cbd oil for breastfeeding moms

Trading Xanax for ‘Natural’ CBD Oil — Is it Safe While Breastfeeding?

Sleepless, anxious new mom Sara Gaynes Levy had a prescription for Xanax. Then her friends started talking about cannabinoid oil as an alternative.

When my daughter was about five months old, she finally began sleeping through the night. Well, sometimes. Would this be a good night, or a bad one? We never knew.

That uncertainty generated an anxiety I’d never experienced before, and soon that was what was keeping me awake. Then the worry began to take over my daytime hours, too, as I obsessed about whether tiny decisions would have some kind of magical, predictive effect on the night’s outcome: did she sleep through the night the last time I wore these pajamas? Was it this lullaby or that one that did the trick? I was spiraling into full-blown insomnia, waking for the day around 3 a.m., even on nights my daughter continued to sleep soundly.

Intellectually, I believe there should be no shame or fear in treating mental illness.

So I went to a psychiatrist. He identified my problem as postpartum anxiety, gave me a list of cognitive behavioral strategies — deep breathing, tensing and releasing my muscles — and, for the nights when those techniques didn’t work, wrote me a prescription for Xanax.

The drug is fast-acting; if I took it at 3:30 a.m. after nursing, he reassured me that little would be left in my bloodstream when I nursed her again at 7 a.m. Even as I stood wobbling, exhausted, in line at the pharmacy, my daughter sleeping peacefully in her carrier on my chest, filling that prescription gave me pause. Intellectually, I believe there should be no shame or fear in treating mental illness, but as a wellness-lover and a breastfeeding mother — and as a woman who felt an irrational surge of pride when, after I donated my cord blood after my daughter was born, the technician at the hospital told me, “I don’t know what you’ve been eating, but your placental blood is amazing” — I struggled to internalize that message. I eat organic, run half-marathons, do yoga every Sunday. Taking a psychiatric pharmaceutical that comes with the potential for dependence does not fit the profile.

I was anxious all over again.

My wellness-obsessed friends shared my doubts — and, seemingly, were all onto the same miraculous alternative. One after another, they gently asked why I was choosing a prescription when I could take something like CBD oil, which, after all, comes from a plant, not a lab. Let me remind you of what you’ve probably already heard countless times in the roughly two years during which cannabinoid oil, aka CBD, has risen to GOOP-era stardom: It’s derived from the marijuana plant, but contains no THC (pot’s psychotropic element), and is said to induce an overall relaxed feeling — think chilled, not stoned. CBD is now, suddenly, available as an additive in coffee, cookies, and smoothies, not to mention skincare. Suddenly, I was anxious all over again, worrying about whether I was making the right choice for my own health, and my baby’s.

This is common enough in new moms, says Catherine Birndorf, MD, the cofounder and medical director at The Motherhood Center in New York City, which specializes in treating pre- and post-natal mood and anxiety disorders. “This idea kicks in that ‘I have to do better than just good enough,'” Birndorf says. “And that extends to not taking anything that’s a drug or perceived as ‘bad’ for you. “People think [CBD and the like] are safer because they’re ‘natural.’ But psychiatric drugs came from natural substances that we’ve figured out how to manufacture. And they’re more well-studied than probably anything else we put in our bodies,” she told me. “Psychiatric symptoms that are untreated have incredibly far-reaching implications — for the baby and you. And people are using illicit drugs or alcohol because they think somehow that’s better? No.”

We do know CBD is generally safe, but it’s also not well regulated.

Very little data exists on CBD oil at all — it may well relax you, but it’s unclear whether that’s due to a chemical reaction in the body or a (very real) placebo effect. “And in pregnant and breastfeeding moms, the clinical studies, the research — even survey research isn’t there,” says Martin De Vita, a doctoral candidate in clinical psychology at Syracuse University who studies CBD. “In general, there isn’t much clinical use. We do know CBD is generally safe, but it’s also not well regulated. Consumers should be careful.”

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According to De Vita, early research indicates that using CBD during pregnancy might actually weaken the placental wall, making it easier for anything in your system (including CBD) to cross the barrier and affect a fetus. And while pure CBD oil should contain less than .02 percent THC, he says it’s possible that, because THC is stored in fat cells, even those trace amounts could bind to the fat in breast milk.

