Preparing to breastfeed multiples

Learn about breastfeeding:

It is really important to learn about breastfeeding before the babies arrive. You would not learn to drive just as you were driving down the slip road onto the motorway, so it’s the same with breastfeeding. Don’t leave it until the babies are actually here before you learn how it works. Yes, breastfeeding is natural, but it is also a learned skill and it is also important that parents understand whether the babies are feeding well and getting enough milk.

There may be an antenatal breastfeeding session at your local hospital or in the community. You may decide to do an online version so you can learn in the comfort of your own home. There are several different organisations that provide these. The Twins Trust have a breastfeeding webinar designed for breastfeeding twins. And join Breastfeeding Twins and Triplets UK Facebook group who have an extensive files section with loads of articles and blogs and a Preparing to Breastfeed Multiples video.

And read all the articles and watch the videos on this website! This will give you great evidence based information and ideas.

There are also lots of great video tutorials online. Global Health Media in particular are excellent.

Learn about normal new-born behaviour:

Just because your babies are twins or triplets, does not mean they will behave much differently to singleton babies. The challenge is how to deal with this as a parent when you have two or three of these new-borns to deal with.

Babies to like to feed frequently. The majority of breastfed babies like to feed every 2-3 hours. So expect to spend a lot of time feeding in the early days. As they get older sometimes they stretch out a little, but more often they just become more efficient and so the feed is shorter. Tandem feeding can help to get more of a gap between feeds, but not everyone enjoys it so it is not something you have to do.

Cluster feeding is normal new-born behaviour. Cluster feeding means babies need to go back on the breast several times in a row before they will settle. Each time you latch baby on you get another let down of milk. So even though it feels like there is none left, there really is! Babies often cluster feed at night in the very early days and then it moves to the evening period from around 3 weeks up until 3 months or so. So eating dinner can be challenging! Learning how to tandem feed helps massively during this time as you can just have two babies on the breast together.

Your babies may get into a pattern where they have one or two longer stretches of sleep. Often this is after the evening cluster feed so it is a good plan to go to bed yourself as well and make the most of it. And they often sleep well during the first nap in the morning. So this can be a good time to stay in bed and get an extra hour, or to get up and have a shower and get ready for the day.

Babies also do not like to be put down very much in the early days. This period is commonly known as the 4th Trimester. As humans we birth our babies quite early in their gestation and new-born human babies consequently, are very immature. In order to keep safe and warm, our babies prefer to settle and sleep on a human, preferably the mother, but sometimes partner or grandparents will do. They need to feel comfort, security, warmth, and be close to their source of food. You cannot spoil a baby by cuddling them and responding to their needs as best you can. This will promote a secure attachment between baby and primary care giver. In fact research shows that a baby that is securely attached for the first 1001 days will go onto be a well-balanced and successful older child and adult. So enjoy the cuddles!

Find your support system:

Your partner and close family will be a big support. Ask them to do some research into breastfeeding and normal new-born behaviour so they are more able to help. Maybe they could accompany you to a face to face antenatal session or watch an online training session. The Association of Breastfeeding Mothers has a nice free course called “Team Baby” which is all about how to support breastfeeding.

Your midwife and then health visitor will be your first port of call for support in the early days. But you may find you need some more specialist breastfeeding support. So before the babies arrive find out what is available locally. See if you can find your local breastfeeding support group, your local breastfeeding counsellor and your local International Board Certified Lactation Consultant (IBCLC). You may want to pop into your local breastfeeding group before the babies arrive just to see how it works. And maybe make contact with you breastfeeding counsellor and IBCLC so you know how they work and how to get hold of them if you need them.

The Twins Trust have trained breastfeeding peer supporters who can be contacted by email and they will support you by email or phone. The National Breastfeeding Helpline is open 9:30am to 9:30pm 7 days a week to talk through any difficulties and answer questions. And Breastfeeding Twins and Triplets UK Facebook Group has an IBCLC and trained peer supporters in its admin team and lots of other parents who are breastfeeding or have breastfed their babies. It’s an amazing group.

Antenatal hand expressing colostrum:

Twins are often born a bit small, a bit sleepy and a bit more difficult to feed. And so they often need a little bit of extra colostrum in the early days just to get them going with breastfeeding.

Antenatal hand expressing has been proven to be safe from 36 weeks of pregnancy. However as many twins are born at 36 weeks, if this is the case for you discuss with your health care professionals whether it would be ok to start in the week leading up to planned induction/caesarean section.

Hand express 2 to 3 times a day. Hand expressing is gentler, and colostrum is so thick and sticky and in such small quantities that it would just get lost in the breast pump. It is totally normal to only get very small amounts. But it is super concentrated, packed full of immunity, and all that baby needs in the first few days so every drop counts. Collect in syringes, either straight from the nipple, or into a sterilised cup first and then transferred to a syringe. Label clearly with name, date and hospital number, freeze in lidded container. When it is time to have the babies, take syringes to the hospital in a cool bag and make sure the staff know they have it. If you have lots of colostrum, don’t take it all, your partner can always pick up more from home if needed.

