Dysphoric Milk Ejection Reflex: A Case Series

Case 1

The participant is a 29-year-old female, para 2, with a 3-year-old son and a 4-month-old daughter. Both pregnancies were uncomplicated. Both infants were delivered at term gestation without complications. After her son's birth, she experienced the “baby blues” during the first three weeks postpartum that resolved spontaneously. Both children were breastfed.

The participant recalls being disconcerted by recurrent negative feelings while breastfeeding her first child. Immediately, when the infant latched and about 45–90 seconds before each milk ejection, she felt intense dread and a deep sinking feeling in the pit of her stomach and found food repulsive. These feelings eased as milk ejection occurred and resolved completely after each MER. On a 10-point intensity scale with 1 being happy/normal and 10 being suicidal ideation, the participant rated her symptoms as a 7 (Table 1).

Her mother expressed similar, but more aggressive feelings while breastfeeding; so the participant assumed that this was a common experience. A search of the internet yielded information mostly on postpartum depression or postpartum mood disorders. She finally found an exact description of her symptoms on the D-MER web domain. She consulted with lactation experts in her area, but none were familiar with D-MER. She was able to find some support through a Facebook support group.

Returning to work after six weeks of maternity leave was difficult. She felt that her coworkers and patients misunderstood what she was experiencing. After she explained D-MER to her coworkers, most were supportive. Soon, they were able to recognize when she was experiencing dysphoria and afforded her time to get through it.

Nonetheless, the patient had guilt about whether or not to continue breastfeeding, concerned that breastfeeding may have had a negative effect on bonding with her baby. Despite this internal struggle, she persisted. At 6 months, she noticed that her spontaneous milk ejections had become less frequent, occurring about 5–10 times per day, and her symptoms were less severe. Although symptoms had decreased, she remained distraught by D-MER and decided to try medication. After giving her primary care provider information from the D-MER web domain, she was prescribed bupropion, an antidepressant. She did not notice any difference in her symptoms and discontinued its use after 8 weeks.

At 1 year, symptoms continued decreasing. She described it as a homesick feeling and noticed that the dysphoric episodes were shorter (about 30 seconds). It was not until 2 months after her son weaned himself at ∼16 months that her dysphoria resolved completely.

The participant's D-MER experience was nearly identical with her second child, but this time she was better educated and cognizant about the condition. As a result, she was able to avoid many factors that seemed to exacerbate her D-MER (Table 2). She also experienced fewer spontaneous milk ejections, ∼10 per day rather than up to 5 per hour. She tried Rhodiola rosea, a root supplement suggested on D-MER.org, and noticed a small improvement in symptoms. However, due to the financial cost, she stopped using the supplement. Her D-MER symptoms were still strong at 4 months, but she remained steadfast in her decision to continue breastfeeding.

Case 2

The participant is a 36-year-old female, para 4, with a 19-year-old daughter, an 18-year-old daughter, a 3.5-year-old son, and an 8-week-old son. The participant delivered all children at term. Three of her four children were breastfed and she experienced D-MER symptoms with her two youngest children.

D-MER symptoms began 4–5 days postpartum. She described these emotions as a churning in the pit of her stomach “like when you hear bad news,” and stated that she felt sad. These feelings lasted up to 2 minutes and resolved between MERs. She initially thought that these negative feelings were due to postpartum depression, but began to notice that the feelings only occurred while breastfeeding. Furthermore, she noticed that these emotional lows were followed by the physical sensation of milk being released.

Although her D-MER symptoms were similar with both of her sons, they were more intense with her youngest. On the 10-point intensity scale, the patient rated her feelings as a four during the day and a five to six at night. Due to this intensity, she dreaded when it was time to feed and became anxious during the feeds. She felt isolated from other breastfeeding mothers because she did not want to breastfeed.

In addition to D-MER, she experienced an insufficient supply of breast milk with her youngest son. She started expressing milk after feedings and tried taking metoclopramide 2 weeks into breastfeeding to increase her supply. She noted that her negative emotions increased after beginning medication. She usually ended her milk expression sessions after the first milk ejection to avoid the negative feelings of the following MERs. Despite her efforts, she was unable to establish a sufficient supply and thus supplemented with formula.

At about 7 weeks, the participant stopped breastfeeding due to her D-MER symptoms along with postpartum depression and insufficient milk supply. Approximately 5 days after stopping, her symptoms dissipated.

Case 3

The participant is a 28-year-old female, para 2, with 3-year-old and 1-year-old boys. Both pregnancies were uncomplicated and ended with late-term deliveries. She experienced a postpartum hemorrhage with her first son, but had no complications during her second postpartum recovery. She experienced D-MER with both children.

