know about other potential risks of in utero marijuana use on the developing child, including risks of preterm birth and low birth weight.

TABLE 3

Newborn Nursery Director Knowledge and Attitudes (N = 69)

N (%)
Confidence of knowledge of marijuana effects on health 
 Very confident 12 (17) 
 Confident 44 (64) 
 Not confident 13 (19) 
Marijuana (ie, tetrahydrocannabinol) is 
 Found in breast milk 67 (97) 
 Stored in fat tissue 62 (90) 
Known health effects of marijuana use 
 Short-term memory loss 62 (90) 
 Loss of coordination 60 (87) 
 Poor judgment 66 (96) 
 Paranoia 54 (78) 
 Addiction 54 (78) 
 Impaired driving 66 (96) 
 Risk for mental illness 46 (66) 
Effect of marijuana is “somewhat” or “very harmful” for 
 Recreational use for adults 52 (75) 
 Use during pregnancy for a fetus 63 (91) 
 Maternal use for a breastfeeding baby 60 (87) 
“Somewhat” or “very harmful” to a baby if mother breastfeeds and 
 Drinks 1–2 alcoholic beverages daily 45 (65) 
 Drinks >5 alcoholic beverages at once 68 (98) 
 Smokes ≥1 pack of cigarettes daily 69 (100) 
 Smokes e-cigarettes or vapes daily 68 (98) 
 Uses marijuana 1–2 times a week 66 (96) 
N (%)
Confidence of knowledge of marijuana effects on health 
 Very confident 12 (17) 
 Confident 44 (64) 
 Not confident 13 (19) 
Marijuana (ie, tetrahydrocannabinol) is 
 Found in breast milk 67 (97) 
 Stored in fat tissue 62 (90) 
Known health effects of marijuana use 
 Short-term memory loss 62 (90) 
 Loss of coordination 60 (87) 
 Poor judgment 66 (96) 
 Paranoia 54 (78) 
 Addiction 54 (78) 
 Impaired driving 66 (96) 
 Risk for mental illness 46 (66) 
Effect of marijuana is “somewhat” or “very harmful” for 
 Recreational use for adults 52 (75) 
 Use during pregnancy for a fetus 63 (91) 
 Maternal use for a breastfeeding baby 60 (87) 
“Somewhat” or “very harmful” to a baby if mother breastfeeds and 
 Drinks 1–2 alcoholic beverages daily 45 (65) 
 Drinks >5 alcoholic beverages at once 68 (98) 
 Smokes ≥1 pack of cigarettes daily 69 (100) 
 Smokes e-cigarettes or vapes daily 68 (98) 
 Uses marijuana 1–2 times a week 66 (96) 
FIGURE 1

Nursery director knowledge of potential risks of in utero marijuana use on the developing child.

FIGURE 1

Nursery director knowledge of potential risks of in utero marijuana use on the developing child.

Close modal

After dichotomizing breastfeeding practices as “restricted” (12 sites) or “not restricted” (57 sites), the only statistical association was between breastfeeding restrictions and provider knowledge of marijuana’s effect on short-term memory loss. Those who restricted breastfeeding were less likely than those who did not restrict to be aware that memory loss is an adverse effect of marijuana use (8/12 vs 54/57; P = .02). With dichotomization of breastfeeding practices as “encouraged” (41 sites) or “discouraged” (28 sites), there was a statistical association between breastfeeding encouragement and hospital setting (4/6 rural vs 15/17 suburban vs 22/46 urban sites encourage breastfeeding if there is a positive cannabinoid screen at time of delivery; P = .01). There were no other statistically significant associations, including none between breastfeeding practices and census region, legalization status, or child welfare referral. We also found no other statistical associations between provider specialty or provider knowledge and breastfeeding practices by either dichotomization.

Our survey of 69 BORN nursery directors from across the United States identified substantial variation in how these providers approach breastfeeding and counseling for mothers with perinatal marijuana use. This variation was not associated with US region or state marijuana legalization status. Respondents’ knowledge about the potential risks of perinatal marijuana use to the developing infant also varied and was overall not associated with reported breastfeeding support practices. There were no consistent statistical associations between breastfeeding restrictions and nursery directors’ marijuana knowledge, geographic region, or state marijuana legalization status.