Kathryn Stagg IBCLC, 2020

Combination Feeding Twins and Multiples

There 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. I usually suggest to give breastfeeding a really good go to start with as it is far easier to move from breastfeeding to formula, than it is from formula to breastfeeding.

Around 40% of twin babies and nearly all triplet and higher order multiples are born premature or unwell and have to go to the neonatal unit (TwinsTrust, 2020). In this situation the breastfeeding journey is started via expressing colostrum and 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, milk supply is easier to establish. There seems to be little research into whether there is a window of opportunity to establish a full milk supply. It is certainly possible to increase milk volumes several months into their breastfeeding journey.

The majority of twins are born around 36 to 37 weeks gestation. This can mean they struggle initially as even though a twin pregnancy is deemed as “full term” at 37weeks, the babies are not full term babies! They can be quite small, sleepy and inefficient on the breast to begin with (Ayton, et al., 2012). These babies sometimes need topping up with expressed milk or formula after a feed to start with, often called triple feeding. Parents start by breastfeeding the babies, topping up with expressed if they have it, or formula if they don’t by cup, syringe or bottle, and then double pumping with a hospital grade pump. 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. But again as the babies approach 40 week gestation, they are often feeding more effectively and top ups can be gradually phased out. Sometimes one baby may establish breastfeeding more quickly than the other and this can prove a bit of a juggle.

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.

There may be a point where the family think they are at maximum capacity for breastfeeding and milk production, whether this being sometime in to the journey of establishing supply, or after a full supply has been established. This can be because of physiological reasons for not being able to produce enough milk (this is actually pretty rare), a difficult start with breastfeeding where milk supply was never fully established, or for other reasons to do with mental overload.

Combination feeding can be a good option for these families. It is so important to value every drop of breast milk these families can give. Formula can be a good tool to prolong the breastfeeding relationship if used in a considered way.

So many families start by breastfeeding and then topping up with formula. However this is not really something that can be kept up long term. Feeding both breast and bottle every feed can be too much work, especially once the partner has gone back to work. If there are physiological reasons for low supply, using a supplementary nursing system can be a great option. The babies can be topped up at the breast and so the breastfeeding relationship is protected and milk supply will be maximized.

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.

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. This becomes more doable as the babies become more efficient on the breast and feeds shorten. Many exclusively breastfeeding triplet families tandem feed two babies together and single feed the third, and rotate the pattern. Some prefer to tandem feed two babies and express milk feed the third, pumping after for the next feed and rotating the pattern. Or they can single feed one baby and express for two. Some prefer to combination feed with formula. They can tandem two babies and give formula to the third, and rotate. They can single feed one baby and formula feed the other two. Some prefer a similar pattern to twins where they exclusively breastfeed for some of the day and give a couple of set bottle feeds. There are all sorts of combinations. And for higher order multiples, similar patterns can be adopted.

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: http://www.twinstrust.org

2020, Kathryn Stagg IBCLC

 

Supporting Breastfeeding Triplets

This article is available as a downloadable pdf here:

Supporting Breastfeeding Triplets

When parents find out they are expecting triplets, this can cause a wide variety of emotions – shock, love, excitement, worry, and even panic. One of the biggest concerns for many parents is whether they will be able to breastfeed their babies.

The good news is that it is very possible to breastfeed twins and triplets. There are some difficulties to negotiate, but with expert breastfeeding support these can be overcome.

Before their babies are born, parents should have a positive conversation with health care professionals. Professionals need to be mindful of the language they use. Often parents report that they have been told it will be too difficult or not possible to breastfeed their babies. This is not the case, and parents should be encouraged to give breastfeeding a try. There is no harm in being realistic; breastfeeding can be a difficult journey. But having triplets is a difficult journey in itself.

Health care professionals can signpost parents to local breastfeeding support – if possible, an experienced breastfeeding counsellor or International Board Certified Lactation Consultant (IBCLC). Good quality online support can be found in the UK via Facebook groups such as Breastfeeding Twins and Triplets UK, and via the Twins Trust.

Going along to a ‘Preparing to Breastfeed’ session will inform parents about the practical elements of breastfeeding and normal newborn behaviour. Some hospitals also offer a specialist multiples session. Accessing antenatal education at around 30 weeks’ gestation is a good idea, in case the babies are born prematurely.