If I took CBD oil, I’d have no way of knowing how much was getting into my daughter’s system. With Xanax, we know this down to the microgram: 1.1 hours after I popped my 0.5 milligram dose, Xanax would have filtered into my breast milk at 3.7 micrograms per liter (or 0.11 micrograms per ounce, since no one measures breast milk in liters). The concentrations drops from there but, to be clear, Xanax has a long half life — some trace of is detectible in breastmilk for an average of 14.5 hours — which is why it would not be a first choice drug for many nursing moms. My doctor chose it for me because I took it infrequently — maybe once a week — and needed something that works really fast, since new moms are grabbing slivers of sleep between feedings. Plus, I always nursed her at least three hours after taking it.

Ultimately, I decided to save my experiments with CBD for when I’m no longer nursing. Eventually, my sleep anxiety subsided on its own. But for three months, I took that little white pill intermittently, and without fail, it did the trick — I slept. And though I was always watchful for possible side-effects, like vacantness, difficulty eating, and excessive sleeping, that would indicate my daughter had been exposed to the drug, I never picked up on even a hint of grogginess. Still, did I ever feel great about taking it? Not completely. Birndorf says that’s normal too — although we don’t talk about it nearly enough. “The reason people get dogmatic about parenting choices is because we don’t know,” she says. “It takes a lot of courage and confidence to admit, ‘I’m not sure, but this is how I do it.'”

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Bookshelf

NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Drugs and Lactation Database (LactMed) [Internet]. Bethesda (MD): National Library of Medicine (US); 2006-.

Drugs and Lactation Database (LactMed) [Internet].

Cannabis

Last Revision: November 15, 2021 .

Estimated reading time: 9 minutes

Drug Levels and Effects

Summary of Use during Lactation

The main psychoactive component of cannabis, tetrahydrocannabinol (THC), is excreted into breastmilk in small quantities. The duration of detection of THC in milk has ranged from 6 days to greater than 6 weeks in various studies. Concern has been expressed regarding the possible effects of cannabis on neurotransmitters, nervous system development and endocannabinoid-related functions.[1,2] A 1-year study found that daily or near daily use might retard the breastfed infant’s motor development, but not growth or intellectual development.[3] This and another study[4] found that occasional maternal cannabis use during breastfeeding did not have any discernable effects on breastfed infants, but the studies were inadequate to rule out all long-term harm. Although cannabis can affect serum prolactin variably, it appears not to adversely affect the duration of lactation. However, maternal perception that their use of cannabis is harmful to their infants are likely to discontinue breastfeeding earlier than mothers who do not believe it is harmful.[5] Other factors to consider are the possibility of positive urine tests in breastfed infants, which might have legal implications, and the possibility of other harmful contaminants in street drugs.

Because of insufficient long-term data on the outcome of infants exposed to cannabis via breastmilk, health professionals’ opinions on the acceptability of breastfeeding by cannabis-using mothers varies. In general, professional guidelines recommend that cannabis use should be avoided by nursing mothers, and nursing mothers should be informed of possible adverse effects on infant development from exposure to cannabis compounds in breastmilk. In addition to possible adverse effects from cannabinoids in breastmilk, paternal cannabis use may also increase the risk of sudden infant death syndrome in breastfed infants. Cannabis should not be smoked by anyone in the vicinity of infants because the infants may be exposed by inhaling the smoke.[6-9]

Drug Levels

The main active psychoactive component of cannabis is delta-9-tetrahydrocannabinol (THC), although it also contains other active compounds. THC is very fat soluble and persistent in the body fat of users and slowly released over days to weeks, depending on the extent of use.

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Maternal Levels. Two women who smoked marijuana daily while nursing had their randomly collected milk analyzed. One mother who reported smoking marijuana once daily had a milk tetrahydrocannabinol concentration of 105 mcg/L; other metabolites were absent. The second mother who reported smoking marijuana 7 to 8 times daily had a milk concentration of 340 mcg/L; the metabolite 11-hydroxy-THC was found in a concentration of 4 mcg/L and 9-carboxy-THC was absent. A milk sample that was collected 1 hour after smoking marijuana contained 60.3 mcg/L of THC, 1.1 mcg/L of 11-hydroxy-THC and 1.6 mcg/L of 9-carboxy-THC.[10] One source used data in this case to estimate that the infant receives about 0.8% of the maternal weight-adjusted dosage.[11] However, a poorly characterized assay was used that might not be accurate and the portion of milk (i.e., foremilk versus hindmilk) that was collected by the mothers was not stated. This is important because of the high fat solubility of THC.

