D-MER (Dysphoric Milk Ejection Reflex)

Written and Fact-Checked by: Jenna Carberg

What Is D-MER?

For the wider question of feeding and mood, see breastfeeding and postpartum depression.
Dysphoric milk ejection reflex (D-MER) is a sudden wave of negative emotion that hits just before milk lets down during breastfeeding or pumping, and fades within minutes. It was first described in a 2011 case report of a mother who felt an abrupt emotional “drop” every time her milk released, even though she felt happy and bonded with her baby the rest of the time.

If this is happening to you, the most important thing to know is that it has a name, other parents experience it, and it is not a sign that you don’t love your baby or don’t want to breastfeed. Researchers and lactation specialists who study it describe it as tied to the letdown reflex itself.

What D-MER Feels Like

Parents describe the feelings in different ways. Commonly reported emotions include:

  • Sadness, hopelessness or a sense of dread
  • Anxiety or tension (the most common symptoms in one U.S. clinic study, reported by 67% and 52%)
  • Irritability, frustration or anger
  • Feeling overwhelmed, lonely or hypersensitive
  • Nausea or a hollow feeling in the stomach (reported by 30% in one survey)

Severity ranges from mild wistfulness to intense despair. At the severe end, some parents have brief thoughts of harming themselves. If that happens to you, tell your doctor, even if the thoughts pass in minutes.

Timing Is the Key Feature

  • Feelings start suddenly, just before or as milk releases.
  • In most people they last less than 5 minutes. One survey found about 24% had symptoms for under a minute and another 55% for 1 to 5 minutes.
  • They can come with every letdown, including unexpected letdowns, so some parents have many episodes a day and night.
  • Mood usually returns to normal between feeds.
  • Symptoms usually begin in the first month of breastfeeding.
  • For most parents, pumping triggers milder or no symptoms compared with nursing, but about 12% in one large survey had symptoms only when pumping.

How Common Is D-MER?

There is no reliable single figure, because studies define and measure it differently.

  • The only study using a validated questionnaire found 5.9% of breastfeeding mothers had D-MER.
  • A U.S. survey found about 6%, a U.S. military clinic about 9%, a German survey about 14% and a U.S. breastfeeding clinic about 15.5%.
  • Higher figures, around 23% to 28%, come from small or self-selected samples.

A fair summary is that D-MER affects somewhere in the range of about 1 in 17 to 1 in 7 breastfeeding parents. Awareness is low: in one U.S. study, 62% of mothers had never heard of it, and in a Japanese survey most women who had it told no one.

D-MER vs. Postpartum Depression vs. Breastfeeding Aversion

D-MER Postpartum depression Breastfeeding aversion
When Right before and during letdown Most of the day, nearly every day The whole time the baby is latched
How long Usually under 5 minutes At least 2 weeks Lasts through the feed
Typical feelings Sudden sadness, dread, anxiety or anger Low mood, loss of interest, guilt, hopelessness Agitation, disgust, irritability, skin-crawling
Between episodes Mood usually normal Symptoms persist Only during breastfeeding

These are different experiences, but they can happen together. Mothers with D-MER had higher depression scores, more anxiety and more bonding difficulties than those without it in several studies, and in one U.S. clinic they were more likely to report a history of panic attacks. Researchers also point out that depression questionnaires can pick up D-MER symptoms, so a high score is worth talking through with a clinician. If low mood lasts beyond feeds, see postpartum depression or take the Edinburgh Postnatal Depression Scale.

What Causes D-MER?

The cause is not known. D-MER is not listed in the DSM or ICD, and no professional body, including the Academy of Breastfeeding Medicine, has issued a protocol for it.

  • Dopamine theory: the original authors proposed that a brief drop in dopamine, which normally falls to let prolactin rise for milk production, might cause the mood drop. They called it a “humble hypothesis,” based on one case, and dopamine has never been measured during D-MER.
  • Stress-response theories: other researchers suggest oxytocin release might trigger a stress response instead of calming it in some people, or that other hormone pathways are involved.

What is clear from surveys is what makes it worse: stress (reported by 62%) and lack of sleep (60%). See postpartum insomnia.

