Dysphoric Milk Ejection Reflex: A Descriptive Study

Prevalence

To determine the prevalence of D-MER, a retrospective chart review was conducted over a 12-month period. Data were collected from responses to screening questions asked during the 6- to 8-week postpartum visit at a large military medical center located in the southeastern United States. The women were asked two “yes/no” response items about breastfeeding during their current postpartum period. The prevalence of D-MER was determined with the numerator being the number of women who self-identified as having had a negative emotional response to the MER over a denominator of the total number of women who self-identified as breastfeeding.

Survey

Survey participants were initially recruited through advertisements in the medical center's outpatient clinics, electronic media bulletin boards, and at various locations across the military installation frequented by parents with children. Patients who self-identified as having negative feelings during the prevalence data collection also received information regarding participation in the survey. After ∼10 months with a low response rate (n = 25), the sample was expanded by advertising the survey on a publicly available D-MER website. The self-assessed inclusion criteria included women currently breastfeeding or who had breastfed within the previous 6 months.

The anonymous survey consisted of 36 items accessible through a link to an online survey management platform. After asking for basic demographic and obstetric information, the participant was asked if she had experienced negative emotions just before milk let down, when latching, and/or when pumping. If the answer was “no” the participant was thanked for their participation and no further questions were provided. If the answer was “yes” the participant was guided to the remaining 29 items describing the experience of D-MER. The items were developed by the research team based on the limited information currently available in the literature, the available websites regarding D-MER, and the personal experience of a research team member. Although most of the items had closed response choices, some open-ended items allowed participants to further describe any experiences that may not have been captured by the provided options.

Data were analyzed using SAS 9.4 (SAS Institute, Cary, NC). Data were reported in counts and frequencies or medians and interquartile ranges (IQRs) as appropriate. Comparing subjects who did and did not report symptoms in specific categories was carried out using Fisher's exact or the Wilcoxon rank sum tests as appropriate. Comparing subjects who met symptom criteria was performed using Fisher exact test with a Monte-Carlo estimate or Kruskal–Wallis test as appropriate. Comparisons between symptom groups were carried out with Fisher's exact test with a Monte-Carlo estimate or Kruskal–Wallis as appropriate. A p value <0.05 was considered significant.

Although no formal studies have previously been conducted, informal research has shown patterns in the D-MER experience. Based on her observations, Heise categorized the D-MER experience into a spectrum of either Despondency, Anxiety, or Agitation. ⁴ Based on their answers to the question, “I feel ___ just before my milk lets down,” respondents were grouped into one of these three categories. If any anger symptoms were selected (Irritable, Agitated, Tense, Annoyed, Impatient, Frustrated, or Angry), respondents were placed into the Agitation category. If symptoms did not include agitation, but one or more anxiety symptoms (Anxious, Panicky, Restless, Fearful, or Paranoid) were selected, these respondents were placed in the Anxiety category. The remaining respondents, with only despondent symptoms (Sad, Oversensitive, Tearful, Homesick, Worthless, Guilty, Lack of Focus, or Depressed), were placed in the Despondency category. An additional analysis was conducted after grouping respondents into these categories.

Prevalence

In the retrospective chart review, 15 women self-identified as having a negative emotional response to MER of 164 women total who answered positively that they were breastfeeding for a prevalence rate of 9.1%. Three women who selected “yes” that they were breastfeeding and then did not select “yes” or “no” to indicate a negative emotional response were excluded from the analyses.

Survey

Of the 115 respondents who began the questionnaire, 5 did not experience D-MER. Eleven additional respondents quit the questionnaire at the question “Do the feelings come on suddenly and for no apparent reason?” for a total of 99 respondents.

Respondents who completed the survey were predominately white (84.9%), college educated (79.8%), between the ages of 20 and 34 years (76.8%), married (87.9%), and not employed (49.5%; Table 1). All respondents lived with a spouse or partner and 68.7% had other children living in the home. Three-quarters reported having a history of anxiety, depression, or both and rate their current stress level a “3” on a scale from 1 to 5, where 1 is “No Stress” and 5 is “Unable to Cope” (median = 3, IQR = 2–3).

Respondents had been pregnant a median of two times, with 89.9% of the most recent births having been full-term (Table 2). Approximately one-third of respondents (32.3%) stated they had taken no medications during their most recent pregnancy, 29.3% reported taking prenatal vitamins and 16.2% had taken antidepressant or anti-anxiety medications. During the most recent pregnancy, 51.5% of respondents indicated having had postpartum blues, defined as “less than 1 month of mood swings, feeling very happy, then very sad, crying for no apparent reason, feeling impatient, unusually irritable, restless, anxious, lonely or sad,” whereas 14.1% reported receiving a diagnosis of postpartum depression.