Premature Birth

The majority of triplets are born early, usually arriving around 34 weeks gestation. This means the babies are taken to the neonatal unit, the mother should be supported to hand express as soon as possible after the birth (ideally within 2 hours). Following this, hand expressing should be encouraged at least 8 to 10 times every 24 hours to prime the prolactin receptors and ensure a full milk supply. Once her milk begins to come in, or if large volumes of colostrum are being extracted, the mother should move onto a hospital grade pump. A breast pump can also be used from the day of birth, in addition to hand expressing colostrum, to provide extra breast stimulation.

Every mother wishing to breastfeed should be supported to pump 8 to 10 times in 24 hours. Breast massage before and during the expressing session should also be encouraged, as research shows this can increase milk output (Morton, et al., 2009). Double pumping also results in higher milk volumes.

Kangaroo care should be supported as soon as the babies are stable. Preterm babies become more stable more quickly when held skin to skin. Frequent and extended skin to skin has also been associated with earlier exclusive breastfeeding and higher volumes of milk when expressing (Nyqvyst, 2004).

Rooting has been observed as early as 28 weeks’ gestation in very premature babies, and longer sucking bursts at 32 weeks, so once babies are stable they should be given the opportunity to try the breast. Skilled breastfeeding supporters can assess when the babies are feeding well enough to move towards exclusive breastfeeding.

Triplet babies are often discharged before exclusive breastfeeding has been established, and are commonly breastfeeding and being topped up with expressed milk or formula when they go home. This is called ‘triple feeding’ and is a very intense routine. Lots of support from family and friends is useful during this time.

Breastfeeding triplets once they get home

Many premature babies are still very sleepy and not feeding particularly efficiently once they are discharged from hospital. They may have short sucking bursts or to be uncoordinated in their suck, swallow, breathe pattern, which is significantly associated with suboptimal breastfeeding. Some will be able to breastfeed exclusively and transfer enough milk; some will not. A skilled breastfeeding assessment should be offered.

The babies may be too sleepy to cue for feeds. If this is the case, parents should be encouraged to feed no later than three hours from the start of the previous feed, thus ensuring a minimum of eight feeds a day. If the babies are not feeding effectively, a feeding plan incorporating time at the breast, pumping and topping up is often necessary. Breast compressions can help the milk flow and encourage more effective milk transfer. Lots of support at home is essential during this time as trying to make sure all babies are fed and changed leaves little time for anything else. As the babies begin to breastfeed more effectively, top-ups can be gradually reduced.

Logistics of exclusively breastfeeding triplets

It is totally possible to exclusively breastfeed triplets. Breasts work on a supply and demand basis. If there are three babies “demanding” milk from the breast, then so long as the babies are feeding frequently and efficiently, or milk is removed regularly by hospital grade breast pump, the breast will respond by making three times the milk.

Some prefer to tandem breastfeed two babies and then breastfeed the third, rotating who gets the individual feed. Some prefer to tandem breastfeed two and give a bottle of expressed milk to the third, rotating who gets the bottle each time. In the second case the mother will need to pump after the feed for the next session. Others prefer to breastfeed all three separately to get some individual time with each baby. It is also possible to do more expressed bottles and less direct feeding, maybe breastfeeding one baby each feed directly and pumping for the other two. Or sometimes having a one or two feeds using all expressed bottles given by the partner or helpers so that mum can have a stretch of sleep.

There is no right or wrong way to do this – it’s whatever suits the family best. And feeding patterns can be changed for different times of day or for different stages and ages. Keeping an open mind and being flexible is likely to help maximize breastfeeding.

Tandem feeding

Babies can successfully tandem feed from early on, even whilst they are still in the neonatal unit. If one baby is feeding more effectively than the other, tandem feeding can help the poor feeder as the stronger baby does all the hard work of stimulating the mother’s let down reflex and maintaining the flow of milk. Research suggests that when tandem feeding, the milk has a higher fat content, and the mother experiences more frequent let downs (Prime, et al., 2012). Of course the main benefit to tandem feeding is that two of the babies can be fed in the time of one, thus increasing the efficiency of the feeding session.

Combination feeding triplets

Triplet families often decide that formula feeding should be part of feeding their babies. We must always value every single drop of breast milk triplets babies receive. Sometimes the option of combination feeding will result in the babies being able to be breastfed or receive breast milk for longer, and that can only be a good thing.

Many triplet families fall into a pattern of tandem breastfeeding two babies and formula feeding the third, rotating which babies received the formula each feed. Some families prefer to breastfeed one baby each feed and formula feed the other two babies. Sometimes families may prefer to use a combination of breastfeeding directly, pumping and formula feeding. Or maybe just expressed milk and formula with no direct breastfeeding. Again it is whatever works best, and be flexible, it may change with time.

