Saturday, May 30, 2009

Dysphoric Milk Ejection Reflex (D-MER) and Me


Defining D-MER: What It Is
Dysphoric Milk Ejection Reflex is a newly recognized condition affecting lactating women that is characterized by an abrupt dysphoria, or negative emotions that occur just before milk release and continuing not more than a few minutes.

Preliminary testing tells us that D-MER is treatable and preliminary research tells us that inappropriate dopamine activity at the time of the milk ejection reflex is the cause of D-MER.

Clarifying D-MER: What It Is Not
  • D-MER is not a psychological response to breastfeeding.

  • D-MER is not nausea with letdown or any other isolated physical manifestation.

  • D-MER is not postpartum depression or a postpartum mood disorder.

  • Lastly, D-MER is not the "breastfeeding aversion" that can happen to some mothers when nursing while pregnant.
How D-MER Presents: What Mothers Feel
The negative emotions, or dysphoria, that a mother with D-MER experiences often manifest "in the mother's stomach" - a hollow feeling, a feeling like there is something in the pit of the stomach, or an emotional churning in the stomach. Mothers report varying types of emotions with D-MER ranging from dread to anxiety to anger, these emotions fall on the D-MER spectrum which has three different levels. The common thread between these levels, is the wave of negative emotions or dysphoria, prior to letdown, when nursing, expressing and with spontaneous letdowns, that then lifts within another 30-90 seconds, and then usually repeats with each letdown.

A key piece of D-MER is that a mother with D-MER feels absolutely fine except just
before her milk starts to flow. D-MER is a brief feeling, not more than 30 seconds to 2 minutes, only and always beginning before let-down. This is not postpartum depression and most of these mothers feel perfectly fine except for that pre-milk moment. A brief interval after the negative feelings appear, the milk begins to flow.

D-MER can easily go unrecognized since
  1. some mothers have so many closely spaced letdowns per feeding that the feelings do not have a chance to dissipate before the next D-MER is upon her, making her feel that she experiences on long D-MER through most of, if not all of, the feeding

  2. many mothers do not physically feel a letdown in their breasts and so does not connect the feeling as to being just prior to letdown and

  3. given the fact that D-MER happens with spontaneous letdowns as well, a mother may not immediately connect the way she is feeling to being a breastfeeding phenomenon.
I first read about D-MER a few months ago, maybe in January or February, and I recognized it immediately as something that I was experiencing, on the mildest end of the spectrum.

This level is described on as: [italics mine]

A sensation of a pit/hollowness or sinking in the stomach
An urge to "get away"
General negative emotions
Feelings of being hopeless
Feelings of being apprehensive

There's a long list of other feelings that "level one" moms describe; below are the things from that list which sound like what I experience:

A "twinge"
A "pang"
An inability to cope
Ill at Ease
A fear of having failed
(not any more, but very
much so before Peeper learned to nurse)

In fact, I had identified, with the first few weeks that Peeper was actually nursing (by our trip to Texas, at which point she'd been nursing for less than a month) that I quite often got what I can best describe as an "oh shit" or "I've fucked up" feeling in my gut, just as she started to nurse.

I had attributed it to leftover emotional baggage from the pumping. In retrospect, I'm sure I was feeling it each time I pumped, but since negative feelings were totally justifiable then, it never struck me as odd.

When I continued to feel it when Peeper actually nursed, it did strike me as out of place, but I figured I was just still associating letting down with the negative feelings I had about the pump.

When I read about D-MER, those feelings made sense, and it was helpful to have a reason for them, and to be able to say (usually), "Oh no! What's wrong?! Oh yeah, that's what it is, and . . . now it's gone. Whew."

I didn't really think too deeply into it, but I am now realizing that maybe I don't always recognize the negative feelings as D-MER and dismiss them as I shoud, and I've started to put together that perhaps this is, while certainly not the root of, at least exacerbating some issues that I've been having over the past, oh, I dunno, seven months or so.

The weird thing is that I've never had negative feelings about breastfeeding.

About the difficulties we had getting started, of course, but never about Peeper breastfeeding.

That, I love.

Even when it seemed like that's all she did all day, and even when I would think, "Are you kidding me? Again?!" I still couldn't say that I didn't love everything about it.

I love the connection that she and I have because of it, I love that until recently (and other than that bit of formula that, yes, I will always regret) I built her all by myself, and I love that, for all its imperfections, in both form and function, my body is doing exactly what it was designed to do, nurturing her both physically and emotionally.

So the breastfeeding itself, I do not feel negatively about one bit, but I do often have negative feelings that occur while I am breastfeeding.

(Of course, one could argue that there are many things that "often happen while I am breastfeeding" because I am breastfeeding so much of the time!)

It occurs to me that many of those times when I let myself get insecure about my parenting, and start fretting about whether we're doing things "right," or when I let comments from less-than-supportive people get to me, or when I just get scared about, well, everything, it's very likely that I'm actually experiencing D-MER and letting the feelings take me on that trip toward negativity, before I recognize that they are, in fact, false emotions.

When I'm not actually in the middle of it, it's pretty easy to recognize that if Peeper is sleeping in my lap, and starts to stir, and I offer her a breast, and she latches and settles back down, and I then immediately begin to worry about whether I'm nursing her "too much" (does such a thing exist?) or making her sleep "too much" (ditto) or just "making" her nurse (not possible - tried it for six fucking weeks, remember?) to make her go back to sleep, because I'm just too selfish to want to deal with entertaining her when she wakes up (and what kind of a mother does that make me?!) that, yeah, just maybe that's some crazy talk being inspired by the feelings of dread and guilt and anxiety that are produced by a dropping dopamine level when she latches and my milk starts to flow for her.

