Dysphoric Milk Ejection Reflex (D-MER)

by Cynthia Billiar, BSN, RN, IBCLC, ANLC,  ICBD, ICCE

D-MER is described as a wave of negative emotion that occurs just prior to the milk release of a breastfeeding mother during breastfeeding, pumping, and even with a spontaneous release.

I recently had the privilege of attending a conference where Alia Macrina Heise spoke and described her personal story of how D-MER affected her breastfeeding journey with her third child in 2007. Alia explained that very little was known about this condition and few mothers even talked about it prior to 2007. Since 2007, Alia has made it her mission to bring awareness to this uncommon, yet underreported, very real phenomenon. In fact, Alia was part of giving D-MER its name. In 2008, Alia established a website to connect with others who suffer from D-MER. This website brings awareness to D-MER and hopefully will help to find solutions to this condition. It is through this web site and from thousands of mothers sharing their personal experiences with D-MER that Alia has been able to bring common threads of D-MER together, which has helped many women begin to understand D-MER. You can find her story here.

In Alia’s article, Understanding Dysphoric Milk Ejection Reflex, she explains that the breastfeeding mothers with D-MER experience a feeling of dysphoria as a surge of negative emotions lasting about 30-90 seconds prior to their milk release. She explains that as soon the milk is released and the baby is transferring milk the negative emotions are gone, but they do return prior to every milk ejection reflex, (MER). This surge of negative emotions mothers feel with D-MER appears to fall within one of a three-level spectrum: hopelessness, anxiety or agitation with varying intensity. The intensity can be mild, often described as a pang or a sigh and rated in severity on a scale of one to three. Moderate D-MER is usually rated in severity on a scale of four to seven and severe D-MER is rated on a scale of seven to ten. Severe D-MER can present with suicidal ideations and other thoughts of self-harm. These negative feelings with D-MER are directed inward toward self, not toward her nursing child or her family. The nursing mother may say things like, “What is wrong with me?”, “I can’t do anything right”, “I am a horrible mother”, and “I am worthless.” All of these negative feelings are gone once her milk begins to flow. D-MER is not postpartum depression; mothers with D-MER feel perfectly fine except just before milk release. The dysphoria felt with D-MER is brief, lasting no more than thirty seconds to two minutes and always begins before a milk let down, MER. Many mothers describe the negative feelings as a hollow feeling in their stomach, a churning or something in the pit of their stomach. Here are a few common words you may hear mothers use when describing D-MER: anxiety, sadness, dread, panic, gross, icky-ness, homesick, exhaustion, anger, discouraged, paranoia, urge to “get away”, and weepy.

D-MER appears to have a physiological cause which is believed to be caused by a hormonal shift just prior to MER. The question however is which hormone?  There are a couple of hypotheses at this time, the first being dopamine. With Alia’s personal experience and research through her website, dopamine appears to be the link that leads to D-MER. The second hypothesis is oxytocin, (Moberg & Tackett, 2018). More research is needed and more awareness needs to be brought to the professionals that work with breastfeeding mothers.

Things that have been shown to improve D-MER symptoms due to the effect on dopamine levels are hydration, exercise, and plenty of rest. The use of Wellbutrin has been shown to decrease D-MER symptoms, while SSRI’s has been shown to have no effect. Cigarette smoking and pseudoephedrine (Sudafed) have both been shown to decrease symptoms but are not recommended; smoking for health reasons and Sudafed because it can decrease milk production.  Caffeine and Metoclopramide (Reglan) have both demonstrated an increase or worsening of D-MER symptoms along with dehydration and stress, (Bosco, 2012). Being mindful of D-MER can be helpful; when some mothers become aware of what D-MER is they are able to talk themselves through their emotional feelings just before their MER. Increasing oxytocin levels through skin to skin contact is another way some mothers might be able to decrease the intensity of D-MER. One mother reported that she was able to decrease her symptoms of D-MER by increasing protein and decreasing carbs in her diet. Her thoughts were that the protein helped her maintain her blood sugar levels where the carbohydrate overload she was eating caused her blood sugars to fluctuate too much.

In conclusion, D-MER is real and we need to be talking about it.  There is still much we don’t know about D-MER; however, we know enough that we are able to validate a mother’s feelings when she describes what we now know as D-MER. Resources and handouts for mothers and providers can be found at d-mer.org. You can email Alia at info@d-mer.org with questions or find more info on Facebook.  There is also a D-MER support group on Facebook. You can read Alia’s blog and find her on Twitter.

”These mothers serve as a reminder to us all that we do not yet have a complete understanding of human lactation.” (Heise & Wiessinger, 2011)

Bosco, M. L. (2012). Dysphoric milk ejection reflex (D-MER). Retrieved from https://www.fhea.com/content/content/breastfeeding/september2012.pdf
Heise, A. M., & Wiessinger, D. (2011, June 6 2011). Dysphoric milk ejection reflex: a case report. International Breastfeeding Journal, 6. https://doi.org/10.1186/1746-4358-6-6
Moberg, K. U., & Tackett, K. K. (2018). The Mystery of D-MER. Clinical Lactation, 9, 23-29. https://doi.org/10.1891/2158-0782.9.1.23

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