©Breastfeeding Twins and Triplets UK, 2020 – Kathryn Stagg, IBCLC

Breastfeeding Twins and Triplets UK – Registered Charity no. 1187134 (Registered in England)

www.breastfeedingtwinsandtriplets.co.uk     Breastfeeding Twins and Triplets UK    @BfTwinsUk

©Breastfeeding Twins and Triplets UK, 2020

References

Forster, D. A. & al, e., 2017. Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Iabetes and ANtenatal Milk Expressing [DAME]: a multicentre, unblinded, randomised controlled trisl. Lancet, 389(10085), pp. 2204-2213.

Morton, J. et al., 2009. Combining hand techniques with electric pumping increases milk production of mothers with preterm infants. Journal of Perinatology, 29(11), pp. 757-764.

Nyqvyst, 2004. How can kangaroo mother care and high technology care be compatible?. Journal of Human Lactation, 20(1), pp. 72-74.

Prime, D. K., Garbin, C. P., Hartmann, P. E. & Kent, J. C., 2012. Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression.. Breastfeeding Medicine, 7(6), pp. 442-7.

Supporting Breastfeeding Twins

This article is available as a downloadable pdf here:

Supporting Breastfeeding Twins

When parents find out they are expecting a multiple birth, this can cause a wide variety of emotions – shock, love, excitement, worry, and even panic. One of the biggest concerns for many parents is whether they will be able to breastfeed their babies.

The good news is that it is very possible to breastfeed twins or even triplets. There are some difficulties to negotiate, but with expert breastfeeding support these can be overcome.

Before their babies are born, parents should have a positive conversation with health care professionals. Professionals need to be mindful of the language they use. Often parents report that they have been told it will be too difficult or not possible to breastfeed their babies. This is not the case and parents should be encouraged to give breastfeeding a try. There is no harm in being realistic; breastfeeding can be a difficult journey. But having twins is a difficult journey in itself and once breastfeeding is established, mothers generally find it far easier than bottle feeding.

Health care professionals can signpost parents to local breastfeeding support – if possible, an experienced breastfeeding counsellor or International Board Certified Lactation Consultant (IBCLC). Good quality online support can be found in the UK via Facebook groups such as Breastfeeding Twins and Triplets UK, and via the Twins Trust.

Going along to a ‘Preparing to Breastfeed’ session will inform parents about the practical elements of breastfeeding and normal newborn behaviour. Some hospitals also offer a specialist twins session. Accessing antenatal education at around 30 weeks’ gestation is a good idea, in case the twins are born prematurely.

Antenatal Colostrum Harvesting

Research shows that from 36 weeks of pregnancy, mothers can begin hand expressing and harvesting colostrum (Forster & al, 2017). This can provide valuable insurance against the babies not being able to feed effectively straight away, or needing a boost to stabilise their blood sugars. If birth has been scheduled for before 37 weeks’ gestation, parents can discuss with their doctor or midwife whether it is appropriate to begin hand expressing before 36 weeks. Colostrum should be frozen in syringes clearly labelled with the date of expression, the mother’s name and her hospital number and taken to the hospital at delivery.

Birth at 36 – 37 weeks

Most twins are born at 36 to 37 weeks’ gestation. This is considered a full-term pregnancy for twins; however, it is important to remember that this is still quite early in terms of the babies’ development. They are more likely to be sleepy, to have short sucking bursts or to be uncoordinated in their suck, swallow, breathe pattern, which is significantly associated with suboptimal breastfeeding. Some will be able to breastfeed exclusively and transfer enough milk; some will not. A skilled breastfeeding assessment should be offered.

The babies may be too sleepy to cue for feeds. If this is the case, parents should be encouraged to feed no later than three hours from the start of the previous feed, thus ensuring a minimum of eight feeds a day. If the babies are not feeding effectively, a feeding plan incorporating time at the breast, pumping and topping up may be necessary. Breast compressions can help the milk flow and encourage more effective milk transfer. It should be stressed that this is a short-term intervention until the babies are feeding more effectively and can move towards exclusive breastfeeding. Support for the mother is essential during this time. As the babies begin to breastfeed more effectively, top-ups can be gradually reduced, then stopped.

Premature Birth

If the babies are born early and taken to the neonatal unit, the mother should be supported to hand express as soon as possible after the birth (ideally within 2 hours). Following this, hand expressing should be encouraged at least 8 to 10 times every 24 hours to prime the prolactin receptors and ensure a full milk supply. Once her milk begins to come in, or if large volumes of colostrum are being extracted, the mother should move onto a hospital grade pump. A breast pump can also be used from the day of birth, in addition to hand expressing colostrum, to provide extra breast stimulation.

Every mother wishing to breastfeed should be supported to pump 8 to 10 times in 24 hours. Breast massage before and during the expressing session should also be encouraged, as research shows this can increase milk output (Morton, et al., 2009). Double pumping also results in higher milk volumes.

