What is your experience with breastfeeding? Do you feel angry or tearful as soon as you start? Is there a sense of dread when you begin another pumping session? How intense is your anxiety during these moments? When it comes to nursing, there are many parents who enjoy the experience and feel it’s an opportunity to connect with their infants. However, there are also many parents who are frustrated and distraught by the same encounter. Before we assume that the reason we are struggling with nursing is due to postpartum mental health, we want to rule out a physiological illness called D-MER.

Signs of D-MER:

Dysphoric Milk Ejection Reflex (a.k.a. D-MER) is a breastfeeding struggle that occurs during letdown of milk. This includes nursing, pumping, or manual expression to release milk. Normally when lactating, parents experience the warm and loving feelings that come with an increase in oxytocin. However, with D-MER, a caregiver has a sudden drop in mood, and can experience any of the following difficulties:

• dysphoria, or a state of unhappiness
• panic
• restlessness
• hopelessness
• anger
• anxiety
• sense of dread/doom
• paranoia
• thoughts/urges about suicide or self-harm

D-MER most commonly shows up as anxiety, agitation or sadness. The intensity of these experiences can vary from mild to moderate to severe. These symptoms can last anywhere from a few seconds to 2-3 minutes. It typically shows up about 30 seconds prior to milk release. D-MER struggles subside as you continue to nurse, but reoccurs as soon as another let down happens. Typically, parents start to feel better after 3 to 6 months once milk production regulates. Unfortunately, there are no specific tests or assessments to confirm you have D-MER. If you notice an abrupt shift in mood when you are pumping or nursing, it warrants considering whether D-MER is a factor for you.

D-MER versus Postpartum Mental Health

D-MER is a physiological issue. It happens because of hormonal and chemical changes in the brain during breastfeeding. This is not a psychological issue, although it certainly feels like one. Folks who have a history of mental health struggles are not more vulnerable to experiencing D-MER. It is completely by chance. Parents who have experienced D-MER with their first child have a higher likelihood of experiencing it again with future children.

D-MER is not the same as postpartum mental health. While an episode of postpartum anxiety can last for hours or days, D-MER lasts a few minutes and only occurs during the release of milk. Once breastfeeding is completed, parents moods regulate and they are able to re-engage in their daily activities. Unlike any prenatal or postpartum disorder which involves a combination of biological, psychological and social influences, D-MER is caused solely by hormonal shifts.

This does not mean that the two are mutually exclusive. Parents with perinatal mood and anxiety disorders can also struggle with D-MER. If this is the case, then a combination of treatment is useful in order to address both needs.

Why it happens:

D-MER has only recently been identified as a breastfeeding struggle, and research has started in the past 10 years. However, dopamine has been identified as the primary influencer to experiences of D-MER. Dopamine (a hormone connected to feelings of pleasure) must drop in order for prolactin (the hormone which helps produce milk) to increase. What research has found with D-MER is that the drop in dopamine is too significant during milk letdown, which triggers an abrupt drop in moods.

What you can do if you have D-MER:

The first and most important thing to remember about D-MER is that it is not your fault. You are not doing breastfeeding or parenting incorrectly. This is truly a chemical change that is happening outside of your will power. It is not a psychological issue, and there is absolutely nothing “wrong with you.” It’s an automatic reaction, and the emotions and thoughts that come with D-MER are not based on facts, reality, or any truth to your capacity as a parent.

Approximately half of nursing parents stop breastfeeding by 6 months. This can happen for a variety of reasons, and only you are the judge of what is right for your body. If D-MER is one of the reasons to stop breastfeeding, it may be helpful to know that most parents struggling with this issue feel an improvement of symptoms in 3 months once milk production regulates.

Connecting with your health care team:

Knowing that this ailment is a chemical imbalance, it’s best to speak with your physician or lactation consultant about your experience. In moderate to severe cases of D-MER, treatment options will likely involve medication or herbal supplements to support adequate dopamine production.

Behavioural Strategies

With milder versions of D-MER, there are several behavioural strategies that can be used to support your nursing experience. Firstly, it is helpful to keep track of your symptoms. What varies on days when your D-MER symptoms are worse? Common factors that can improve or exacerbate D-MER include: stress, rest, caffeine intake, hydration, and exercise.

Changing the Pattern:

Secondly, we want to create a more positive experience when nursing or pumping. When we know we are walking into a stressful event, our system braces in anticipation. With enough occurrences of D-MER, parents are typically anxious about lactation. To break this pattern, we want to pair positive experiences with breastfeeding. While nursing or pumping, add in a pleasurable activity that you can use as a distraction. Options can include: listening to your favourite podcast, reading a novel, playing a game on your phone, watching your favourite TV show, eating a delicious piece of cake. Use this activity only when you are breastfeeding to help your system create positive anticipation.

Mindfulness

Thirdly, mindfulness practices can be used to help during this time. When our system anticipates threat, we are hypervigilant of all signs and symptoms related to the threat. Unfortunately, this can make things worse because we are fixated on every nuance that can go wrong. We can also get caught in a negative spiral after breastfeeding is done because we continue to think about the experience and fret about what did not go well.

Mindfulness involves choosing a neutral anchor to focus our attention. For example, you can focus on the sensation of holding your baby, or keep count of baby’s gulps during a feed. You can pay attention to your own body or breath. You may also focus on external anchors like listen to music or noticing what is outside in your backyard. Your mind may wander, and mindfulness involves re-directing your attention to the safe and neutral anchor whenever this occurs.

Breastfeeding is Tough

There are a lot of factors that can influence our postpartum year, including breastfeeding struggles and D-MER. At the end of the day, no one can or should make the decision to start or end breastfeeding other than you, the lactating parent. If you find your mental health is influenced by your breastfeeding experience, please reach out. You do not have to struggle in isolation.

Take care,

Kasi