THE 21ST-CENTURY CHALLENGES TO THE DEVELOPING BRAIN

Wakako Minamoto Eklund, DNP, APRN, NNP-BC

Neonatal nurses are committed to providing developmentally sensitive care with gentle and nurturing experience to neonates whose brains are undergoing rapid growth. Multiple approaches and programs have been introduced and studied1-3 to create an environment where cortical development, connections of synapses, and myelination of every neuron can continue following the in utero trajectory. Neonatal nurses not only care for developmentally challenged preterm infants; they also care for not so preterm infants who are challenged with behavioral symptoms related to prenatal substance exposure. One of the substances that is increasingly a frequent finding within the maternal drug screen is tetrahydrocannabinol (THC). THC is the principal psychoactive element of cannabis, also known as marijuana that has been increasingly legalized in the United States for not only medical use, but for recreational use.4

On August 29, 2019, the office of the US Surgeon General issued an Advisory on Marijuana Use and the Developing Brain emphasizing the importance of "Protecting the Nation from the health risks of Marijuana use in adolescence and during pregnancy ..."4

Marijuana, the most frequently used illicit substance in the United States, impacts the brain by binding to the cannabinoid receptors inducing euphoria, or cognitive/motor impairment, and, with higher doses or long time use, a link to mental illness including schizophrenia is reported.5 This federal advisory generally reflects the recommendations issued earlier in 2015, 2017, and 2018 by the American College of Obstetrician and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP)6,7; however, it notably does not recommend against marijuana risk in lactation. It does recommend "No one should smoke Marijuana or tobacco around a baby."

The same cannabinoid system/receptors that lead to desired symptoms for adults who use marijuana also impact the fetal cortical development that later impacts mood, and ability to make decisions or coping.8 The cannabinoid system plays a key role again during adolescence when neural connections undergo refinement, as the brain progresses from adolescence to young adults.9

The National Survey on Drug Use and Health indicates that increased use of marijuana among the general public is significant. Marijuana use among those 12 years and older increased from 6.2% in 2002 to 8.9% in 2016.10 For young adults 18-25 years old, 1 in every 5 (20.8%) indicated the use of marijuana within the last month, showing the highest since 2002.10 Thus, the reported bifold increase of marijuana use among pregnant mothers between 2002 and 2017 (3.4%-7%) may be underestimated today.11

Newnam12 pointed out, in the August issue of Advances in Neonatal Care in 2018, that the problem of increasing cannabis use is likely to progress due to the increased cannabis legalization in multiple states. The increased encounter with infants with in utero exposure to THC translates as a significant public health reality requiring vigilance and heightened need for well-informed healthcare professionals equipped with accurate information to support infants and families.

The ACOG had published recommendations in 2017 by updating the earlier 2015 recommendations.6 By accessing the following link, the readers can examine the evidence illuminating the increasing health threat of maternal use of marijuana to neonatal population: https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Commi.

Concerns for negative pregnancy outcomes, such as low birth weight, preterm births, or stillbirths, are included. The report updates that current evidence does not demonstrate the perinatal marijuana exposure to perinatal mortality; however, it indicates an increased risk of stillbirth (relative risk 1.74; 95% confidence interval [CI], 1.03-2.93). Frequent use of marijuana was associated with an increased risk for small-for-gestational births (6.7% vs 11.2%; 95% CI, 1.44-2.45). The report also maintained the earlier findings of smaller head circumference associated with marijuana exposure, which were more prominent with first- and second-trimester exposure.

The recommendations published late 2018 by the AAP Committee on Substance Use and Prevention, Section on Breast Feeding, addresses more specifically regarding the marijuana use during pregnancy and breastfeeding.7 Prenatal use of marijuana can affect the fetal cortical development13 as well as the maternal placental function.14,15 Mean lower birth weights, lower Apgar scores, and increased risk for stillbirth are also reported.16 THC is also a lipid-soluble substance with a low molecular weight, which transfers easily to human milk. The full report is available at https://pediatrics.aappublications.org/content/pediatrics/142/3/e20181889.full.p.

The report does describe the challenges in identifying the specific effects of THC, since most marijuana users are not using marijuana alone, confounding the results. However, polysubstance exposure is the actual reality seen frequently in today's environment making the findings quite valuable and relevant. The 10 evidence-based recommendations made available in this guideline are useful for nursing professionals who work with pregnant mothers or their newborns. A few of the most practical recommendations include the following points:

* Marijuana should not be used during pregnancy, and when using medical marijuana for conditions such nausea and vomiting, consider alternative treatments.

* The use of marijuana during pregnancy in states where marijuana is legal does not exempt a mother from potential investigation for having positive results due to the priority placed on the child's welfare. Testing is done to offer options for maternal treatment.

* Mothers are encouraged not to use marijuana while breastfeeding and mothers need to be informed of potential impact of THC on the rapidly growing brain.

* Pediatricians are urged to work with local or state agencies to advocate for policies to protect infants and families.

The last recommendations address pediatricians, but this advocacy effort is also highly relevant to neonatal nursing professionals. We are caregivers, nurturers, educators, but also advocates for the infants and their families. We encourage you to be vigilant and knowledgeable about the health risks of marijuana and current recommendations. Additional reports from legalized states are likely going to become increasingly available. A report published last year from Colorado revealed that marijuana use was associated with 50% increased likelihood for low birth weight (odds ratio, 1.5; 95% CI, 1.1-2.1) independent of maternal age, race, level of education, or prenatal tobacco.17

The Colorado Department of Public Health and Environment offers various resources designed in response to marijuana legalization (https://www.colorado.gov/pacific/cdphe/marijuana-clinical-guidelines). Some information is offered in multiple languages and highly useful. The Center for Disease Control and Prevention website provides information in a friendly and easy-to-access format (https://www.cdc.gov/marijuana/index.htm). Please share these resources. Today, general public is gaining the perception that marijuana is OK due to the widespread legalization for both medical and recreational use. It is not OK for infants.

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