Almost all (99.0%; Table 3) reported that the D-MER feelings came on suddenly and for no apparent reason. Most respondents experienced D-MER before every letdown while their baby fed (67.7%) and before every spontaneous letdown (54.5%). Many respondents also experienced these feelings when their baby first latched (49.5%). Over half of respondents reported feeling anxious (83.8%), sad (63.6%), panicky (54.5%), irritable (53.5%), oversensitive (52.5%), agitated (50.5%) and tearful (50.5%). These feelings typically lasted for <5 minutes. On a scale from 1 to 10, where 1 is feeling “Happy/Normal” and 10 is “Wanting to hurt self/others,” roughly half (52.5%) of respondents reported values between 6 and 8 (median = 6, IQR = 3–7). Over one-third (35.4%) had already quit or were considering quitting breastfeeding because of these symptoms. Of concern, approximately one-third (29.3%) had thoughts of hurting themselves or others. Between letdowns, 79.8% of respondents felt happy most or all of the time.

When asked what made symptoms worse, the respondents more frequently reported lack of sleep (54.5%) and stress (46.5%), followed by extended time between feeds/engorgement (24.2%), spontaneous letdowns (21.2%), and caffeine (20.2%). Although only 5 respondents (5.4%) reported worsening symptoms with orgasm, in a later open-ended question, 2 additional respondents mentioned D-MER symptoms just after orgasm or in relation to sexual intimacy, for a total of 8 (8.1%). Distraction (44.4%), sleep/rest (40.4%), and hydration (36.4%) were the most frequently reported strategies for improving symptoms (Table 4).

Of respondents who had previous breastfeeding experience (n = 65), the majority (72.3%; Table 4) had previously encountered D-MER. They reported that their experiences after the most recent pregnancy were the same or worse than those after previous pregnancies (60.0%).

The last question was open-ended. “Is there anything else you would like to tell us about your experience?” Some answers reiterated or expanded on previous questions, including those who described their symptoms in greater detail (8.1%), provided more information on conditions that improved or worsened their symptoms (7.1%), overall duration of symptoms (5.1%), immediate duration of symptoms (4.0%), medication (4.0%), quitting or thoughts of quitting (4.0%) and sexual intimacy (3.0%). There were some common themes that had not been previously addressed. For example, although nausea had not been included as a survey response selection, three respondents noted that nausea was a common symptom of their D-MER episodes. This was in addition to the eight respondents who wrote it in as an “other” response to a previous item (Table 3). Six respondents (6.1%) mentioned having symptoms similar to D-MER either during childhood or during their pregnancy, specifically during the third trimester. Five respondents (5.1%) mentioned that knowing what D-MER is helped them through D-MER episodes; these being distinct from the two who noted awareness of D-MER helped them manage symptoms in a previous question, making a total of seven respondents (7.1%) for whom knowing that D-MER existed provided some relief.

The narrative statements provided a greater depth and breadth to the description of the symptoms. One respondent noted that “I feel like it's hard to breathe. Like someone is sitting on my chest.” Other respondents specified how the combination of symptoms affected them, such as “I experience distress, but do not have thoughts of harming myself or others… my worst experience was after a previous pregnancy when the anxiety caused a panic attack with nausea and derealization.” Another emphasized the intensity of the symptoms experienced: “When I experienced this with my first child [it] was to the point of vomiting every time I would have a let down, with latching or not. I felt as though I was on the border of psychosis because of the severe anxiety.” There is also description from a respondent of trying to understand what she was experiencing related to other physiological cycles: “I chart my cycles and have noticed a connection to parts of my cycle and when my D-MER is stronger and harder to cope with.”

D-MER category comparisons

There were no significant differences between those with symptoms in the Despondent-only category, the Anxiety and/or despondent categories, or the any-Agitation symptom category (Table 5).