Variation in breastfeeding support after delivery fundamentally shapes the family experience after birth, may have lasting impact on child wellbeing, and contributes to uncertainty and confusion among clinicians and families. Practice variation may also exacerbate socioeconomic, racial, and ethnic inequalities in breastfeeding. Nursery directors play a crucial role in setting and updating policies. Black women in particular disproportionately experience barriers to breastfeeding, receive less lactation support, and have the lowest rates of breastfeeding initiation and continuation compared with all other racial or ethnic groups in the United States.20,21  Previous research found an increased likelihood of toxicology testing for prenatal substances, reporting to child welfare services, and child separation because of prenatal substance use among Hispanic families, non-Hispanic Black families, and families living in poverty.22 26  The intersection of race, poverty, and prenatal marijuana use represents an important focus for hospitals to implement safe policies and practices that promote rather than worsen health equity. Health and child welfare systems can promote health equity and reduce systemic racism by adopting strategies such as racial bias training, use of health equity assessment tools, and employing people representative of the population served.27,28 

Contrary to the AAP’s policy statement on breastfeeding, in which marijuana use is not a contraindication to breastfeeding,13  mothers who test positive for marijuana are restricted or potentially restricted from breastfeeding at 16% of BORN hospitals. A qualitative study of 9 nurses in Washington state, where recreational marijuana use has been legal since 2012, reported “tension between advocating for breastfeeding versus counseling a patient to avoid breastfeeding if using cannabis.”29  Although the adverse effects of direct marijuana use on neurodevelopment in children and adolescents are well-established,7  longer term effects from marijuana exposure in breastmilk are not currently well-studied. In contrast, the benefits of breastfeeding and breastmilk are well-known, including associated reductions in sudden infant death syndrome, hospitalizations for diarrhea and respiratory infections, and maternal postpartum depression.13  Based on current available evidence, breastfeeding restrictions for mothers who test positive for marijuana may not be in the best interest of the mother or infant.

Routine toxicology screening of pregnant women and newborns remains controversial. American College of Obstetricians and Gynecologists cautions against punitive use of drug screening and recommends that testing only be done with the patient’s consent. For mothers with positive cannabinoid screens, clinicians should carefully consider the 4 principles of medical ethics: (1) beneficence: to benefit patients and promote their welfare; (2) nonmaleficence: to weigh the benefits against the burdens of interventions and to avoid harm; (3) autonomy: to allow patients to make rational decisions and moral choices; and (4) justice: to treat persons fairly, equitably, and appropriately. An in-depth discussion on ethics as it pertains to marijuana use and lactation can be found in a 2022 review article.30 

Both the AAP and Academy of Breastfeeding Medicine recommend counseling breastfeeding mothers about marijuana exposure through breastmilk.10,11  However, only 30% of directors reported that resources for marijuana cessation are provided for mothers with positive marijuana drug screens. These results echo research from the outpatient obstetrical setting that found low rates of counseling to pregnant women who endorsed marijuana use.21  In a qualitative study of obstetrics-gynecology providers, many “felt unprepared to have conversations about cannabis use with their patients.”31  In our study, many respondents were not aware of some of the potential risks of perinatal marijuana exposure. These findings suggest that clinicians may need more information about marijuana and lactation to support more tailored and balanced counseling with families.32  A number of written resources are available. For example, Colorado, 1 of the first 2 states to legalize recreational marijuana use in 2012, developed a factsheet on marijuana use while pregnant and/or breastfeeding, available in 7 languages.33  In 2018, the Philadelphia Multi-Hospital Breastfeeding Task Force developed a city-wide factsheet on marijuana use and breastfeeding endorsed by all 6 maternity hospitals (available on request).

Though not directly addressed in our survey, some providers may also feel uncomfortable addressing marijuana use in the context of conflicting federal and state laws and potential mandated child welfare reports.34,35  For example, Colorado law mandates reporting positive infant cannabinoid toxicology results to child protective services36 ; on the other hand, as of 2017, the Department for Children and Families in Vermont “no longer accepts reports where the sole concern is regarding marijuana use during pregnancy.”37  Data from this study may help clinicians benchmark their own hospital practices against the national landscape of care and identify where the nursery community needs to standardize practices.