During the pregnancy of her first child, she and her husband were both active duty soldiers, stationed at separate locations. He was present for the birth and left 3 days later. She remembered feeling frequently sad and recalled that the sadness increased every time she breastfed. These feelings lasted 30 seconds to 1 minute. She also noticed these symptoms when expressing milk. She rated these symptoms as a 3 on the 10-point intensity scale. These feelings started, she believes, within the first 6 weeks of maternity leave. She also experienced similar symptoms while breastfeeding her second child.

When the participant experienced an MER, she wanted to cry, but often did not even have the energy for tears. She stated, “It was like I was suddenly completely drained of all energy and emotion. It was almost as if a feeling of dread came upon me, and I felt like something bad was about to happen.” She also experienced a loss of appetite during milk ejections and physical discomfort, like a very sharp twinge in her nipples with the milk ejections. She found that the physical and emotional feelings were more intense if there had been longer time lapses since she had breastfed or expressed.

Assuming these feelings were normal, she tried to ignore them. She also tried praying and reading the Bible, but the feelings of hopelessness and sadness completely consumed her.

The participant found that the D-MER symptoms lessened as both children became older. At 9 months, it was more bearable and had almost completely subsided by 11 months. At 1 year of breastfeeding with her second child, she continued to experience periodic negative emotions. She speculates that if the D-MER symptoms lasted longer than a minute, it would have been very difficult to continue breastfeeding, and she would have weaned them sooner. She verbalized remorse that she never experienced the bonding sensation or feelings of happiness or satisfaction that many women speak of when breastfeeding.

Presentation

D-MER presents as an emotional reaction to the MER that may also produce a hollow or churning feeling in the pit of the stomach. ² The dysphoria begins just before milk ejection and continues for no more than several minutes. It may recur with every MER or in some cases remain isolated to only the initial MER of each feeding session. ¹ These negative bodily responses should not be confused with nausea, pain, or other physical manifestations of breastfeeding. ¹

Spectrum

Women experiencing D-MER report a spectrum of unpleasant emotions, ranging from despondency to anxiety, to agitation (Table 1). Despondency is the most common experience and agitation D-MER is the least common.^1,5 The more intense the experience, the longer it is likely to last. ⁶

A rating of 1–3 on the 10-point intensity scale indicates mild D-MER. Women experiencing mild symptoms normally do not seek help or any type of treatment. The problem usually self-corrects within the first three months. It is reported that with education about D-MER, these women are able to tolerate their symptoms. ¹

Women who experience moderate D-MER rate their symptoms from 4 to 7. They often seek management options due to the increased severity, combined with the extended occurrence of symptoms, lasting between 6 and 12 months. Knowledge and education are also helpful for this group.^1,6

Women who experience severe symptoms often stop breastfeeding or seek help through prescription treatment. These women typically rate their symptoms from 7 to 10. Suicidal ideation may be present at this intensity, and symptoms may not resolve until weaning.^1,6

Pathophysiology

Although research on D-MER is sparse, anecdotal information from a number of sources establishes a basis for its understanding. When considering factors that relieve or aggravate D-MER symptoms, it seems likely that dopamine is involved. In lactation, the secretion of prolactin is dependent upon the inhibition of dopamine. ⁷ One theory for this condition is an inappropriate drop of dopamine.^1,6,8

Treatment

Awareness, education, and support groups can help minimize the distress that D-MER can cause. ² In addition, activities, treatments, foods, and medications that raise and maintain dopamine levels have been shown to be effective at relieving or even eliminating D-MER in some individuals (Table 2). At this time, there is no medically approved product to treat D-MER.

Off-label prescription treatment includes bupropion. Bupropion is a norepinephrine dopamine reuptake inhibitor. Although its mechanism of action is not fully understood, it is one of the few medications that help to increase dopamine, while being sustainable for everyday use. Bupropion is in the L3 lactation risk category because there are no controlled studies among breastfeeding women. No adverse consequences have been documented, but two cases have been reported of complications in infants of mothers prescribed bupropion. There are also anecdotal reports of decrease in milk supply while taking this medication. ⁹ Although other prescriptions exist to increase dopamine in the body, not all of them are appropriate for this condition or for a breastfeeding woman. ¹⁰

Natural treatments tried by women with D-MER include, but are not limited to, R. rosea, placenta encapsulation, B-vitamin complex, and acupuncture. R. rosea is a monoamine oxidase inhibitor that prevents the breakdown of dopamine, increasing its availability. Since this is a herbal medication, there is little research to suggest any effect on breastfeeding infants; so future research is needed. ¹¹

Lifestyle changes include the following: distraction during feeding, increasing water intake, sleep, and exercise, reducing caffeine, solitude from others, and reducing stress. Many women find that distracting themselves by watching television or reading while breastfeeding helps take their mind off their symptoms. Others find it hard to read, focus, or perform simple tasks until the feelings pass. ¹