A lot of multiple birth babies are discharged from hospital topping up with either formula or expressed milk. This can be for a number of reasons; babies were born early and were not efficient feeders, babies were premature and started life with tube feeds, babies have lost too much weight, babies had low blood sugar, baby may have had a tongue tie fixed, there was more than one baby! So how do we move on from this? Once a baby is efficient at feeding the breast, there are a number of stages we can go through to move towards exclusive breastfeeding. I cannot stress strongly enough to get some face to face breastfeeding support to make sure you have an optimal latch and that baby is feeding well. Dropping top-ups should not be started until babies are gaining weight steadily, have plenty of wet and dirty nappies, and are generally settled between feeds. A breastfeeding supporter will help you determine this and talk about what to look for. This journey can be started at any point depending on how much topping up is happening, or left at any point if happy with a certain level of mixed feeding. Sometimes one baby may be ready before the other.
Nappy output is a fundamental sign that baby is getting enough milk and staying hydrated, and is something parents can keep an eye on very easily. For a baby between roughly 1 week and 6 weeks old we should see at least 2 to 3 dirty nappies a day and 6 wet nappies. For older babies they can go for a longer stretch without a poo and be fine, as long as it’s soft and abundant when it does arrive, but there should still be lots of wet nappies. Baby should also be weighed between each stage to make sure they are still roughly following their curve on the growth chart.
Firstly we need to make sure baby is going to the breast every feed. If a feed is missed because of giving a bottle, milk production will decrease. When milk is left in the breast it sends messages to the milk producing cells not to make any more. If the breast is emptied frequently the production goes up. The more you feed, the more you make. If baby will not go to the breast for some feeds or the parent decides to do one bottle feed for a break, then milk should be expressed instead. If baby is fussy at the breast and not feeding well, expressing after a feed should be encouraged to boost supply.
It is important to put baby to the breast during the night. It might be tempting to skip a feed and get some sleep but this can be detrimental to your milk supply. Prolactin, the milk making hormone, is at its highest at night so we want to take advantage of this to put in an order of milk for the next day and help maintain a full milk supply. Learning to feed lying down can be life changing as long as safe bed sharing guidelines are adhered to. Your local breastfeeding supporter will be able to help you with different positions, making sure the latch is still good.
If baby is having a high volume top up after every feed (e.g. more than 30-40ml) but is now feeding efficiently and putting on weight steadily, the first step is to drop the volume of formula in each top up. Your baby will probably start doing this naturally themselves as feeding becomes more efficient, so follow their lead. However babies may often take more milk than they need from a bottle. It is important to pace the feed. After a smaller volume, baby can be put back on to the breast to settle if necessary. This will increase the amount of stimulation on the breast and will help boost milk supply. It will also encourage baby to get used to settling on the breast. If the baby will not tolerate going back on the breast then you can pump instead and replace some top ups with expressed. We want to start increasing milk supply towards the level that the baby is taking without risking weight gain issues. You should be encouraged to be baby-led and allow the baby to feed frequently. If baby is still a little sleepy and not waking for feeds then they should be woken no later than 3 hours from the start of the last feed so there will be at least 8 feeds in each 24 hours, the bare minimum. It is good to clear the diary, get a feeding station set up with everything you need; snacks, drinks, phone, remote control and some good box sets to watch, and do as much feeding and skin to skin as possible. I like to call this ‘Topless Telly Time’. Breast compressions, compressing the breast whilst baby is latched on, can help increase the amount of milk the baby is getting during the feed and can also stimulate a sleepy baby to start sucking again.
Once the baby is on a small volume top up every feed (30ml or less) you can work to drop some of them. It is important to get baby weighed before this next stage to ensure weight gain is steady and has not slowed due to the decreased top ups. If weight is suffering, adding some larger top ups back in may be necessary and get some further face to face breastfeeding support. It may be a case of waiting a bit longer to start decreasing the volume.
If the baby is growing well and has a good nappy output on the smaller volumes, a good place to start is to aim to top up 3 or 4 times a day. Pick times of day when baby is more settled to stop your top ups. You will probably find that baby will start to do this themselves at certain times of day so again, follow their lead. Take a section of the day and let the babies feed frequently or cluster feed during this time until they are settled enough. Feed when baby shows early feeding cues, do not wait for them to cry. You can put them back on the breast as many times as it takes. Skin to skin continues to be very beneficial at this stage. Over the next 3 or 4 days you should see some of the cluster feeding behaviour diminish or the frequency of feeds reduce a little as milk supply catches up to the needs of the baby. Remember the more often milk is removed from the breast, the more milk is produced. Breasts are factories, not store rooms. If demand is increased, production increases to match. Feeding frequently is completely normal for a breastfed baby, and they often have periods of fussy cluster feeding for the first few months, often in the evenings. You will learn what is normal for your babies if you follow their needs, and this will give you confidence that everything is going well. Continuing to get them weighed during this time is important to ensure milk intake is sufficient. And keep in touch with local breastfeeding support.
Another option is to pump after every feed and work to replace formula top ups with expressed milk. This technique will be necessary to increase milk supply if the baby is not so efficient at the breast, is not transferring the milk well, or is too sleepy to take a whole feed. Then as the baby becomes stronger and more able to feed baby will be able to take more milk directly and you will find that you do not need to top up as much and you can reduce the pumping. Face to face breastfeeding support can help with this. You will need to pump as often as it takes to make the volume they are taking from a bottle. A good guide can be to pump every time they have a bottle.
Once you have a few top ups a day with responsive breastfeeding in between it is relatively straightforward to stop the last of the top ups. You can either stop them all at once or drop one at a time. It is often a relief to have the relative simplicity of just breastfeeding without all the faff of bottles, sterilizing, pumps and making up formula safely. Breast milk is always ready, day and night, it sends both baby and you off to sleep easily, and it’s free!
It may be a good plan to get some support with tandem feeding during this process. Tandem feeding obviously maximizes the time spent feeding as there’s less waiting time for babies. It syncronizes the babies’ feeding times and more importantly sleeping times! A stronger feeder can help a weaker feeder by stimulating the let down and getting the milk flowing. It increases milk supply and also the milk can have a higher fat content. Here’s our guide to tandem feeding.
You may get to a stage where you are at maximum capacity for breastfeeding, whether there be physiological reasons for not being able to produce more milk and baby just cannot maintain weight on solely breastfeeding, or maybe you decide you need to keep some formula for other reasons. If this is the case you can mix feed. Doing one or two whole feeds of formula each day, and continue with responsive breastfeeding for the rest of the day and night works well. Or you could continue to top up some of the feeds. Any amount of breastfeeding is so important for baby and for you. We must value every single drop. Once baby moves on to solid foods and begins to reduce their milk intake naturally, the formula can be gradually reduced if you wish and breastfeeding can continue for as long you and baby enjoy it.
Kathryn Stagg IBCLC, updated Feb 2023
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