A Doula and Biologist Answer Your FAQs about Lactation and Cannabis Use
by Heather Thompson, MS, PhD
Note: This ^ signs in this article indicate footnotes, which can be found at the end of the piece.
My journey talking to families about their perinatal cannabis use started as soon as I became a birth worker and started providing postpartum support nearly 20 years ago. Families confide in me about their thoughts, feelings, and worries related to their perinatal cannabis use. I am trained as a scientist, so folks often asked me about “the data.”
I read all the scientific literature I could get my hands on, learned all I could learn, and kept up with what was being published in the early 2000s. Then, in 2012, I was the Director of Research at a community birth center when recreational cannabis became legal in my home state of Colorado. I soon found myself talking to midwives, doctors, doulas, nurses, and pregnant/lactating cannabis consumers about what we knew about the health effects of perinatal cannabis use on parents and children.
For the past 10+ years, I have continued this work as the Co-Deputy Director of Elephant Circle, a birth justice organization. As a result, my work is grounded in the Elephant Circle values of reproductive justice, feminism, design thinking, and intersectionality. It is also deeply rooted in and informed by harm reduction.
At Elephant Circle, we lean into two specific pieces of the Harm Reduction Coalition’s definition:
strategies to reduce negative consequences and
the belief in and respect for people who use drugs.
We also embrace the fact that harm reduction does not require abstinence or a plan to move towards abstinence - less use or safer use is harm reduction. Finally, we believe in the expertise of people’s lived experience and strive to be person-centered and trauma-informed in how we support clients who use perinatal cannabis.
A Glimpse into the Political and Cultural Context
This approach is especially suited for doulas and birth workers, who already use some of these strategies with their clients in other ways. In this blog I will answer some of the frequently asked questions I receive about cannabis and lactation. But first, I want to be crystal clear on the history of using cannabis as medicine as well as the history of cannabis criminalization and the drug war in the United States.
The first documented medicinal use of Cannabis was in the third millennium B.C.^1 by Chinese Emperor Shen Nung, and cannabis tinctures were part of the US pharmacopeia until 1942. The criminalization of cannabis in the late 1930s was a response to Mexican immigration and ongoing anti-Blackness, not a response to concerns about the health effects of cannabis use. Similarly, the drug war initially amplified by the Nixon administration in the early 1970s was designed to fracture certain communities, not to protect the public from drugs. This is made especially clear by John Ehrlichman, one of Nixon’s top aides,
“We knew we couldn’t make it illegal to be either against the war or black, but by getting the public to associate the hippies with marijuana and blacks with heroin, and then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up their meetings, and vilify them night after night on the evening news. Did we know we were lying about the drugs? Of course we did.”
This history is extremely important because the stigma we have in the US about perinatal cannabis use is rooted in this history. Many of the clients I have worked with over the years have used cannabis medicinally and intentionally during the perinatal period. However, the stigma that results from the narratives of the drug war, in my experience, often gets in the way of being able to see or talk about the medicinal use of cannabis. I wish we had a more nuanced conversation about this as I see folks talking less and less to their health care providers about their perinatal cannabis use because they worry about being judged and reported to child protective services. Both of these fears are grounded in reality and research.
So on to some of the FAQs:
Does THC pass into human milk?
Yes. THC (delta-9-tetrahydrocannabinol, the most well-known psychoactive molecule in cannabis) is one of the cannabinoids that passes into human milk after consumption by a lactating person^4,5,6. Like alcohol, cannabinoids are metabolized from human milk with somewhat predictable timing (one hour after consumption, THC levels peak in human milk and 4 hours after consumption, THC levels return to their baseline^2), and 24 hours of abstention can reduce THC levels to undetectable in occasional users^2,4. In regular users, however, THC has been reported at low levels in human milk after 6 weeks of abstention^3.
How much THC is a nursing infant exposed to in human milk?
The bioavailability of a drug is important to understand exposure. In the case of Cannabis, only 1-5% is available through oral consumption, so infants are exposed to a dose at least 100 times less than the amount consumed by the lactating parent. Generally, drugs with a Relative Infant Dose (RID) of less than 10% are considered safe for infants receiving human milk. The RID of THC has been calculated to be 2.5%^2.
What about CBD?
Concentrated individual cannabinoids require an extensive extraction process to remove CBD from the cannabis plant. If CBD is preferable to consuming the whole plant, know where your CBD comes from to reduce exposure to harmful solvents or other agents used in, or left over from, CBD extraction. Oftentimes hemp-based tinctures are cleaner final products. Also, in my experience, cannabis is often most effective as whole plant medicine - isolated cannabinoids commonly do not provide the same relief.
What do we know about the health effects of infant exposure to cannabinoids in human milk?
