Sleep tips for multiples are not always the same as those for singletons. I’m not saying that multiple babies always bring exponentially more sleep problems! In fact, some people find that their multiples were easier than their singletons! But many families find that general sleep books contain tips that don’t always work very well with multiples.
Lyndsey Hookway, paediatric nurse, health visitor, IBCLC and gentle sleep and behaviour coach works at http://www.feedsleepbond.com as well as for the NHS and as an independent lecturer and trainer, teams up with the Kathryn Stagg, breastfeeding counselor, soon to be IBCLC and mum of twins as well as singletons to bring together our collective wisdom on sleep tips for multiples.
In the early days
The best time to lay the foundations for good sleep with multiples babies is in the newborn period. Prevention is better than cure after all! There are several strategies for families of multiples that are simply not an option for singleton newborns.
- Multiples are often smaller and born a little earlier than singleton babies. For these reasons, they often stay a little longer in hospital. Use this time to access as much support as possible for feeding, especially getting breastfeeding established. Many of the problems with low blood sugars, excessive weight loss and jaundice can be minimized or even avoided completely by frequent, effective feeding.
- Plan to feed your babies at least 10-12 times in 24 hours
- Try to not allow your babies a gap between feeds of any longer than 3 hours to avoid them dropping their blood sugars and becoming sleepy, cold or jaundiced
- Ensure your babies are drinking effectively at the breast, and not just latching on and then having a nap! Watch this video to see what really effective feeding looks like.
- Ask for help from the infant feeding team, peer supporters, a breastfeeding counselor, or IBCLC – check this interactive map to find your nearest.
- Very young babies are not great at maintaining their body temperature. Dress your babies in thin, 100% cotton layers, but remember to avoid using a hat indoors unless you have been advised to use one by your baby’s medical team.
- Consider placing your babies in the same crib for sleep, ensuring that they are still in the back to sleep and feet to foot position. Twins and triplets are often comforted by being near their sibling(s). for more information click here.
- If your babies fall asleep feeding on a feeding cushion, then provided you are awake and watching them, just leave them where they are! Lots of babies wake up when they are transferred. At first, the priority is getting your babies to sleep simulataneously, rather than get them to sleep in their cot.
- If your babies like to take their time feeding, consider tandem feeding, where you feed them at the same time. Try watching this video for some inspiration with positions and how to manage more than one baby for feeds.
- Use a variety of sleep cues from the very beginning to encourage your babies to associate several cues with sleep. These could include shushing, patting, white noise, and a small thin muslin cloth with your scent on.
What sleep problems may occur?
To some extent, multiples are no different than singletons – they still enjoy being close to their parents, being cuddled, rocked, and fed to sleep. Nothing new there! The specifically tricky thing with more than one baby is managing the logistics!
|Babies not sleeping at the same time||· Review feeding needs, weight gain· Try to feed babies at the same time
· Consider babies individually, to see if they have different needs that need to be met in different ways
· Prioritise when babies sleep over where or how – try pram walks or baby carriers to get babies to sleep
|One baby wakes the other||· Try white noise to help the sleeping baby to ignore the breakthrough sound· First try briefly separating the babies to establish good sleep habits. Then return them to the same room once they are both sleeping well|
|Hard to settle more babies than there are adults to help||· Consider enlisting the help of others just for bedtime· Consider tag-teaming at bedtime – one baby to one adult
· Place one baby in a bouncer whilst settling the first baby
· Place both babies in the crib and shush and pat both at the same time
|Remember your sleep basics||· Initiate a bedtime routine from the beginning· Prioritise naps – watch your babies’ early sleepy cues and put them down for naps at the first sign of tiredness
· Try earlier bedtimes to minimize overtiredness
Points to remember:
You gave birth to two, three or more completely individual little people. They may share many characteristics, features, and parents. However, that does not mean they will have the same sleep requirements, or go to sleep in the same way. Just as with a single baby, it is not your responsibility to make your babies sleep. It is only your responsibility to keep them loved and safe and provide the right environment for sleep.
If you do reach the utopian scenario when your babies are sleeping at the same time, in spite of the excitement you will feel at having achieved such a miracle, try to sleep! Resist the urge to catch up on your social media, laundry or batch cooking. The babies can sit in a bouncy chair watching you while you do those things. Sleep is a precious commodity – guard yours with your life!
Learn how to wrap your babies in a sling/baby carrier – this can be a lifesaver for when you need to get chores done, or you want your babies to sleep whilst you’re out and about. It’s well worth going to a sling library or asking a trained sling consultant to help you find the right sling – not all babies and mums get on with the same slings.
Remember the basics:
- Bedtime routine (do 3-4 calming activities that are predictable before each and every sleep, and do a mini-version of the routine for naps as well)
- Good sleep hygiene (uncluttered sleep environment, dim lighting, regular bedtime, bedtime routine)
- Avoid over-tiredness – watch for early sleep cues: losing interest in toys, avoiding eye contact, becoming quiet. Later sleep cues include yawning, eye rubbing, crying, back arching and high pitched squealing. Putting your babies down after you see late tired cues may make it harder for your little ones to fall asleep.
- Stay calm! Babies are masters at knowing our psychological state. You have to be wise to this and plan to mentally ‘park’ your baggage prior to trying to get your little ones to fall asleep. If they sense your frustration or desperation, chances are they will get worked up and be harder to settle. I often recommend a thought or mood journal to dump any unhelpful or negative thinking patterns.
