Triple Feeding Twins – topping up

Twins are often born a bit early, a bit sleepy and a bit inefficient on the breast. They have higher risk of jaundice, low blood sugar and weight loss due to their early birth. Twins are also generally smaller than average singletons of the same gestation, meaning it can be more challenging to latch effectively.

Sometimes these issues can be overcome by concentrating on achieving a deeper latch, more frequent feeding, and by using breast compressions to increase the flow of milk. Compressions maintain active feeding for longer and increase the length of the sucking bursts. We can encourage the babies to have a second go on the breast by waking with a nappy change and relatching them. When more awake the babies will suck more vigorously and may trigger a second milk ejection reflex and take more milk.

However, it is sometimes clinically indicated that babies need a little extra milk in the early days. Many twin parents start their breastfeeding journey topping up their babies with formula to make sure they are getting enough milk, but if their long term goal is to exclusively breastfeed, or even majority breastfeed, using formula will be detrimental to their future milk making potential. To protect their breastfeeding goals, it is important to encourage parents to pump whenever babies are getting milk from elsewhere. This breastmilk can then be used for all or some of the top-up feeds, meaning less formula is necessary and milk supply is closer to the babies’ intake. The volume and frequency of top ups should be the minimum necessary to maintain an appropriate rate of growth.

The act of breastfeeding, top-ups and pumping is often called “Triple Feeding” because there are three parts. Doing all three parts, every feed can be very overwhelming and time consuming, so it is important to stress to parents that this is a temporary intervention. As soon as babies are nearer full term and breastfeeding more effectively they should be able to reduce and eventually remove the extra milk, or move to a more manageable combination feeding pattern. Triple feeding is not a long term solution.

Triple Feeding Plan – Single Feeding Twins

*Wake first baby, or pick up baby who is waking

*Bring first baby to the breast with a deep latch

*Watch for deep suck and swallows

*Use breast compressions to maintain active feeding and extend sucking bursts

*Once compressions are no longer stimulating deep sucks and swallows, helper should wake other baby if not already awake

*Pass first baby to helper to top-up with expressed milk or formula, pacing the bottle feed

*Bring second baby to the other breast with a deep latch

*Watch for deep sucks and swallows

*Use breast compressions to maintain active feeding and extend sucking bursts

*Once compressions are no longer stimulating deep sucks and swallows, take baby off

*Pass second baby to helper to top-up with expressed milk or formula, pace feed

*Pump for 15-20 mins with an efficient double pump, this milk can be used for future top-ups

*If no helper is available then the first baby will need to be breastfed and topped up before waking the second baby. Then breastfeed the second baby and top up, and then pump afterwards.

Triple Feeding Plan – Tandem Feeding Twins

*Wake both babies or if one baby is stirring wake the other baby

*Bring both babies to the breast with a deep latch

*Make sure positioning is good and sustainable

*Watch for deep sucks and swallows

*If babies are well supported with a feeding cushion, move hand to do some breast compressions to maintain active feeding and extend sucking bursts

*Once deep sucks and swallows can no longer be encouraged, take babies off and consider waking babies and bringing them back to the breast for another go to trigger a second milk ejection reflex and take more milk

*Once breastfeeding has finished, if there are 2 helpers they can take one baby each to top up, pacing the bottle feed. If there is one helper take a baby each and top up, or consider a tandem top up

*Pump for 15-20 mins with an efficient double pump, during top-ups if the breastfeeding parent is not needed. Use this milk for future top-ups.

*If no helper is available, breastfeed both babies, top-up both, then pump after.

Moving away from triple feeding and topping up

Before moving away from triple feeding regime, certain criteria must be met:

*Babies should be gaining weight appropriately with the top ups in place before thinking about reducing, and also be having appropriate wet and dirty nappies

*Babies should be able to latch well with deep sucks and swallows, developing longer bursts of sucking, especially towards the beginning of the feed. They should be maintaining active feeding for more than a few minutes

*Babies should be feeding at least 8 times in 24 hours and mainly waking themselves for feeds

Once the babies are beginning to be more alert and breastfeeding is improving we can begin to gradually reduce the extra milk. Regular weight checks are necessary.

Frequency of feeding

Exclusively breastfed babies will often want to feed more frequently than every three hours. If babies are waking “early”, they can be brought to the breast. But we should not need to top up more frequently if weight gain is appropriate.

Reduce the volume of the top ups

Babies can be offered a second go on the breast before a top up is offered. They will trigger a second let down of milk and take more milk, meaning a smaller top-up.

Babies can be encouraged to settle on the breast. The breast is offered first, a small top up given in the middle, and then babies are brought back to the breast to settle, taking some more milk directly.

Removing top ups

Babies will often be more settled in certain parts of the day. Mornings especially are a time when babies tend to feed well and the parents may naturally have more milk.

Take a 4 or 5 hour period in the morning and just breastfeed, putting babies back on the breast as many times as it takes to settle. Top ups continue the rest of the day. Then extend or add another stretch of exclusive breastfeeding.

During night feeds, babies will begin to settle more easily, not needing extra milk.

Pumping

As the need for top-ups decreases, pumping can be reduced. Either pump whenever babies get extra milk, or pump the total 24hr top-up volume over a set pattern.

Kathryn Stagg IBCLC, Nov 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!