Hidden Breastfeeding Challenges

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The benefits of breastfeeding to both mother and child are numerous, well studied, and irrefutable. Every year during World Breastfeeding Week, newspapers, magazines, and social media are flooded with vast information advocating the wonders of this act, painting an image that it is both graceful and effortless. 
Although breastfeeding seems like the most natural thing to do, for many it is no easy feat. For some, the journey may be tortuous and at an ascent. No single breastfeeding experience equates with another, and this applies regardless of the number of times a mother has gone through it. 
Let us delve into two challenges that are not often discussed yet may be endured by women during their breastfeeding journeys. It is important to acknowledge the existence of these challenges, as only by doing so can they be addressed, methods to cope with them be sought, and overall improve the breastfeeding experience for mothers and children around the world.

Dysphoric Milk Ejection Reflex (D-MER). 

The term Dysphoric Milk Ejection Reflex (D-MER) has only been making appearances in medical literature over recent years. It describes a sudden, intense, onset of negative emotions, just before a ‘let down’ or the release of milk occurs. An estimation of 5 to 9 percent of breastfeeding mothers experience this at some point, and it can take place during direct feeding, expressing of milk, or whenever let down occurs out with this, for example in response to a crying child.
As its name suggests, D-MER is a reflex and thus is seen as a physiological response, rather than a psychological condition. The symptoms last only for a few minutes and disappear when the milk flow is established. 
Many different words have been used by affected lactating mothers to describe the wave of negative emotions that they experience. The common symptoms mentioned are the feeling of sudden anxiety and irritability, sadness or hopelessness, anger, self-hate or low self-esteem, a sinking feeling in the stomach or dread. In some cases, the symptoms can be severe, such as suicidal ideation. 
Not much is known as to why D-MER occurs, but it is postulated to be due to a sudden drop in the level of dopamine, or ‘happy hormones’ in the brain. The suckling action during direct feed or mimicked by a breast pump secretes the hormone oxytocin, which stimulates milk production and release. Studies have shown that it also inhibits dopamine release. Most women who have experienced D-MER reports decreased frequency after the first 3 months, although it can persist as long as breastfeeding or pumping continues. 

Breastfeeding Aversion Response (BAR)  

A similar yet separate phenomenon that breastfeeding mothers may experience is the Breastfeeding Aversion Response (BAR). BAR is a complex experience lacking research and literature that is important to guide healthcare providers and women affected in understanding and managing this condition. BAR is described as a feeling of aversion while breastfeeding which occurs the entire time the child is latched resulting in a compulsion to unlatch. 
An empirical study done in Australia that observed the lived experiences of women with BAR concluded that experiencing of BAR is unexpected and difficult for mothers and may result in detrimental effects on maternal identity, mother-child bonds, and intimate family relationships. Some of the participants in this study described the experience as “skin crawling” while others reported negative sensations that were “visceral”, “overwhelming” and “uncontrollable”. 
This phenomenon has been shown to occur in a worrying number of women with a study in Australia reporting that the prevalence of BAR is one in five women. In Malaysia, the rate of exclusive breastfeeding for up to 6 months is only 47 percent, lower than the national Key Performance Index set which at 58 percent. As of now, there has been no research done to study the prevalence of BAR among Malaysian women and if BAR may be a key factor for the low rate of exclusive breastfeeding.  
Potential factors that have been linked to an increased risk of developing BAR include breastfeeding the first child, breastfeeding two or more children at the same time, menstruation, and breastfeeding during pregnancy. 

Coping with D-MER and BAR 

The difference between these two conditions and postpartum depression is that the wave of negative emotions and sensations only occur during the feeding or pumping event. However, the guilt of feeling contemptuous towards their baby, albeit being brief, may trigger a spiral into or worsen pre-existing depression. Unfortunately for some, all three conditions might coexist. 
Recognising these conditions is an important first step. The main takeaway message for women who experience them is that it does not equate to them being a bad mother. On the contrary, feeling guilt itself and the fact that some do persist with their breastfeeding journey despite the negative experiences signifies the immense maternal love they have for their child. 
Having said that, no women should act as a martyr to the breastfeeding cause. There is an urgent need for effective strategies and interventions to help women cope with complex challenges faced when breastfeeding. Experts have recommended self-help strategies like meditation, positive self-talk, and personal distraction during the feeding or pumping sessions to manage these emotions better. 
It may be something simple like tuning into their favourite music or binge-watching an episode of the latest Korean drama. Drink a soothing cup of tea, or better yet, indulge in a piece of chocolate. These little actions can help to increase the levels of happy hormones, as well as shine a positive light in anticipation of the next breastfeeding session. 
It is also important that these women do not face these challenges alone. It is pivotal that they feel safe to talk about these negative emotions with their partners and loved ones without feeling judged and receive ample support from them. Do seek help from healthcare professionals such as lactation consultant and nurse, counsellors or therapists if needed.

About the Authors: Dr. Aishah Mohd Hafiz is a Senior Lecturer in Emergency Medicine at Taylor’s University, within the School of Medicine, Faculty of Health and Medical Sciences. With expertise in emergency medicine, Dr. Hafiz contributes to medical education and research, preparing future healthcare professionals to handle critical situations effectively. Dr. Durga Vettivel holds the position of Senior Lecturer in Family Medicine at Taylor’s University. As a part of the School of Medicine, Faculty of Health and Medical Sciences, Dr. Vettivel’s work focuses on advancing knowledge in family medicine, promoting holistic healthcare approaches for patients of all ages.

Editor’s Note: This article was contributed by the academics at Taylor’s University, Malaysia.This is an opinion column. The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of this publication.

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