To date, there are no documented health effects to infants exposed to cannabis in human milk. I want to be clear that a lack of data indicating risk does not equal safety, but if someone tells you that lactating parents who use cannabis will negatively impact their child’s ability to learn, they are citing data gathered during pregnancy, NOT lactation^7.
Are there other considerations aside from health effects birth workers should think about?
In my 10+ years of experience, legal and child welfare impacts of perinatal cannabis use are more impactful, harmful, and profound than health effects. If a family is on public insurance or reads as people of color by health care providers, the legal/child welfare risks tend to be higher and should be part of any strategizing about perinatal cannabis use. If your client has an increased risk of legal and/or child welfare involvement, that should be an important part of your harm reduction plan. Intersecting with the child welfare system, even without a finding of child abuse or neglect, can cause trauma and long-term harm to the entire family unit.
My client is using cannabis and nursing their baby. How can I best support them?
Be curious about their story and how cannabis fits in. Learn as much as you can about how, when, and why they use cannabis. Your ability to practice harm reduction can be improved by a non-judgmental understanding of your client’s relationship to cannabis.
Strategize around sober caregiving. In the same way you talk about alcohol and opiate use during postpartum, have a plan for sober caregiving when cannabis is being used.
If cannabis is smoked (in my experience, this is the most common way perinatal folks consume cannabis), minimize exposure to secondhand/thirdhand smoke the same way you would with tobacco. Smoking outdoors, changing clothes, being aware of off gassing^8 for 30-45 minutes, and washing hands and face thoroughly after use can be useful tools.
Resist pumping and dumping. It does not work and is not a data-driven practice.
If you are a mandated reporter and feel that someone’s substance use concerns you enough to call child welfare, please discuss this decision thoroughly with your client and at least two colleagues. This is a very serious decision and should not be made in isolation or without the family’s knowledge. At Elephant Circle we encourage considering three points before reporting. One, you should be very clear that the support you hope for this family is available within the child welfare system in your state. It is not uncommon that child welfare has no support to offer lactating families using cannabis, but the investigation still results in a finding of child abuse and neglect. Two, be clear that the risk of not reporting exceeds the risk of a finding of child abuse and neglect as this can impact housing, employment, and other elements of a person’s experience for the rest of their life. Finally, if you do make a report, do so with the family present and be clear in your report about both your concerns and the strengths the family brings to the situation.
Practice harm reduction! Reduce negative consequences (health, legal, child welfare) and have a respect for and belief in your client. Remember, harm reduction does not require abstinence.
Footnotes:
Cannabis, A History, Martin Booth, 2003
Woodruff et al., Pregnant people’s experience of discussing their cannabis use with prenatal providers in a state with legalized cannabis, Drug Alcohol Depend, 2021
Cannabinoids are molecules found in the cannabis plant. THC, 11-OH-THC, COOH-THC, and CBD are some examples
Baker et al., Transfer of Inhaled Cannabis into Human Breastmilk. Obs and Gyn, 2018.
Wymore et al., Persistence of delta-9-tetrahydrocannabinol in Human Breast Milk, JAMA Peds, 2021
Bertrand et al., Marijuana Use by Breastfeeding Mothers and Cannabinoid Concentrations in Breastmilk, Peds, 2018
The link between academic achievement and cannabis exposure during pregnancy is weak, but cited often. For an excellent review of the literature, please read Torres et al., The Totality of the Evidence Suggests Prenatal Cannabis Does Not Lead to Cognitive Impairments, Front. Psych, 2020.
Offgassing is when chemicals from smoked products linger on the breath and clothes of the smoker. Waiting 3-45 minutes after smoking before interacting with baby, especially close to their face, reduces baby’s exposure to these chemicals.
Heather Thompson (she/they), MS, PhD is a molecular and cellular biologist, clinical researcher, birth worker, and queer parent with non-binary gender.
Heather has worked for equity, access and autonomy in childbirth for more than 25 years, and was part of the team that passed the historic Colorado Birth Equity Bill Package in 2021. Currently she is the Co-Deputy Director of Elephant Circle, a birth justice organization, doing work that allows her to combine her background in birth access and equity with science and community organizing. Heather has been educating consumers and clinicians about perinatal cannabis since its liberalization in Colorado in 2012, work that has resulted two peer-reviewed publications. Heather’s application to birth justice issues goes back to her work as the Director of Research at a community birth center in Colorado (2010-2017), and participation in an NIH Task Force evaluating the evidence-based literature on SIDS and bedsharing/cosleeping in the context of AAP guidelines on infant sleep.
These experiences – plus 19 years of postpartum doula work - feeds Heather’s passion for supporting family ecology by helping families navigate their own journey, particularly as it relates to perinatal care, birth choices, and legal cannabis. Born and raised in Colorado, Heather lives in Denver and enjoys being outside around a campfire with her partner, two teens, and larger community.