Kangaroo care should be supported as soon as the babies are stable. Preterm babies become more stable more quickly when held skin to skin. Frequent and extended skin to skin has also been associated with earlier exclusive breastfeeding and higher volumes of milk when expressing (Nyqvyst, 2004).

Rooting has been observed as early as 28 weeks’ gestation in very premature babies, and longer sucking bursts at 32 weeks, so once babies are stable they can be given the opportunity to try the breast. Skilled breastfeeding supporters can assess when the babies are feeding well enough to move towards exclusive breastfeeding.

Twin babies are often discharged before this, and are commonly breastfeeding and being topped up with expressed milk or formula when they go home. This is called ‘triple feeding’ and is a very intense routine. Lots of support from family and friends is useful during this time.

Responsive breastfeeding

Once the babies are feeding efficiently and waking themselves before or around the three hours’ mark, are past their due date and gaining weight as expected, the mother can follow their lead and move to responsive feeding. The average breast-fed baby aged one to six months feeds 11 times in 24 hours, with a range of six to 18 feeds. Parents should be reassured that frequent feeding is normal. If tandem feeding, parents can follow the feeding cues of the hungrier or more alert baby, and wake the other in order to feed both together.

Tandem feeding

Tandem feeding is a useful skill, but not essential. It enables the mother to settle both her babies at once and can help stimulate her milk supply. It is the mother’s choice whether she tandem feeds all the time, occasionally or not at all. There are many different positions to try.

Babies can successfully tandem feed from early on. If one baby is feeding better than the other, tandem feeding can help the poor feeder as the stronger baby does all the hard work of stimulating the mother’s let down reflex and maintaining the flow of milk. Research suggests that when tandem feeding, the milk has a higher fat content, and the mother experiences more frequent let downs (Prime, et al., 2012).

Many mothers wonder whether they should swap breasts when tandem feeding. Swapping means that each eye and ear of both babies will be stimulated by being on top during feeds, and that if one breast has a stronger flow, both babies will benefit. However, not swapping may mean that each baby gets more ‘personally tailored’ breastmilk. There is no right or wrong answer as long as babies are developing well.

©Breastfeeding Twins and Triplets UK, 2020 – Kathryn Stagg, IBCLC

Breastfeeding Twins and Triplets UK – Registered Charity no. 1187134 (Registered in England) www.breastfeedingtwinsandtriplets.co.uk     Breastfeeding Twins and Triplets UK    @BfTwinsUk

References

Forster, D. A. & al, e., 2017. Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Iabetes and ANtenatal Milk Expressing [DAME]: a multicentre, unblinded, randomised controlled trisl. Lancet, 389(10085), pp. 2204-2213.

Nyqvyst, 2004. How can kangaroo mother care and high technology care be compatible?. Journal of Human Lactation, 20(1), pp. 72-74.

Prime, D. K., Garbin, C. P., Hartmann, P. E. & Kent, J. C., 2012. Simultaneous breast expression in breastfeeding women is more efficacious than sequential breast expression.. Breastfeeding Medicine, 7(6), pp. 442-7.

 

 

Stopping breastfeeding toddlers

So hopefully we all know that breastfeeding well into toddlerhood and beyond is recommended by the WHO and that it is normal to do so (although this message still seems to be a bit slow to filter through to some!).

But sometimes breastfeeding just isn’t working for the parent. Maybe they have aversion, maybe they’re feeling totally exhausted and touched out, maybe they’re uncomfortable with still breastfeeding, maybe they just need to stop!

Breastfeeding is a two way relationship and anyone who says a parent is breastfeeding their toddler for them hasn’t breastfed a toddler. And especially if you are breastfeeding 2 or 3 toddlers! It is INTENSE! They often seem to want to feed all day.

So the first step is try getting into a loose routine. A lot of parents find feeding first thing in the morning, mid morning before or after nap depending on whether they still feed to sleep, mid afternoon before or after nap and bed time works well. (They may still be having night feeds as well, I have written a separate blog on gentle night weaning, here. I wouldn’t try to do both at once!) You may find just cutting back a bit like this and taking a bit more control makes it more doable anyway and that then you feel you can keep going for a bit.

But if you still want to gradually wean then the easiest feed to drop is usually mid morning, especially if you go out to groups a lot as you can distract whilst out and baby will tend to fall asleep on the way home in sling/car or buggy. Have lunch ready for when for wake up.

Then once you’ve done that, try stopping the mid afternoon feed. Again get ready with drink and snacks to combat the post nap grumps if they happen.

Once you’re down to morning and bedtime, a lot of people actually enjoy it again and hang on to those two feeds for a while. Once you’re ready to drop the first thing in the morning feed just get up straight away and have breakfast (although I left this feed until last as I preferred to stay in bed at 6.00am having a nice breastfeed than get up and make breakfast!).