Does D-MER Go Away?

The course varies.

  • In the largest survey, about 40% said symptoms stayed about the same until weaning, 30% said they became milder and about 10% said they disappeared before weaning.
  • Reviews and La Leche League Canada describe many parents improving over the first several months, most commonly around 3 months, while more severe cases may last a year or longer.
  • For some, symptoms end only when breastfeeding stops.

Breastfeeding With D-MER

D-MER leads some parents to stop earlier than they planned. In the largest survey, about 17% stopped breastfeeding because of it and another 19% considered stopping; in a study using the validated questionnaire, 45% stopped. Whether to continue is your decision, and both choices are valid. Continuing is possible for many people, especially with support, and stopping is not a failure.

What Helps

There are no clinical trials of any D-MER treatment. Everything below comes from surveys of what parents found helpful, small qualitative studies and expert opinion.

Knowing What It Is

The original authors and later reviews found that simply learning D-MER is a recognized, letdown-linked reaction often makes it more bearable. Being believed by a clinician or partner helped parents cope.

Strategies Parents Report

  • Distraction at letdown: music, a show, a phone call, a puzzle or a snack
  • Support from a partner (35% said this eased symptoms) and talking with other parents who have had it
  • More sleep and rest (30% said sleep helped)
  • Mindfulness, relaxation or deep breathing when a letdown is coming
  • Drinking cold water or having privacy during feeds
  • Skin-to-skin contact with the baby

In one qualitative study, parents were able to reduce but not eliminate symptoms through trial and error.

Medication

You may read that bupropion (Wellbutrin) treats D-MER. The evidence is a single case: a low dose reduced one mother’s symptoms, but side effects led her to stop within a few weeks and D-MER returned. According to LactMed, bupropion is not a reason to stop breastfeeding, but another drug may be preferred for newborns and preterm babies. See Wellbutrin and breastfeeding. Herbal remedies such as rhodiola rest on single anecdotes and are not recommended.

When to Talk to Someone

Postpartum Support International advises reaching out to your perinatal provider if you think you have D-MER. Talk to your doctor, midwife or a lactation consultant, and especially if:

  • The feelings are severe or include thoughts of harming yourself
  • Low mood, anxiety or guilt continue between feeds
  • D-MER is making you consider stopping breastfeeding before you want to

Find a perinatal mental health therapist

Call or text the National Maternal Mental Health Hotline at 1-833-TLC-MAMA (1-833-852-6262), free and available 24 hours a day. If you have thoughts of harming yourself, call or text 988.

Frequently Asked Questions

What does D-MER stand for?

Dysphoric milk ejection reflex: a brief wave of negative emotion that comes right before milk lets down.

How long does D-MER last?

Each episode usually lasts under 5 minutes. Over time, some parents improve within a few months, while others have symptoms until weaning.

Is D-MER a type of postpartum depression?

No. D-MER is tied to letdown and passes within minutes, while postpartum depression lasts most of the day for at least 2 weeks. They can happen together, though.

What causes D-MER?

The cause is unknown. A drop in dopamine at letdown is the leading theory, but it has not been proven.

How common is D-MER?

Estimates range from about 6% to 15% in the better studies, with higher numbers in smaller samples.

How do you treat D-MER?

There is no proven treatment. Learning what it is, distraction, partner support, rest and relaxation are what parents most often report helps.

Can D-MER happen when pumping?

Yes. Most parents find pumping milder than nursing, but some have symptoms only when pumping.

PostpartumDepression.org Team
Written by:

Jenna Carberg was diagnosed with postpartum depression following the birth of her daughter in 2016. It was a healthy birth but in the following days, Jenna's mood changed quickly. Doctors suggested that it might be the "baby blues", but her husband Chris suggested she seek a second opinion. Jenna was diagnosed with postpartum depression and began a journey that lasted 9 long months with significant ups and downs. Jenna's mental health care and her experiences became a passion for her to share with the world. She and her husband Chris founded PostpartumDepression.org as a support website designed to help women suffering in silence and their loved ones.

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