Having to breastfeed a newborn for a second time didn't seem as complicated as the first. Well, I was wrong. I don't remember when it started exactly, but the memories are still vivid: every time I would begin breastfeeding my daughter, I would feel like being covered by sadness, and then, a wave of anxiety would hit me. Is this real? Can breastfeeding trigger these negative feelings? Yes, it is very real and it is called the dysphoric milk-ejection reflex (D-MER).
D-MER is characterized by a generalized dissatisfaction feeling (dysphoria) triggered by the baby's suckling every time mothers start breastfeeding. It begins with milk ejection (or shortly before), lasts for several minutes, and then, ceases. This can occur in both first-time and experienced breastfeeding mothers, leading them to associate lactation with fear and rejection that in some severe cases can even trigger suicidal thoughts. D-MER symptoms commonly decrease after three months of lactating but it can last up to a year or, in some cases during the entire lactation period.
Although D-MER can be challenging, it is important to reassure mothers that they can still have a positive breastfeeding experience.
D-MER is complex and different from post-partum depression
When an infant starts suckling it stimulates the release of oxytocin, the hormone responsible for initiating the milk ejection reflex. Once this reflex is triggered, prolactin levels (the hormone responsible for breastmilk production) start to rise, and to facilitate it dopamine release has to be reduced. Since dopamine is a hormone and neurotransmitter related to pleasure, this reduction has been associated with the negative emotions often felt by individuals with D-MER.
Symptoms of D-MER include anxiety, sadness, hopelessness, nervousness, irritability, agitation, anger, nausea, chills, palpitations, and a sinking feeling in the stomach.
Research has shown that breastfeeding may trigger mood alterations and significantly impact the mental well-being of nursing mothers, possibly resulting in postpartum depression. However, the main difference between postpartum depression and D-MER is that while the first has been identified as a psychological disorder, the latter is a physiological disorder related to a hormonal imbalance.
The need for awareness and mother-centered interventions
Having a negative breastfeeding experience can significantly affect the mental health and overall well-being of postnatal women. It can make them more vulnerable to postpartum depression and general feelings of dissatisfaction due to the inability to nurse as intended. Fortunately, there has been an increase in awareness of postpartum depression in recent times, but there is still a lack of understanding about D-MER and consequently its treatment.
Therefore, training for healthcare providers on D-MER management is also important since insufficient knowledge of this disorder and the lack of evidence-based resources
can result in many mothers with D-MER without being diagnosed or treated. This could negatively impact their lactation and eventually lead them to wean earlier.
While more research and guidance on treating D-MER is necessary, experts advise helping nursing mothers alleviate their symptoms by:
Self-regulation through relaxation techniques.
Breastfeeding with distracting enjoyable activities such as watching a show, eating, or having a conversation with a partner, friend, or family.
Lifestyle changes such as being hydrated, prioritizing sleep, and avoiding caffeinated drinks.
Professional interventions depending on the severity of D-MER.
Raising awareness among mothers and educating them about D-MER is absolutely essential. By doing so, symptoms can be identified and alleviated early, resulting in a much more positive and enjoyable breastfeeding experience.
References:
Huan Liu, Jin Li, Xiaomei Li, and Huapeng Lu.Dysphoric Milk Ejection Reflex: Report of Two Cases and Postulated Mechanisms and Treatment.Breastfeeding Medicine.May 2023.388-394. http://doi.org/10.1089/bfm.2022.0206
Frawley T, McGuinness D. Dysphoric milk ejection reflex (D-MER) and its implications for mental health nursing. Int J Ment Health Nurs. 2023 Apr;32(2):620-626. doi: 10.1111/inm.13115. Epub 2023 Jan 27. PMID: 36705232.
Deif R, Burch EM, Azar J, Yonis N, Abou Gabal M, El Kramani N, DakhlAllah D. Dysphoric Milk Ejection Reflex: The Psychoneurobiology of the Breastfeeding Experience. Front Glob Womens Health. 2021 Oct 29;2:669826. doi: 10.3389/fgwh.2021.669826. PMID: 34816221; PMCID: PMC8594038.
Tamara L. Ureño, Cristóbal S. Berry-Cabán, Ashley Adams, Toni L. Buchheit, and Susan G. Hopkinson.Dysphoric Milk Ejection Reflex: A Descriptive Study.Breastfeeding Medicine.Nov 2019.666-673.http://doi.org/10.1089/bfm.2019.0091
Tamara L. Ureño, Toni L. Buchheit, Susan G. Hopkinson, and Cristóbal S. Berry-Cabán.Dysphoric Milk Ejection Reflex: A Case Series.Breastfeeding Medicine.Jan 2018.85-88.http://doi.org/10.1089/bfm.2017.0086
Heise AM, Wiessinger D. Dysphoric milk ejection reflex: A case report. Int Breastfeed J. 2011 Jun 6;6(1):6. doi: 10.1186/1746-4358-6-6. PMID: 21645333; PMCID: PMC3126760.