Some breastfeeding women feel negative emotions such as sadness, depressed mood, anxiety, irritability or anger just before their milk lets down and starts to flow. These emotions might continue for a few minutes. The feelings are usually described as either Dysphoric Milk Ejection Reflex (D-MER) or breastfeeding aversion and agitation (Aversion). The two phenomenons are similar but slightly different. Some women may feel nauseous during breastfeeding. This article looks at both D-MER and Aversion and answers frequently asked questions.
What is Dysphoric Milk Ejection Reflex (D-MER)?
D-MER is described as an abrupt drop in emotions just before milk is released from the breast by the milk ejection reflex or let-down reflex. The drop in emotions only lasts for a few minutes and is always associated with the let-down reflex. The negative feelings involved might range from feeling sad to feelings of hating oneself. Three distinct emotions are often described namely depression, anxiety and anger. The strength of these feelings varies between sufferers. D-MER is not connected to postnatal depression.12
What causes D-MER?
Physiological not psychological
D-MER is thought to have a physiological cause (a physical and chemical process occurring in the body) over which there is little control. Heise and Wiessinger liken it to a reflex action that you cannot stop:
Imagine tapping your knee to cause a reflexive jerk. Now tell yourself that you are going to resist the reflex with all your will, and tap again. Does your willpower make any difference? This is precisely the problem for the mother with D-MER. The emotions are unavoidable. She can feel them coming, but cannot stop them.
Theories to explain the phenomenon include:
Drop in dopamine
One theory for the cause of the negative feelings of D-MER is a drop in dopamine (a chemical messenger released by the brain) that occurs whenever milk is released. During the let-down, dopamine may fall more than usual in some women causing a temporary deficit or they may be more sensitive to the drop in level (Heise and Wiessinger, 2011).
Oxytocin surge
Another theory suggests the sudden oxytocin surge during the let-down reflex may be the trigger.3
Is there any treatment for D-MER?
Avoid stress, dehydration, caffeine
It can be useful for mothers to try and track their own symptoms against life style factors such as stress, dehydration or caffeine as these may exacerbate symptoms of D-MER. Details such as getting more rest, drinking more and having more exercise can be helpful for some mothers. Uvnas-Moberg and Kendall-Tackett explain how lowering stress levels to make the mother feel comfortable and safe might be helpful:
A clean and orderly environment can be helpful in downregulating a mother’s stress response—have music the mother enjoys, with a comfortable place to sit, and nice things to look at. Warmth also triggers the oxytocin response. Give the mother a hot pack around her shoulders, or suggest that she soak her feet in warm water. The goal is to use the mother’s environment to help her feel comfortable and safe.
Dopamine
Dopamine is an important hormone and messenger (neurotransmitter) in the body. An information sheet on Alia Macrina Heise’s Dysphoric Milk Ejection Reflex website discusses prescription treatment for severe cases of D-MER in the form of dopamine supporting medications.4
Skin to skin contact
Skin-to-skin contact between mother and baby is another way to increase oxytocin and reduce stress in mother and baby. The power of skin to skin contact may help override the negative feelings of D-MER (Uvnas-Moberg and Kendall-Tackett. 2018).
Mindfulness
Being aware of negative thoughts and focussing on one’s breathing is part of mindfulness and may be helpful to cope with the emotions of D-MER. Uvnas-Moberg and Kendall-Tackett explain:
With mindfulness, mothers focus on their breathing, are in the present moment, and treat themselves with compassion. They remind themselves that the negative thoughts they are experiencing are thoughts, not facts. Patient education about the symptoms can also be helpful, so mothers know what these symptoms are and that they will go away soon.
Nutrition and self care
One case study showed that increasing protein in the mother’s diet and not pumping beyond her baby’s immediate needs helped alleviate symptoms (Uvnas-Moberg and Kendall-Tackett. 2018)
Where can I get help and support?
Most women with D-MER usually find that their symptoms gradually reduce, sometimes disappearing as time goes on but for others symptoms do not completely disappear until their baby is weaned and they are no longer breastfeeding. Finding out as much as possible about D-MER and seeking help and support can make D-MER more manageable. Many mothers find knowing that the phenomenon has a name and has a physiological cause is helpful (Heise, 2011). Three good places for assistance include the D-MER.org website, the book Before The Letdown: Dysphoric Milk Ejection Reflex and a Facebook support group run by Alia Macrina Heise.
Clinicians can support women with D-MER in several ways; often, simply knowing that it is a recognised phenomenon makes the condition tolerable.
Breastfeeding aversion and agitation
Breastfeeding aversion involves the nursing mother feeling negative emotions. The reasons why are not known and more research is needed.5 A website dedicated to breastfeeding aversion collated by Zainab Yate explains:
Breastfeeding / Nursing Aversion & Agitation (BAA) is a phenomenon whereby breastfeeding / pumping mothers experience negative emotions triggered whilst breastfeeding, these include anger, rage, agitation and irritability. Women also struggle with an ‘overwhelming urge to de-latch’, and often a skin itching sensation. BAA or ‘aversion’ can be experienced by any breastfeeding (or even pumping) person, at any stage of their feeding journey, and it varies in onset, severity and duration.
Anecdotal ideas to help with breastfeeding aversion are listed on Zainab’s website. These include making sure baby’s attachment at the breast is as good as possible, distracting oneself with other activities during breastfeeding, getting enough sleep, making sure you have enough time for yourself away from breastfeeding and ensuring you have drunk enough and are eating well. For some mothers a hormonal imbalance can trigger the aversion. Finding peer to peer support from others who experience BAA can also be helpful.
Nausea
Feeling nauseous (as if one might be sick) during breastfeeding is not common but may be due to high levels of oxytocin and other hormones active during the let-down reflex. 6.
Allergic to breastfeeding?
There are occasional case reports in the literature of mothers noticing physical symptoms with breastfeeding similar to those experienced with allergy for example rashes, itching or shortness of breath.78 9 The severe form of this occurrence is known as breastfeeding induced anaphylaxis or lactation anaphylaxis and can be managed with antihistamines.
Lawrence and Lawrence also discuss less dramatic rashes/hives (urticaria) associated with the let-down reflex which can be managed with antihistamines or low dose corticosteroids. 10 The reactions are thought to be associated with the let-down (when milk is ejected from the breast), a time when the hormones oxytocin and prolactin are released. However the direct cause of the symptoms is not known and more research is needed.
Summary
Dysphoric Milk Ejection Reflex or D-MER, is a collection of negative emotions—anxiety, depression, anger—experienced by some breastfeeding mothers just before they have a milk let-down (milk ejection reflex). These feelings last for a few minutes. The cause is thought to be due to a sudden drop in dopamine during let down which can affect susceptible women. There are a number of treatments available that can help. Other negative states experienced by some nursing mothers include breastfeeding aversion and agitation or nausea. Very rarely, a mother can experience an allergic reaction to breastfeeding.