For bedtime feed you can switch around the order of the bedtime routine. So instead of feeding to sleep or feeding as the last thing to settle, you can try feeding them first, then do teeth, pyjamas, story and cuddle to sleep instead. This breaks the feed/sleep cycle and will make it much easier to stop the feed completely.

Once you have weaned be very gentle on yourself as the drop in hormones can make you feel very down for a while. It takes your body a bit of time to function normally again. Lots of cuddles will get the oxytocin flowing and help everyone adjust.

Kathryn Stagg IBCLC – Oct2019

Breastfeeding twins/triplets in the Neonatal Unit

Around 40 per cent of multiple births need some extra support after birth and end up having to go to the Neonatal Unit (NNU) of Special Care Baby Unit (SCBU). It the babies need more intensive care they may go to the Neonatal Intensive Care Unit (NICU). This can be a very worrying time for parents. We have put together some tips to help parents survive and also to help ensure they meet their breastfeeding goals, despite having to be separated from their babies.

If you have warning that the babies might come early, prepare yourself by researching breastfeeding, and go to see the NNU so you know what to expect. It can be quite a daunting place full of wires and beeps.

Try to go to a breastfeeding class before babies arrive. If there is a preparing to breastfeed session in the hospital once your babies are in NNU you could attend to learn about it then, even though your babies are already out!

If you have some notice of your impending birth you may want to try collecting some colostrum before they arrive. This might give you a head start. Talk through this with your doctor if you are less than 36 weeks pregnant.

Once babies arrive, make sure you are shown how to hand express, ideally within the first hour after birth. If you are too unwell then try to do it as soon as you are able. You can collect drops of colostrum in a syringe. Here is a really great video tutorial from Global Health Media

Once your milk begins to come in, usually around day 3, you can move on to the pump. Hospital grade pumps should be available for you when you are in hospital. Often hospitals have a pumping room. You may also be able to pump by the side of your baby’s incubator.

Make sure, once you are discharged, that you have access to a hospital grade double pump. Sometimes hospitals or children’s centres have pumps to borrow. If not, you can hire them from the manufacturer. Some NNUs will have a discount code for you to use.

Ask questions, nothing is too silly. Make sure you are consulted on everything and if you do not understand something, ask what it means. Write down questions as you think of them or you won’t remember when the doctors comes round.

Write notes about what they say. It’s hard to remember later. Especially if trying to relay things back to your partner or family members.

Try to be fully involved in their cares. It may feel like your babies aren’t yours as they are being looked after by the nurses and doctors. But there are plenty of things you can do. And they are you babies. It is very important to remember this.

Do not let anyone tell you breastfeeding preemies is not possible. Yes, it is a more difficult journey, but there are many, many families who have managed to breastfeeding their babies.

Find supportive staff. You won’t get on with everyone. But there will likely be one or two nurses who you really click with and you feel you can trust.

Ask to see the Infant Feeding Lead and talk through your plan to breastfeed your babies. They will be able to talk you through the different stages your babies will go through.

Ensure that the staff talk through the risks and benefits of giving formula or fortifier. Make sure you are fully informed before you make a decision to supplement.

Ask about donor milk. Hospitals often have certain criteria a baby will need to meet but it is always worth asking.

Pump as frequently as you can. The more often you express the more milk you will make, ideally 8 to 10 times a day for around 15-20 mins. Try to set alarms so you don’t forget.

Pumping sessions do not have to be evenly spaced.

It is however, very important to pump in the early hours of the morning, between 1-5am, as this is the time that your body has its highest levels of prolactin, the milk-making hormone.

Have something to remind you of the babies when you’re not there, photos, video, cloths that smell of them, some NNUs have fabric squares you can leave in the incubator with the babies and take home with you. Smell is a very evocative scent and this can help with bonding and milk supply!

If you can, pump by the incubators so you can continue to be with them and see them.

If you miss a pumping session, try to squeeze up the others so you still get to your total in 24 hours.

You may find power pumping once a day helps your supply. It mimics babies cluster feeding.

For more detailed info, read “Establishing Milk Supply With a Pump”

Expressing milk for your babies feels great as it is something you can actually do for them whilst they are in the NNU.

As soon as the babies are well enough, ask for skin to skin. And as soon as they have reached around 33 weeks gestation they should be able to begin trying to breastfeed.  

Ask for support with transitioning your babies to the breast. The nurses and infant feeding team should be able to talk you through the steps needed to get baby breastfeeding. For more info read our article “Transitioning Premature Babies onto The Breast”

See if your partner can stay overnight, some hospitals have facilities for this.

Try to have a support network around you to feed you and look after you whilst you look after the babies, especially if you also have older children to think of. Get them to fill the freezer with nutritious food, run the vacuum round, give you lifts to the hospital, do the school run….

Make sure you have plenty of snacks! Get food delivered to the hospital by friends or family so you don’t have to live on hospital food all the time. Have a bottle of water on you at all times. Hospitals are hot and dry.