One area of need is the standardization of patient education for mothers pre- and postnatally regarding marijuana use. Pregnant mothers have expressed wanting to better understand the impact of marijuana use on their baby, and when they did not receive enough information from medical providers, they turned to other sources such as employees of marijuana retailers.2  Just as education about avoiding raw foods and alcohol are routinely provided to all pregnant women, we propose that education about the potential harms of marijuana use also routinely be provided, independent of reported marijuana use. Education for the general public may also be warranted because pregnant mothers may turn to family and friends for advice. Similarly, newborn providers should consider including education about marijuana exposure in routine postnatal counseling that addresses common topics such as feeding guidelines, safe sleep, and secondhand smoke.

This study has several limitations. First, we had a small sample size limited to BORN sites, most of which were university and teaching hospitals. Thus, the practices reported by these nursery directors may not be representative of all US hospitals that provide newborn care. Data on patient race and/or payer mix for participating hospitals were not obtained, precluding comparison of policies by sociodemographic characteristics. In addition, the responses of the BORN nursery director may not reflect the practice or knowledge of all of the nursery providers or other clinical staff at each BORN site. Second, fluidity of laws meant that, for some sites, there was a change in the legalization status of marijuana during the survey period, potentially affecting directors’ responses. Third, some of the complexities and subtleties of marijuana hospital practices and knowledge may not have been sufficiently captured on a multiple-choice survey. Future research on this topic would benefit from qualitative and mixed methods data, particularly to explore decision-making for the development and implementation of newborn feeding policies in the context of perinatal marijuana use. Such investigation should ideally include all perinatal patient care staff, including nurses and International Board Certified Lactation Consultants, and evaluate factors such as patient race and payer mix as potential drivers of policy variation.

Newborn nursery directors from BORN network hospitals differ in their approach to mothers with perinatal marijuana use. As a growing number of states legalize marijuana use, a more standardized, ethical, and family-centered approach to the care of newborns whose mothers use perinatal marijuana is needed to ensure health care equity. Further studies are needed to establish an evidence-based approach to the counseling of families and management of newborns with perinatal marijuana exposure.

The authors thank the BORN network research staff for their assistance of this project.

Dr Chang led the data analysis and contributed to manuscript writing and revision; Dr Goyal participated in the data analysis and contributed to manuscript writing and revision; Dr Chung conceptualized the study and created the survey instrument, oversaw the data collection and analysis in collaboration with the Academic Pediatric Association’s Better Outcomes through Research for Newborns network, and contributed to manuscript writing and revision; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no potential conflicts of interest to disclose.