Presentation

D-MER has been described as presenting as an emotional reaction to the MER that may also produce a hollow or churning feeling in the pit of the stomach. Although nausea was not initially considered a symptom of D-MER, 11 respondents (11.1%) used the open-ended options to note that nausea was a common symptom of their D-MER episodes, suggesting that more respondents may have selected this symptom had it been offered as an option. This is different from the previous assertion that nausea is not considered part of the phenomenon.^1,4,7

The symptoms reported by >50.0% of the respondents, such as being anxious, sad, panicky, irritable, oversensitive, agitated, and tearful are similar to those reported in previous case studies.^2,6 Although the respondents did not describe their symptoms differently based on a severity categorization,^3,8 further exploration is warranted. There is a potential that individuals who completed the survey were experiencing more severe symptoms, whereas individuals with mild symptoms may have been less likely to have responded.

These symptoms represent more emotional alterations than identifiable physiologic responses. However, the timing and duration of symptoms suggest a physiologic trigger. Almost all respondents (99.0%) stated that the feelings came on suddenly and for no apparent reason and 86.9% stated that feelings went away within 5 minutes. Despite these symptoms, most (79.8%) reported feeling happy between letdowns, separating this experience from postpartum depression and other psychological breastfeeding conditions.

The findings that ∼75% of the respondents had previously diagnosed anxiety and/or depression should be given consideration. Specifically, it may be advised that providers advise their breastfeeding patients with any history of anxiety or depression that D-MER is a possibility. Alternatively, providers should have awareness of the differentiating symptoms of D-MER to assist in accurate diagnoses. Future research should also explore the potential of misdiagnoses for individuals who experience D-MER, rather than postpartum blues or depression symptoms.

Variables that exacerbated symptoms were both physiological and psychological (Table 4). Roughly half of respondents reported that lack of sleep and stress exacerbated symptoms, as previously reported. ⁶ Engorgement, spontaneous letdowns, and caffeine worsened symptoms in approximately one-fifth of respondents.

A new finding in this study was 10 respondents reported thyroid problems and 9 reported autoimmune disorders. This may indicate a need to explore the effect of other hormonal variables on D-MER symptoms.

Of note, respondents were asked “How long did your symptoms last?” after the question “Did you encounter similar symptoms with previous breastfeeding experiences.” However, 17 respondents who indicated they either had no previous breastfeeding experience or no previous D-MER experience still answered this question. We suspect that respondents without previous breastfeeding experiences, but who are no longer having episodes of D-MER may have answered this question for their most recent breastfeeding experience. Keeping in mind that respondents may have answered this question for previous or current breastfeeding experiences, 48.4% of the 62 respondents who have had D-MER symptoms reported they lasted 6 months to 1 year and 29.0% reported having them for more than 1 year.

Treatment

Awareness, education, and support groups have previously been found to minimize the distress that D-MER can cause. ¹ In this study, only 6.1% of respondents reported that counseling/therapy made symptoms better; however, we did not collect data on the number of respondents who sought out counseling and/or therapy. Likewise, only 7.1% reported an improvement in symptoms from an awareness of D-MER, but no data were collected on the proportion of respondents who were aware of D-MER during their experiences. Lifestyle changes may include the following: distraction during feeding, sleep, increasing water intake, exercise, solitude from others, music, meditation, and aromatherapy. Many women found that distracting themselves by watching television or reading while breastfeeding helps take their mind off of their symptoms, similar to that previously reported. ⁶ Others, however, find it hard to read, focus, or perform simple tasks until the feelings pass.^2,8 More focused research regarding effectiveness of different treatments and personal awareness of D-MER symptoms is needed.

At present, there is no medically approved product to treat D-MER. Because education is effective for some women experiencing D-MER, simple acknowledgement and awareness of this condition by obstetric and lactation professionals may make a difference.

Limitations

This study has several limitations. First, it was based primarily on a purposive sample. Thus, the noticeable dearth of women of color and the preponderance of postsecondary educated women. Socioeconomic data were not collected, which could be another important factor. It is unknown whether other multicultural societies experience similar results. Because of an inevitable degree of selection bias, no accurate calculation as to incidence of this phenomenon could be made.

Survey results may have also been impacted by the source of recruitment of participants. Most of the responses to the survey occurred immediately after advertising on a D-MER website. This website contains a plethora of anecdotal information about D-MER including the experiences of other women with these symptoms and dialog between them. There is potential that the respondents were influenced by this information. In addition, an elevated level of symptom severity may be plausible to cause individuals to seek information about D-MER and lead them to this website. As a result, the individuals who viewed the survey information on this website may have had more severe D-MER experiences than the general population.

Finally, the items in the survey were developed with limited information regarding D-MER. As previously discussed, several of the survey questions may have been unclear, and future research may benefit from additional components, such as the onset of symptoms and potential contributing factors, or the inclusion of a control group.