Combination Feeding Twins and Multiples

There is little evidence regarding making enough milk for two or three babies. Milk supply works on a demand and supply basis. Having two or three babies coming to the breast means the breasts are stimulated two or three times more than those feeding a singleton. And so, they should produce two or three times the milk (L. Saint, 1986).

When I speak to expectant multiple parents, many assume that they will have to combination feed. Our society, friends, family, and health professionals all believe it is difficult, even impossible to make enough milk for more than one baby. However with good breastfeeding support and frequent and efficient feeds, most find they can make enough milk for their babies.

But many twin and triplet families find they need or want to combi-feed long term. For some it is a milk supply thing. For some it can be to get some more sleep, to spend time with older children, or to do something for themselves. For others it is the only way they can see themselves continuing to breastfeed. I usually suggest to give breastfeeding/pumping a really good go at the start and establish their milk supply as much as possible. That way they will have more choice in their feeding patterns. Although it is possible to move from formula feeding to breastfeeding, it is far easier to establish breastfeeding first and then move to adding some formula.

Common scenarios in the early days

If the babies are born premature, the breastfeeding journey is started via expressing breast milk and feeding via a tube. Frequent pumping with a hospital grade double pump will give the best chance of establishing a copious supply (Hill, et al., 2005) But as the babies grow and become more efficient feeders, they should be able to take it directly from the breast. Establishing a good supply in the early days will make it easier to make a full supply long term. However there is potential for supply to be increased later, especially once the babies begin latching onto the breast. See our premature baby articles

The majority of twins are born around 36 to 37 weeks gestation. This can mean they struggle to breastfeed initially as they can be quite small, sleepy and inefficient on the breast (Ayton, et al., 2012). See our article in this topic. Although some babies born at this gestation are able to fully breastfeed from the start, some may need topping up with expressed milk or formula after a breastfeed to ensure they take enough milk to thrive. This often called “triple feeding” and involves time at the breast, a top-up feed of expressed milk or formula, and pumping to make that extra milk. And they should be doing this 8 times a day, every 3 hours. This is a very intense regime and many struggle, especially with the pumping element. It is very much a short term intervention and as the babies are nearer full term, support should be given to move away from this pattern. See our article

Multiples that are born closer to full term are likely to struggle less with breastfeeding, and so as long as the parent are supported to feed frequently with optimum positioning and attachment, the breasts should be stimulated sufficiently to make enough milk for more than one baby. Tandem feeding can often help make feeding more efficient and will help the parents cope with fussy behaviour and cluster feeding. But some may decide to switch out one or two feeds to formula.

Combination feeding longer term

There may be a point where the family think they are at maximum capacity for breastfeeding and milk production, whether this be for milk supply reasons or for reasons due to mental overload. Combination feeding can be a good option for these families and many people do not understand breastfeeding does not have to be all or nothing. It is so important to value every drop of breast milk and even small quantities can have an impact on the health of mum and babies. Formula can actually be a tool to prolong the breastfeeding relationship if used in a considered way.

“Using some formula each day meant I could continue to breastfeed for longer. I actually ended up breastfeeding for over a year. If you had asked me at 4 weeks when I was trying to exclusively breastfeed, I never thought that was possible!”

Many families start their combination feeding journey by breastfeeding and then topping up with formula. However it is not ideal in the long term. Feeding both breast and bottle every feed can be too much work, especially once the partner has gone back to work. And also this will mean many bottles in 24 hours, which can increase the risk of breast refusal.

Some may decide to breastfeed one baby and then bottle feed the other and swap each feed, thus the breastfeeding parent would need to make enough milk for one baby for this to work well. The downsides to this are that the babies will be getting a lot of bottles over 24 hours which can mean they are more likely to reject the breast. Also, it is very easy for the formula fed baby to take more milk than the breastfed baby, and formula is more difficult to digest than human milk. So this can make them out of sync with their feeds.

Many families prefer to give one or two set bottle feeds of formula a day and breastfeed responsively in between. This pattern is often suggested when the babies are struggling with weight gain and some families choose to keep it long term. It is protective of breastfeeding as long as the babies are being breastfed responsively the rest of the time, and the parents don’t fall into “the top up trap” when babies are fussy or feeding more frequently. The top up trap is when as babies need more milk, more formula is offered, and so babies come to the breast less. This then means less milk is produced by the breast which then means more formula is needed. And so on until the babies begin to refuse the breast because of a low supply. So breastfeeding responsively in between the bottle feeds prevents this from happening. If the bottle feed can be given by someone other than the breastfeeding parent, this can be a good way of having a break, getting more sleep, or spending more time with older children.

If there are physiological reasons for a significant low supply, this may prevent the babies from ever being satisfied just on the breast. In this scenario, using a supplementary nursing system can be a great option. The babies can be given extra milk at the breast. This reduces the risk of bottle preference developing and protects the breastfeeding relationship.

For triplet families, as well as the twin related scenarios discussed above, there is also the issue that there are more babies than breasts! Various patterns of breastfeeding, expressing and formula feeding can be adopted. Some triplet families prefer to breastfeed each baby individually. For more information on triplets, see our triplet articles

Bibliography

Ayton, J., Hanson, E., Quinn, S. & al, e., 2012. Factors associated with initiation and exclusive breastfeeding at hospital discharge: late preterm compared to 37 week gestation mother and infant cohort. International Breastfeeding Journal, 7(16).

Hill, P. D., Aldag, J. C., Chatterton, R. T. & Zinaman, M., 2005. Primary and secondary mediators’ influence on milk output in lactating mothers of preterm and term infants. Journal of Human Lactation, Volume 212, pp. 138-150.

  1. Saint, P. M. P. E. H., 1986. Yield and nutrient content of milk in eight women breastfeeding twins and one woman breastfeeding triplets. British Journal of Nutrition, 56(1).

L.Saint, P. M. P. E. H., 1986. Yield and nutrient content of milk in eight women breastfeeding twinsand one woman breastfeeding triplets. British Journal of Nutrition.

TwinsTrust, 2020. Twins Trust. [Online]
Available at: www.twinstrust.org

2020, Kathryn Stagg IBCLC, updated 2023

Can you help?

We imagine a world in which mums-to-be know that it IS possible to breastfeed multiple babies and that they have the information and support available to do so. We need your help to achieve this. For example, we want to: produce printed and online information for parents and medical professionals; roll out training to medical professionals so they can support new mums better; train more breastfeeding peer supporters with experience and knowledge to support parents of multiples. PLEASE HELP!