A woman who admitted to smoking cannabis (amount not stated) donated milk for analysis at an unknown time after the previous use. THC was present in a concentration of 86 mcg/L and 11-hydroxy-THC was present in a concentration of 5 mcg/L; 11-nor-carboxy-9-tetrahydrocannabinol was not detected.[12]

Eight exclusively nursing women who were 3 to 5 months postpartum and reported previous or current cannabis smoking were studied. After 24 hours of abstinence, each smoked a 100 mg of a standardized cannabis containing 23.18% THC. The product was smoked over 10 to 20 minutes from a glass pipe until it was fully consumed. Milk was pumped before smoking and at 20 minutes, 1, 2 and 4 hours after inhalation. THC and its metabolites, 11-OH-delta-9-tetrahydrocannabinol and 11-nor-9-carboxy-delta-9-tetrahydrocannabinol were measured in the milk samples. Six of the women had baseline THC concentrations of <2 mcg/L; the other two had 5.8 and 15.8 mcg/L of THC in their milk at baseline. The average THC concentration in breastmilk was 53.5 mcg/L (median 27.6 mcg/L; range 8.4 to 186.1 mcg/L), and the average peak THC concentration was 94 mcg/L (range 12.2 to 420.3 mcg/L) 1 hour after inhalation. The metabolites were not measurable (<0.097 mcg/L). The estimated daily THC intake for the infant was 8 mcg/kg, which corresponded to 2.5% (range 0.4 to 8.7%) of the weight-adjusted maternal dosage.[13]

Fifty women who reported using cannabis in the prior 14 days donated milk samples for analysis of THC and its major metabolites. Four women donated two samples each for a total of 54 samples. THC was detectable in 63% of the samples. The median concentration of THC was 9.47 mcg/L (range 1 to 323 mcg/L). Only 5 samples had measurable concentrations of 11-OH-THC (range 1.3 to 12.8 mcg/L) and 5 samples had measurable concentrations of cannabidiol (range 1.3 to 8.6 mcg/L). Samples collected 140 hours (about 6 days) or longer after reported use contained no detectable (<1 mcg/L) THC and the sample with the highest cannabidiol concentration contained no detectable THC. Of the 34 milk samples from mothers who reported using cannabis, the half-life of THC in milk was estimated to average about 27 hours.[14] Using the median value, the median infant THC dosage would be 1.4 mcg/kg daily.

Twenty women in Oregon who admitted to using a cannabis product while breastfeeding their infants provided milk samples for analysis. The mothers reported using cannabis almost daily. Fifteen women provided milk samples at their infant’s 2-week and 2-month checkup and 5 provided a sample at only one of the visits for a total of 35 milk samples. All but one milk sample contained at least one cannabinoid. None of the mothers reported using a cannabidiol (CBD) product, but 13 had detectable CBD in breastmilk. Median (IQR) concentrations in milk were as follows: THC 27.5 (0.8 to 190.5) mcg/L; 11-OH-THC 1.4 (0.7 to 5.2) mcg/L; THC-COOH 1.9 (0.5-16.6) mcg/L; CBD 1.2 (0.5 to 17) mcg/L. Three patients using edible products had similar cannabinoid levels as those who smoked cannabis. Fourteen mothers reported an increase in use of cannabis between the 2-week and 2-month visit. Median breast milk THC concentrations were 16.7 mcg/L at visit 1 and 54.5 mcg/L at visit 2. The authors estimated that overall the breastfed infants received an average THC dose of 4.12 mcg/kg daily (range 0.52 to 123 mcg/kg daily) in milk.[15]