So, I'm trying to remind myself of that. When she's nursing and I get that feeling in the pit of my stomach, I tell myself, "Yep, there it is. Just ride it out. And, there it goes. Okay, we're all good now."

"Ride it out," is a good metaphor for me, because it reminds me of a rollercoaster or something like that. Literally, because the stomach feeling is similar to what you feel when the coaster drops, but also figuratively, because it is a false emotion.

A rollercoaster or a scary movie or a haunted house is "fun" (not for me, but I hear some people like them) because you get to experience the "rush" of fear without actually being in danger.

I try to think of it that way, and try to experience the "wooooo" in my belly and think of it as "ride" that I'm on that will be over in just a few seconds.

What's a bit trickier, though, are the D-MER episodes that come with "spontaneous" letdowns, when it's not so obvious what's going on, and therefore, I'm even more likely to "believe" the feeling and justify it.

I suspect this is probably happening more than I realize.

Let's think it out. . . .

Quite often when she is nursing, I suddenly feel the "oh shit" in the pit of my stomach, and the next thing I know, she goes from barely sucking to gulping. I've felt no physical sensation of the letdown in my breasts themselves, but I felt D-MER and then there was more milk, so it's obviously happened.

And often, when she is not nursing, but she's crying, or I'm looking at photos of her, or thinking about her, or cats are yowling, and I do feel the letdown sensation, which was clearly triggered by some sort of non-physical stimulation. also says:

Touching, feel good times and food raise oxytocin, as well as some kinds of stress. In these situations a D-MER mother's oxytocin may be raised, triggering a letdown. Part of the letdown includes the precursor of D-MER. This means it may feel like the situations are causing the feelings, which cause the letdown, but that is not the case. Instead it is the situation (of stress or family or food) which causes the oxytocin surge which triggers the milk ejection reflex, which starts with a drop in dopamine which is what causes the D-MER. This happens whether or whether not a mother feels the letdown physically in her breasts, as many mothers don't. So uncomfortable feelings/negative emotions do not result in a letdown. So if a mother is feeling D-MER type feelings on and off throughout her day, unconnected to nursing, the feelings are the sign that the milk ejection reflex has been triggered by either a conditioned reflex (sound of a baby crying) fullness of breast (oversupply or missed a feeding) or by emotion (stress or pleasure.) In these situations it is still D-MER and the feelings are not a valid emotional reaction.
So, how often might I be having spontaneous letdowns that I don't feel physically, but with which I am experiencing D-MER and not identifying it?

How often does it happen that, say, someone other than me or Shrike is holding Peeper, and she's crying, and it's all I can do not to snatch her from their arms and "fix" her, and the longer it goes on, the more stressed and anxious and angry I get about the whole situation.

Or how often am I anxious about a stressful situation, related to Peeper - her medical adventures, for example, or an encounter with a less-than-supportive person - or not, and I get way more upset about it than I rationally feel like I "should."

No, I certainly don't think I can blame all my insecurity, anxiety, over-sensitivity to criticism and post-traumatic stress about our early breastfeeding experiences on D-MER, but I would imagine that it can't be helping matters a bit.

As much as I totally love breastfeeding Peeper, as thrilled as I am that it has worked out so well for us, as devastated (and there is no other word for it) as I would have been had it not worked out, as 100% certain as I am that it is absolutely the best thing for her and me and our family, and as strongly as I feel about continuing as long as she wants and needs to, it has, for many, many reasons, been just fraught with anxiety for us from day one.

I do not think that any of this anxiety was caused by D-MER (see My Breastfeeding Story), but it does occur to me now that it has probably been exacerbated by it, at many points along the way.

So, what to do about it? lists three levels of management options, from lifestyle changes, to natural treatments, to prescription treatments.

I don't think that what I'm experiencing requires prescription-level treatment, but if I did decide at some point that it would be appropriate, the suggested medication is Welbutrin, which I've taken in the past and tolerated well, so that's good to know.

The natural treatments suggested include some herbal stuff, but also DHA which I've been taking since pregnancy, for Peeper's brain development, and tryptophan-containing foods which, ironically, include dairy. Great. Might I have actually increase the D-MER when I went dairy-free!?

The lifestyle changes include education about D-MER, which I think is definitely the most important thing - just knowing what's causing the negative emotions is a big help.

They also suggest distraction, including "surfing the internet" while nursing. Well, I'm always in front of my computer when I'm nursing, so that's obviously not helped, but I have noticed that I don't experience the D-MER as much if I'm in the middle of a conversation, or something like that.

I guess that's why it's never impacted my comfort level when nursing in public. I suppose I'm distracted enough by whatever else I'm doing that I don't notice it. In fact, now that Peeper can latch by herself, I can get a boob accessible, and get her intp position, latched and nursing while sitting in a restaurant, talking to Shrike, eating, or hell, ordering, without missing a beat.

It also seems that being well-rested, well-hydrated, and getting adequate exercise can be helpful. Well, I do drink lots of Kool-Aid.

And what to do with all this information?

I'm not really sure just yet. I know that it had helped to just recognize what's going on, and to remind myself what it really is that's making me feel the way I do, when I start getting freaked out about things.

Of course, I will also be talking more with Dr. T about it, especially as it relates to my interpretation of what might actually be D-MER episodes during spontaneous letdowns.

(This has been in the back of my mind for a while, but I finally remembered to mention it to her in like the last five minutes of our last session. It wasn't until afterwards that I really got to thinking about it and figuring out some of the bigger picture.)

And I guess we'll see how it goes from there.

1 comment:

  1. I am so glad you posted this. I always thought I was the only one.

    I am nursing my third baby and I always flood with anxiety for about 90 seconds after letdown. I've asked other mothers if it happened to them, but they said it didn't, so you're the first!

    I find drinking water helps tons. Right as I am feeling the anxiety, I drink water and that helps.


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