AAP

American Academy of Pediatrics

BORN

Better Outcomes through Research for Newborns

1
Odom
GC
,
Cottler
LB
,
Striley
CW
,
Lopez-Quintero
C
.
Perceived risk of weekly cannabis use, past 30-day cannabis use, and frequency of cannabis use among pregnant women in the United States
.
Int J Womens Health
.
2020
;
12
:
1075
1088
2
Barbosa-Leiker
C
,
Burduli
E
,
Smith
CL
,
Brooks
O
,
Orr
M
,
Gartstein
M
.
Daily cannabis use during pregnancy and postpartum in a state with legalized recreational cannabis
.
J Addict Med
.
2020
;
14
(
6
):
467
474
3
Oh
S
,
Salas-Wright
CP
,
Vaughn
MG
,
DiNitto
DM
.
Marijuana use during pregnancy: a comparison of trends and correlates among married and unmarried pregnant women
.
Drug Alcohol Depend
.
2017
;
181
:
229
233
4
Ko
JY
,
Coy
KC
,
Haight
SC
, et al
.
Characteristics of marijuana use during pregnancy - eight states, pregnancy risk assessment monitoring system, 2017
.
MMWR Morb Mortal Wkly Rep
.
2020
;
69
(
32
):
1058
1063
5
Bertrand
KA
,
Hanan
NJ
,
Honerkamp-Smith
G
,
Best
BM
,
Chambers
CD
.
Marijuana use by breastfeeding mothers and cannabinoid concentrations in breast milk
.
Pediatrics
.
2018
;
142
(
3
):
e20181076
6
Baker
T
,
Datta
P
,
Rewers-Felkins
K
,
Thompson
H
,
Kallem
RR
,
Hale
TW
.
Transfer of inhaled cannabis into human breast milk
.
Obstet Gynecol
.
2018
;
131
(
5
):
783
788
7
Moss
MJ
,
Bushlin
I
,
Kazmierczak
S
, et al
.
Cannabis use and measurement of cannabinoids in plasma and breast milk of breastfeeding mothers
.
Pediatr Res
.
2021
;
90
(
4
):
861
868
8
Wymore
EM
,
Palmer
C
,
Wang
GS
, et al
.
Persistence of Δ-9-tetrahydrocannabinol in human breast milk
.
JAMA Pediatr
.
2021
;
175
(
6
):
632
634
9
Committee Opinion No. 722.
Marijuana use during pregnancy and lactation
.
Obstet Gynecol
.
2017
;
130
(
4
):
e205
e209
10
Ryan
SA
,
Ammerman
SD
,
O’Connor
ME
;
COMMITTEE ON SUBSTANCE USE AND PREVENTION; SECTION ON BREASTFEEDING
.
Marijuana use during pregnancy and breastfeeding: implications for neonatal and childhood outcomes
.
Pediatrics
.
2018
;
142
(
3
):
e20181889
11
Reece-Stremtan
S
,
Marinelli
KA
.
ABM clinical protocol #21: guidelines for breastfeeding and substance use or substance use disorder, revised 2015
.
Breastfeed Med
.
2015
;
10
(
3
):
135
141
12
Crume
TL
,
Juhl
AL
,
Brooks-Russell
A
,
Hall
KE
,
Wymore
E
,
Borgelt
LM
.
Cannabis use during the perinatal period in a state with legalized recreational and medical marijuana: the association between maternal characteristics, breastfeeding patterns, and neonatal outcomes
.
J Pediatr
.
2018
;
197
:
90
96
13
National Academies of Sciences Engineering, and Medicine; Health and Medicine Division ; Board on Population Health and Public Health Practice; Committee on the Health Effects of Marijuana: An Evidence Review and Research Agenda
.
The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research
.
National Academies Press
;
2017
14
Paul
SE
,
Hatoum
AS
,
Fine
JD
, et al
.
Associations between prenatal cannabis exposure and childhood outcomes: results from the ABCD Study
.
JAMA Psychiatry
.
2021
;
78
(
1
):
64
76
15
Narendran
N
,
Yusuf
K
.
Marijuana use during pregnancy and lactation and long-term outcomes
.
Neoreviews
.
2021
;
22
(
8
):
e521
e530
16
National Institute of Child Health and Human Development
.
Drugs and Lactation Database (LactMed). Available at: https://www.ncbi.nlm.nih.gov/books/NBK501922/. Accessed December 1, 2023
17
Astley
SJ
,
Little
RE
.
Maternal marijuana use during lactation and infant development at one year
.
Neurotoxicol Teratol
.
1990
;
12
(
2
):
161
168
18
Camchong
J
,
Lim
KO
,
Kumra
S
.
Adverse effects of cannabis on adolescent brain development: a longitudinal study
.
Cereb Cortex
.
2017
;
27
(
3
):
1922
1930
19
Meek
JY
,
Noble
L
;
SECTION ON BREASTFEEDING
.
Policy statement: breastfeeding and the use of human milk
