A baby born between 34+0 weeks and 36+6 weeks gestation is defined as a late preterm baby. A baby born between 37+0 weeks and 38+6 weeks is defined as an early term baby. The average length of a twin pregnancy is 36+4 weeks. Many twin babies are born between 36 and 38 weeks gestation due to the NICE guidelines.
For babies who are born at this time, establishing breastfeeding can be quite difficult. They are often well enough to remain on the postnatal ward with their parents, which is great as they do not have to go to special care. But as such they often get treated the same as a full term baby and are left to “demand feed”.
The problem is that these babies often do not “demand” enough and prefer to sleep. They are often too sleepy for the parent to be able to follow their lead completely. And if they do not feed enough, they get even sleepier and even harder to rouse to feed. Also a lot of slightly early babies are not physically strong enough or coordinated enough to fully breastfeed, often until around due date or even a bit after. They have a few sucks, take on a little milk, and then fall asleep before they have had their fill.
This can lead to real problems! Babies can lose weight, or jaundice can set in. The parent’s milk supply may not be stimulated enough, or they may lose their hard-earned milk supply if they were pumping in the Neonatal Unit. Then after a week or two, the babies have lost too much weight or not put on enough, and it is decided they need supplementing, but the low supply caused by inefficient feeding may mean they need to use formula.
These problems are also experienced by parents of more premature babies as they are often discharged around what would have been 36-37 weeks gestation with minimal breastfeeding support. They are often given the chance to “room in” for a couple of days to practise feeding and looking after their baby or babies full time, and this is often the first time the breastfeeding parent is allowed to follow their babies’ lead. And all the same pitfalls can happen.
These families need lots of support. They need good quality face-to-face breastfeeding support after discharge. They need to be shown the subtle cues their baby makes to show that they need a feed; stirring, mouth opening, turning head from side to side, and the later cues including stretching, moving arms and legs, trying to bring hand to mouth. Crying and agitation are late cues. (Marie Biancuzzo, Dec2018) They should be encouraged to feed their babies frequently. Dr Tena Fry said in her interview with Marie Biancuzzo: “If a baby’s eyes are open they should be offered food”. Parents also need to be supported to understand when their baby is not cueing frequently enough. We would suggest not to let a baby of this gestation go longer than 3 hours from the start of each feed to ensure they have a minimum of 8 feeds in 24 hours.
Parents should also be shown how to ensure the babies are latching on well to feed. And tandem feeding positions can be discussed to help with the intensity of breastfeeding new baby twins. Also breast compressions are a very useful tool to help transfer a bit more milk to the babies during the feed, and to remind them to keep feeding when they get a bit sleepy towards the end of the feed. Sometimes a baby of this gestation may have trouble latching directly on to the breast. Babies who are a little early sometimes latch better and feed more efficiently when using nipple shields. Close attention should be paid to milk weight gain and nappy output if shields are used as they can inhibit milk transfer.
Parents may need support with continuing to pump for top ups if the babies are not ready to fully breastfeed. And they need to be shown how to tell that their baby is developmentally ready and feeding efficiently enough to move away from 3 hourly feeds and on to baby-led, cue-based feeding. The problem is each baby is different. Some will be ready to fully breastfeed at 36 weeks, others at 42 weeks, and everything in between. Parents often continue to supplement and schedule feeds far longer than they need to. We would normally look for each baby to be putting on weight as expected, generally waking themselves for feeds, beating them to the 3 hour schedule, and having a good proportion of “active feeding” during a breastfeed. Then if the parent is pumping for top ups this can be gradually phased out. They will be safe to move on to responsive feeding. If parents are using formula to top up this can be gradually phased out. See our guide here
Ideally each family would be guided by somebody highly qualified such as an IBCLC or experienced Breastfeeding Counsellor. This is a scenario that deserves specialist breastfeeding support in the home on discharge from hospital, to ensure they can maximise the breast milk intake of their babies.
Kathryn Stagg IBCLC, updated May 2021