Find other families in the same situation. Get chatting to others in the pumping room. Join support groups online and on social media. This will be a massive support to you whilst you are in hospital and once you are discharged.

Self care. Make sure you eat and sleep. Have a break. Do something for you whilst babies are being looked after by very capable hospital staff! Allow yourself to leave.

Take pictures of everything. Even the painful bits. You will want to be able to look back at this time one day.

Celebrate every tiny milestone. Celebrate every drop of breast milk. 

You do not have to introduce a bottles to get home. But you may find that babies will continue to need to be topped up for a little while once they are discharged. Many babies are discharged around 36 or 37 weeks gestation if they are well enough and there can still be some feeding issues at this age. Have a read of “Breastfeeding 36 or 37 week babies”  for more info on the issues you may come across.

Once discharged try to make contact with your local breastfeeding support so you have ongoing support throughout the rest of your breastfeeding journey. And of course Breastfeeding Twins and Triplets UK Facebook Group is a fantastic resource.

 

 

Kathryn Stagg IBCLC, Sept 2019

Surviving fussy periods with beastfeeding twins

Babies are fussy sometimes. They have developmental leaps. They have fussy evenings. Sometimes they just have a day when they are not happy for some reason. But when there’s two, it can be quite difficult to cope with. But as long as nappy output is appropriate for their age (generally 2-3 poos in and 5-8 wet nappies in 24 hours, although after 6 weeks babies can go a few das without poo and that’s fine) and weight gain is consistent, it is a completely normal, if difficult stage.

Twins sometimes have their fussy periods at the same time. This can be pretty intense! Sometimes they decide to tag team. Less intense but then it goes on longer. I am not sure which is easier. But unfortunately, as parents we do not have much say in the matter.

So here are some tips to help cope:

Let them cluster feed

Babies like to stock up with milk. Mostly once breastfeeding is established, babies will generally be happy after just one, or possibly two goes on the breast. But during fussy periods they often want to go back onto the breast time after time. This is called cluster feeding. You give them a feed, they begin to snooze, come off, you put them down, they wake up and start routing, you feed them, they snooze and come off, you put them down, they wake and start routing….. repeat for a few hours. The good news is you will get a let-down of milk each time. Your breasts are unlikely to feel full during these periods, but breasts never actually run out. They are constantly making milk, and an empty breast makes milk much more quickly than a full breast. So milk production actually increases. So get set up with everything you need, snacks, drinks, phone, remote control and something good on the TV, and let the babies feed, feed, feed. This is where tandem feeding really helps as you can plug them both in and quieten them down. If you are struggling with tandem feeding then having someone else to entertain the second baby is a massive help and you can keep rotating the babies.

Other settling techniques

But you may find you get to the stage when the babies do not want to feed any more but are still not happy. Often this will mean they try to latch on for comfort but as soon as they get some milk, they come off again as they are not actually hungry. It does not mean you have run out of milk. Babies often like to suck for comfort, so sometimes substituting the nipple for a clean finger can work. But babies also like movement and closeness. So you could try skin to skin (especially with the non-breastfeeding parent as the smell of milk can just mean they want to latch on), rocking, patting, swaying, tiger in the tree position (see pic below), walking or bouncing with them in the sling, baby massage, maybe a bath or sharing a bath with a parent, or even taking them out in the car (many a parent has found themselves driving around late at night willing the baby to sleep!). Often after a bit of a break, the babies will latch on again and have a good feed an eventually settle down to sleep. And often you will find that they sleep for quite a good period of time after a fussy period like this, so this is time for mum to sleep too!

 Some mums prefer to express earlier in the day and offer a bottle during these fussy times. But remember breastfeeding is not just about the milk, it’s about comfort and connection as well. And remember it is important to express if you are missing a feed otherwise it will affect your supply.

Babies often grow out of these fussy, cluster feeding type periods at around 3 or 4 months of age. So although very difficult when we are in the middle of it all, it is reassuring to know it will not last long. 

 June 2019, Kathryn Stagg IBCLC

Twin Feeding Pillow Tutorial

feeding pillow tandem pic (2)

With all U-shaped twin breastfeeding cushions, make sure you are sitting upright and push the cushion right in so there’s no gap by your tummy. Use the back support cushion and maybe add another cushion to make sure there’s enough room for babies’ legs to wrap round you. The cushion should bring your babies to exactly the right height to latch on to the breast. Add some extra cushions if the babies are not high enough or sit on a softer surface so you sink a bit lower. If the cushion is too high try sitting on a cushion, or on a harder surface, like a firm sofa.

