TABLE 3.

Select examples in applying a translational research framework to address cannabis use during lactation

Stage	Examples
T1 Discovery	Existing research at the discovery stage includes rodent models, where it has been determined that perinatal cannabinoid exposure may result in lasting deficits in behavior and function [[117], [118], [119]]; for example, cannabinoid exposure in suckling rat pups adversely affects brain maturation and alters early behavior. However, it is not known if cannabis use alters the hormonal milieu of lactation or milk production outcomes in animal models. There is also a gap in large epidemiologic studies at the T1 stage quantifying effects of exposure during lactation on infant outcomes independent of prenatal exposure. Epidemiologic research is also needed to examine outcomes by mode of use, potency, and timing of consumption during lactation.
T2 Human health implications	It is known that THC crosses the placenta, and prenatal use affects the fetal brain and has been linked to adverse pregnancy outcomes and adverse outcomes in children [120,124]. Postnatal infant exposure may occur via consumption of human milk or inhalation of secondhand smoke [125,126]. THC is lipophilic and remains detectable in human milk for extended periods of time [127,128], with its concentration influenced by the timing of exposure, human milk fat content, and the parent’s metabolism of the drug [129,130]. However, more in-depth research is needed on the pharmacokinetics of THC and metabolites by mode and potency of parents’ exposure, both in relation to transfer into human milk and uptake and metabolism by the infant. To accomplish these studies, research is needed to develop and validate methods to assess dose and exposure to lactating parents and their infants in diverse contexts.
T3 Clinical and Public Health Implications	There are significant gaps in knowledge of the impact of parent cannabis use on parent–infant interactions and related outcomes. Stakeholder-engaged guidelines are needed for the conduct of ethical research in this regard with lactating parents who are already using or exposed to cannabis in their environment. There are also gaps in knowledge regarding cannabis levels in donor human milk, whether procured through human milk banks or informally.
T4 Implementation	Most public health entities emphasize counseling and guidance to reduce or end cannabis use rather than cessation of human milk feeding among users [120,130,131]. However, little is known about the impact of these recommendations on use during lactation. For social desirability and sometimes legal reasons, parents may underreport use, making it more difficult to obtain appropriate counseling and care [132,133]. More research is needed in diverse contexts to better understand influences on use of cannabis products and perceptions of safety during lactation. Also, stakeholder-engaged research is needed to develop and test culturally acceptable and effective strategies to support risk communication and shared decision-making regarding cannabis use during lactation and infant exposure in diverse populations. Research is also needed on effective methods to support reduction or cessation of use among diverse populations. Notably, punitive approaches to perinatal use disproportionately harm Black and immigrant parents [133].
T5 Impact	Research at the community and societal level is becoming increasingly relevant given the growing number of states that have legalized cannabis use. To understand the population-level impact of these changes in legalization, there is a need to monitor changes in perinatal use patterns and how use in diverse populations is influenced by the dissemination and implementation of strategies and guidelines developed in the T4 stage. Research should also include monitoring of racial and socio-economic disparities in the implementation of ethical, evidence-based care for the lactating parent–infant dyad exposed to cannabis.

THC, tetrahydrocannabinol.