In this thought-provoking article, Dr Charlie Middleton explores the hidden emotional realities of breastfeeding through the lens of Dysphoric Milk Ejection Reflex (D-MER), a little-recognised condition that can cause sudden feelings of dread, anxiety, or anger during milk let-down. Drawing on the concept of epistemic injustice, the article examines how women’s experiences are often misunderstood, minimised, or dismissed when they fall outside dominant cultural and clinical narratives surrounding breastfeeding. It highlights the urgent need for greater awareness, compassionate listening, and professional humility in supporting women whose breastfeeding experiences challenge conventional expectations.
Breastfeeding occupies a paradoxical position within contemporary maternal and public health discourse. It is widely recognised as the optimal form of infant nutrition and strongly promoted, yet women often report feeling inadequately prepared for and supported to breastfeed (Tomori, 2022). Antenatal education frequently focuses on breastfeeding initiation and maintenance, while offering comparatively limited preparation for the physiological and emotional challenges it may involve (Kehinde, O’Donnell and Grealish, 2024). In addition, while public health and maternity messaging emphasise the benefits of breastfeeding, the practice is also undermined by aggressive commercial milk formula marketing campaigns, and the expectation that when breastfeeding becomes difficult, women will quietly transition to commercial milk formula feeding rather than openly question the realities of breastfeeding, the adequacy of support, or the cultural narratives surrounding it (Pérez-Escamilla et al., 2023). Consequently, women often begin breastfeeding with expectations that do not adequately reflect its physical, emotional, and relational complexities, leaving them vulnerable to confusion, distress, and self-blame when challenges emerge. When breastfeeding does not feel intuitive, easy, or fulfilling, women may struggle not only with the experience itself, but also with having that experience taken seriously.
One example of a little-known and poorly understood breastfeeding experience is Dysphoric Milk Ejection Reflex (D-MER). D-MER is characterised by a sudden and intense wave of negative emotion which occurs just prior to and during milk ejection, typically lasting from around 30 seconds to a few minutes in duration (Heise and Wiessinger, 2011). Women describe D-MER episodes as intense feelings of dread, anxiety and anger which are often unrelated to their general mood. While the cause of D-MER remains unknown, two main hypotheses exist. The first proposes that D-MER is caused by the sudden drop in dopamine which occurs to allow prolactin to rise and milk to be ejected (Heise and Wiessinger, 2011). The second suggests that D-MER may be triggered by an overreaction to oxytocin (Kendall Tackett and Uvnäs Moberg, 2018). At the time of writing, both theories remain speculative.
Despite increasing awareness of D-MER, many healthcare professionals involved in supporting breastfeeding women remain unfamiliar with the phenomenon (Middleton, Lee and McFadden, 2025). While D-MER appears to be physiological in origin, it presents emotionally and occupies a liminal space outside of medical classification. This is significant because the lack of widespread awareness is often confusing and frightening for women, who frequently find their accounts of D-MER minimised, misattributed, or dismissed.
Experiences of D-MER can be understood through the lens of epistemic injustice, a concept which explains how a person’s knowledge or experience is granted less credibility than it deserves (Fricker, 2007). Within healthcare, epistemic injustice occurs when people struggle to have their experiences recognised because they do not align with existing clinical knowledge or expectations. In the example of D-MER, women’s accounts are doubted because their experiences sit outside familiar clinical and cultural understandings of what breastfeeding should feel like.
In the absence of widespread recognition of D-MER, many women first learn about the phenomenon online, where the experiences of others act to validate and legitimise their own. For many, simply discovering that D-MER exists allows them to re-frame what the experience means. Naming D-MER may not altogether remove the distress it causes, but it may significantly reduce feelings of fear, shame, and self-blame.
Ultimately, D-MER highlights issues which extend far beyond a single lactation phenomenon. It demonstrates how limited research and dominant cultural narratives on breastfeeding render some experiences difficult to articulate and legitimise. For those working with breastfeeding women, D-MER also offers a broader reminder about the importance of epistemic humility and resisting the urge to reinterpret, minimise, or dismiss accounts of experiences which are difficult to understand. Feeling listened to, being believed, and having experiential knowledge validated can be profoundly impactful. Women do not always require immediate solutions to the challenges they face. Often, what matters most is professionals who are willing to remain curious, listen carefully, and recognise the limitations of their own knowledge.
References:
Fricker, M. (2007) Epistemic injustice: Power and the ethics of knowing. Oxford university press.
Heise, A. M. and Wiessinger, D. (2011) ‘Dysphoric milk ejection reflex: A case report’, International breastfeeding journal, 6(1), pp. 6.
Kehinde, J., O’Donnell, C. and Grealish, A. (2024) ‘A qualitative study on the perspectives of prenatal breastfeeding educational classes in Ireland: Implications for maternal breastfeeding decisions’, PLoS One, 19(12), pp. e0315269.
Middleton, C., Lee, E. and McFadden, A. (2025) ‘Negative emotional experiences of breastfeeding and the milk ejection reflex: a scoping review’, Int Breastfeed J, 20(1), pp. 13.
Pérez-Escamilla, R., Tomori, C., Hernández-Cordero, S., Baker, P., Barros, A. J. D., Bégin, F., Chapman, D. J., Grummer-Strawn, L. M., McCoy, D., Menon, P., Ribeiro Neves, P. A., Piwoz, E., Rollins, N., Victora, C. G. and Richter, L. (2023) ‘Breastfeeding: crucially important, but increasingly challenged in a market-driven world’, The Lancet, 401(10375), pp. 472-485.
Tomori, C. (2022) ‘Overcoming barriers to breastfeeding’, Best Practice & Research Clinical Obstetrics & Gynaecology, 83, pp. 60-71.
May 2026
Dr Charlie Middleton , Lecturer in Nursing, University of Dundee