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Seven women who used cannabis during pregnancy more than twice weekly, primarily by smoking, and were documented to be abstinent postpartum donated blood and milk levels 2 to 5 times weekly for 6 to 7 weeks. Maximum milk THC levels ranged from 2.8 to 26.1 mcg/L and the elimination half-life from milk averaged 17 days (range 12.2 to 21 days).[16]

Infant Levels. The urine of 2 breastfed infants whose mothers smoked marijuana found none of the 9-carboxy-THC metabolite. One mother reported smoking marijuana once daily and the other reported smoking marijuana 7 to 8 times daily. Analysis of the feces of the latter mother’s infant revealed a higher proportion of metabolites than THC, indicating that THC was probably absorbed from the milk, metabolized by the infant, and excreted in feces.[10]

Effects in Breastfed Infants

Twenty-seven mothers reported smoking marijuana during breastfeeding. Twelve of them smoked once a month or less, 9 smoked weekly, and 6 smoked daily. Six of their infants were compared at 1 year of age to the infants of mothers who did not smoke marijuana during pregnancy or breastfeeding. No differences were found in growth, or on mental and motor development.[4]

Sixty-eight infants whose mothers reported smoking marijuana during breastfeeding were compared to 68 matched control infants whose mothers did not smoke marijuana. The duration of breastfeeding varied, but the majority of infants were breastfed for 3 months and received less than 16 fluid ounces of formula daily. Motor development of the marijuana-exposed infants was slightly reduced in a dose-dependent (i.e., number of reported joints per week) manner at 1 year of age, especially among those who reported smoking marijuana on more than 15 days/month during the first month of lactation. No effect was found on mental development.[3]

A small, case-control study found that paternal marijuana smoking postpartum increased the risk of sudden infant death syndrome. In this study, too few nursing mothers smoked marijuana to form any conclusion.[17]

A study of women taking buprenorphine for opiate substitution during pregnancy and lactation found that 4 of the women were also using cannabis as evidenced by positive urine screens for THC between 29 and 56 days postpartum. One was also taking unprescribed benzodiazepines. One infant was exclusively breastfed and the other 3 were mostly breastfeeding with partial supplementation. Infants had no apparent drug-related adverse effects and showed satisfactory developmental progress.[18]

Fifty women who reported using cannabis in the prior 14 days donated milk samples for analysis of THC and its major metabolites. THC was detectable in 66% of the samples and below the limit of quantification in 32% of samples. Preliminary evidence found no differences in infant adverse reactions, postnatal growth, or neurodevelopmental outcomes were found between the groups with quantifiable and nonquantifiable THC in breastmilk.[19]

Effects on Lactation and Breastmilk

Acute one-time marijuana smoking suppresses serum concentrations of luteinizing hormone and prolactin in nonpregnant, nonlactating women.[20-22] The effects of long-term use is unclear, with some studies finding no effect on serum prolactin.[23-25] However, hyperprolactinemia has been reported in some chronic cannabis users,[26-28] and galactorrhea and hyperprolactinemia were reported in a woman who smoked marijuana for over 1 year.[28] The prolactin level in a mother with established lactation may not affect her ability to breastfeed.

Of 258 mothers who reported smoking marijuana during pregnancy, 27 who had smoked marijuana during breastfeeding were followed-up at 1 year. No difference was found in the age of weaning between these mothers and 35 who reported not smoking marijuana during pregnancy or breastfeeding.[4]

The US state of Colorado legalized medical cannabis in 2001 and recreational cannabis in 2012. A cross-sectional survey conducted in Colorado in 2014 and 2015 found that both prenatal and postnatal cannabis use were associated with a shorter duration of breastfeeding. Among women who reported using cannabis during pregnancy, 64% breastfed for 9 or more weeks compared with 78% of women who did not use cannabis during pregnancy. Among women who reported postpartum cannabis use, 58% breastfed for 9 or more weeks compared with 79% of women who did not use cannabis postpartum. Both differences were statistically significant.[29]

A study using a database of 4969 postpartum women found that those who reported using marijuana were more likely to smoke cigarettes, experience postpartum depressive symptoms, and breastfeed for less than 8 weeks.[30] Tobacco smoking is known to decrease the duration of breastfeeding, so the effect of marijuana is not clear. Most of the women who smoked marijuana postpartum also used it during pregnancy.