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To get both babies in to position, put one baby in a safe place within reach so you can set up the cushion and get comfortable. Don’t forget to grab a drink, snack and your phone and make sure the remote is within reach! Place first baby on cushion, then reach to pick up second baby. You could roll a muslin and put behind first baby’s back to prevent them rolling off the cushion if you like. Grab the baby grow of the second baby under the chin and lift gently, slide your other hand under as soon as you can. The back of the baby grow will support the neck of the baby, but move slowly. Lift second baby into position on the cushion.

Make sure you’re starting nose to nipple, this means the babies have to be quite far back. Don’t hold the back of their heads or they will not be able to open their mouths wide, support at the shoulders. Baby should be half on their back, half on their sides looking up at the breast. Wait for an open mouth and bring one baby onto the breast chin first. The bottom lip should be quite far from the nipple, the nipple then goes into the roof of the mouth. You can assist by lifting the breast a little by pressing in on the top of the breast with the other hand. Then do the same with the second baby. The cushion should be set up correctly so that once they’re feeding you should be able to let go and feed hands free.

tandem feed above

For babies who are often sick or suffer from bad wind or reflux, it is possible to tilt the cushion a little so babies’ heads are higher than their hips. Try putting your feet on a foot stool to lift your knees a little and then lean back a bit. Or maybe sit cross legged or with your knees bent on the bed. This means the angle of the cushion and your body is still the same but babies’ heads are raised a little.

For the M shaped cushions, start with it in W position, put behind your back, then fold the two sides down and clip together (if you have a clip, some cheaper ones do not have this feature). The centre section becomes the backrest. Then follow the same procedure for latching as the other pillows.

Image result for twin z feeding pillow

May 2019, Kathryn Stagg IBCLC

Breastfeeding babies of 36 or 37 weeks gestation

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 mothers, 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, although I prefer the term “cue-based feeding” or “baby-led feeding”. They are often too sleepy for the mother to be able to follow their lead completely. And if they do not feed enough, they get even sleepier and 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. Mum’s milk supply may not be stimulated enough, or she may lose her hard-earned milk supply if she was pumping in NICU. After a week or two it is decided the babies need supplementing, but the lack of breast milk 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 mother is allowed to follow her babies’ lead.

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. (Maria Biancuzzo, Dec2018) They should be encouraged to feed their babies frequently. Dr Tena Fry said in her interview with Maria Biancuzzo: “If a baby’s eyes are open they should be offered food”. Parents also ned 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. But mums often continue to supplement and schedule 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 before the 3 hour schedule, and having a good proportion of “active feeding” during a breastfeed. Then if mum is pumping for top ups this can be gradually phased out. They will be safe to move on to baby-led 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 2019

Cue-Based Feeding for Late Preterm Infants: 5 Facts You May Not Know

The Baby Friendly Initiative

The Case for the Floor Bed

Many parents worry how they can get their co-sleeping older babies into their own room and into their own cots. However, there’s another way which can be much easier, much more gentle and less stressful for everyone. The floor bed!

The difficulty of using a cot is having to settle them into it. Contrary to popular belief, many children under the age of 2 do not lie down and go to sleep happily on their own. Many still need a feed or a cuddle to do this. But getting them to go into the cot after feeding or cuddling to sleep can be difficult. As soon as you lower them down and let go, they’re awake again, either almost straight away or at the end of the first sleep cycle.

A floor bed can remedy a lot of the problems. Either just a mattress on the floor, or on a low slatted bed base, or on conjunction with a cot (or two) with the side taken off.

Here are some of the positives:

* Baby is settled to sleep in the bed they are expected to sleep in. Often a baby falls asleep in its parent’s arms or bed as this is the easiest way to get them to sleep. Then when the baby wakes up, they find themselves in their cot, sometimes in a different room. This can be very disorienting as any adult who has awoken somewhere different to where they fell asleep can testify!

* If the baby wakes in the night, the parent can settle them back to sleep in the baby’s own bed easily with a feed or a cuddle. No need to move them out of their environment.

* The fact it is on the floor means it is safe if they roll out or get up and wander in the night. And they will not try to climb out of the cot! Ensure furniture is screwed to the walls for safety and nothing can be pulled on top of them. Parents can also use a baby monitor.

* Parents can co-sleep part of the night in baby’s bed if necessary ensuring a good night sleep for all. This also means that the other parent can remain in the parental bed. The co-sleeping parent can sneak back to their own bed if they are still awake once baby has settled.

* It is a very gentle way to encourage a baby to move into their own room or in with their sibling whenever the parents think this is the correct time for their family.

* Later on the parent can gradually retreat by lying next to the child, lying a bit further away, popping out for a minute, until eventually they are happy with a story, a kiss and a cuddle and then sleep.

So for parents wanting a gentle way to transition a child to sleeping on their own space, this can be an ideal solution.

Photos courtesy of Gentle Parenting Twins and Triplets UK & Ireland facebook group.