.
Pediatrics
.
2022
;
150
(
1
):
e2022057988
20
Chiang
KV
,
Li
R
,
Anstey
EH
,
Perrine
CG
.
Racial and ethnic disparities in breastfeeding initiation — United States, 2019
.
MMWR Morb Mortal Wkly Rep
.
2021
;
70
(
21
):
769
774
21
Holland
CL
,
Rubio
D
,
Rodriguez
KL
, et al
.
Obstetric health care providers’ counseling responses to pregnant patient disclosures of marijuana use
.
Obstet Gynecol
.
2016
;
127
(
4
):
681
687
22
Schoneich
S
,
Plegue
M
,
Waidley
V
, et al
.
Incidence of newborn drug testing and variations by birthing parent race and ethnicity before and after recreational cannabis legalization
.
JAMA Netw Open
.
2023
;
6
(
3
):
e232058
23
Rebbe
R
,
Sattler
KM
,
Mienko
JA
.
The association of race, ethnicity, and poverty with child maltreatment reporting
.
Pediatrics
.
2022
;
150
(
2
):
e2021053346
24
Cohen
S
,
Nielsen
T
,
Chou
JH
, et al
.
Disparities in maternal-infant drug testing, social work assessment, and custody at 5 hospitals
.
Acad Pediatr
.
2023
;
23
(
6
):
1268
1275
25
Johnson-Motoyama
M
,
Putnam-Hornstein
E
,
Dettlaff
AJ
,
Zhao
K
,
Finno-Velasquez
M
,
Needell
B
.
Disparities in reported and substantiated infant maltreatment by maternal Hispanic origin and nativity: a birth cohort study
.
Matern Child Health J
.
2015
;
19
(
5
):
958
968
26
Perlman
NC
,
Cantonwine
DE
,
Smith
NA
.
Toxicology testing in a newborn ICU: does social profiling play a role?
Hosp Pediatr
.
2021
;
11
(
9
):
e179
e183
27
Child Welfare Information Gateway; Children’s Bureau.
Child welfare practice to address racial disproportionality and disparity. Available at: https://www.childwelfare.gov/pubpdfs/racial_disproportionality.pdf. Accessed October 1. 2023
28
Hostetter
M
,
Klein
S;
The Commonwealth Fund
.
Confronting racism in health care: moving from proclamations to new practices. Available at: https://doi.org/10.26099/kn6g-aa68. Accessed October 1, 2023
29
Barbosa-Leiker
C
,
Brooks
O
,
Smith
CL
,
Burduli
E
,
Gartstein
MA
.
Healthcare professionals’ and budtenders’ perceptions of perinatal cannabis use
.
Am J Drug Alcohol Abuse
.
2022
;
48
(
2
):
186
194
30
Gross
MS
,
Le Neveu
M
,
Milliken
KA
,
Beach
MC
.
Patient caught breastfeeding and instructed to stop: an empirical ethics study on marijuana and lactation
.
J Cannabis Res
.
2022
;
4
(
1
):
20
31
Ceasar
RC
,
Gould
E
,
Stal
J
, et al
.
Legislation has changed but issues remain: provider perceptions of caring for people who use cannabis during pregnancy in safety net health settings, a qualitative pilot study
.
Womens Health Rep (New Rochelle)
.
2023
;
4
(
1
):
400
408
32
Panday
J
,
Taneja
S
,
Popoola
A
, et al
.
Clinician responses to cannabis use during pregnancy and lactation: a systematic review and integrative mixed-methods research synthesis
.
Fam Pract
.
2022
;
39
(
3
):
504
514
33
Colorado Department of Public Health and Environment
.
Marijuana fact sheets in multiple languages. Available at: https://cdphe.colorado.gov/marijuana-fact-sheets-in-multiple-languages. Accessed November 1, 2023
34
Jarlenski
M
,
Hogan
C
,
Bogen
DL
,
Chang
JC
,
Bodnar
LM
,
Van Nostrand
E
.
Characterization of U.S. state laws requiring health care provider reporting of perinatal substance use
.
Womens Health Issues
.
2017
;
27
(
3
):
264
270
35
Hines
L
,
Glick
J
,
Bilka
K
,
Lantos
JD
.
Medical marijuana for minors may be considered child abuse
.
Pediatrics
.
2018
;
142
(
4
):
e20174310
36
Colorado General Assembly
.
Colorado revised statutes 2021. Available at: https://leg.colorado.gov/sites/default/files/images/olls/crs2021-title-19.pdf. Accessed December 1, 2023
37
Vermont Department for Children and Families
.
Frequently asked questions: marijuana use in pregnancy. Available at: https://outside.vermont.gov/dept/DCF/SharedDocuments/FSD/POSC/FAQ-Marijuana-Use-Pregnancy.pdf. Accessed December 1, 2023

Supplementary data