Some gadgets that may help:
The choice of baby equipment can be overwhelming, but here are some favourite gadgets from mums of multiples:
- Feeding pillows can be really useful – not only for feeding babies, but also to use for support, playtime and sitting up in bed. Check out Kathryn’s blog on feeding pillows here.
- Large side-car cots. There are loads on the market, and they facilitate breastfeeding and easier nighttime settling. If you don’t want to buy a specific co-sleeper crib, your other option is to buy a standard cot. Then take one of the long sides off, so that the cot only has 3 sides. Your babies can then sleep together in the cot.
- Bouncers – these can be a lifesaver as a safe place to put one baby while you attend to the other(s). There are lots to choose from – pick one that has head support so your baby’s head is not slumped, which can cause flat head syndrome.
- Twin buggies with carrycots. This is probably your most expensive purchase! However, if you have a pram with easily removable carrycots, your babies will be more portable. You can then meet friends out and about whilst your babies nap. If they only nap in their cot you may have a tricky situation where you are forced to be housebound for all their naps – not great for your social life or mental health!
I was pregnant with twins, and I was going to breastfeed. I was determined and didn’t even buy any bottles! However, I also planned on giving birth to healthy, full-term babies with a strong instinct to root and latch. Instead I went into labour at 31 weeks and pushed my tiny, fragile twins into the world. They weighed 3lb each and were taken straight to NICU. I then had some complications, need a spinal block and manual removal of placentas and I didn’t get to see my babies for another 7 hours.
I knew they would be too small to breastfeed for at least a month or more, so I was given syringes, collection bottles and sterilising tank. I was shown how to hand express and given a pump which had a special preemie setting for collection of colostrum. This allowed me to express my first colostrum for my babies which they received down their nasal-gastric tubes. Two hours later I hand expressed again and then hooked up to the pump, but I barely got a drop. The NCU staff reassured me that this was normal and not to worry, my milk would be in soon. They explained that removing the colostrum AND nipple stimulation were just as important to establish supply. I personally found hand expressions quite tricky, especially with large breasts and when sore and tired after labour. So I hand expressed and then sat back, relaxed and watched my beautiful babies whilst I pumped and sent all the right messages to produce plenty of milk. The staff explained that George and Elsa were too small and poorly for formula milk, which would be hard on their delicate tummies and also put them a t increased risk of developing a very serious bowel disease called NEC. I signed a form to give my consent for my twins to receive donor milk. I will forever be grateful to the woman or women who fed my babies for those 3 days. My milk came in on day 4 and I was elated to see streams of milk flowing down the flanges and plopping into the bottles. I hired a hospital grade pump and expressed every 2-3 hours round the clock getting up at least twice every night. I was producing far more than my twins needed so my Mum bought us a second freezer for the garage, just for the milk!
After a month in NICU, my daughter was latching well and taking bottles of expressed breast milk (EBM) when I went home at night. She was discharged and came home to us, leaving her brother in hospital, which was very bittersweet. My son had issues where he would stop breathing, his heart rate would slow he would go blue and then with stimulation he would right himself and pink up again. Feeding seemed to trigger these episodes, confirmed by his nurses and consultants. These episodes were very scary and I started to dread latching him on. George would begin feeding, then go very still, he would turn grey then blue, lie limply until I unlatched him desperately rubbed him until his would take a big breath again and the beeping of his alarm would go silent. These episodes knocked my confidence hugely and I preferred feeding him bottles of EBM as I could watch him more closely and feeds were over and done with quicker. Bottle feeding him was much less traumatic and after another week of him bottle feeding and gaining weight, he came home to join his sister.
I nursed Elsa and expressed for George. I tried to make this work but I found it difficult to feed on demand and pump by the clock. I started to feed Elsa EBM in bottles too. This suited us better during those early weeks and months and it allowed my support network to help out with feeds whilst I expressed too. At the time I didn’t think of what would happen long term, I took each day as it came. I (naively) thought I could get my babies back on the breast when I was ready and George had outgrown his breathing and feeding issues.
My mum and my husband were a great support at this time, both practically and emotionally and I think they enjoyed helping to feed them too. The twins gained weight beautifully and whilst our situation was rather unique, it felt like everything was falling into place. By 4 months old, George had completely outgrown his breathing issues, but they had forgotten how to latch and I didn’t have the emotional energy to keep trying and ’failing’ at getting them to nurse. Instead I carried on pumping and slowly became a proud exclusively expressing breast feeder. By 7 months I was expressing 5 times a day (morning, bedtime and during each of their naps, even when out and about!). When they dropped a nap, I dropped a pump, I didn’t want pumping to interfere with our awake time together.
I had a large oversupply of milk which allowed me to I donate to several mothers in need. We would arrange collection of a large 1000-2000 ounces every couple of months. I donated to a lady with insufficient glandular tissue, a lady who had had a double mastectomy and another mum of twins who was nursing one baby but the second couldn’t nurse due to a medical condition. Breast milk is AMAZING stuff and it is very rewarding seeing other babies receive it, and getting to know women who value breast milk as much as I do. Watching my twins grow into strong and healthy toddlers also made it worthwhile too, they are a far cry from the tiny 3lb babies I gave birth to!
The twins are now 3 years old and I eventually stopped expressing milk for them when they were just over 2.5 years. In 2015r I trained as a Mother Supporter with the ABM and feel I can offer a great deal to mothers of premature or poorly babies who cannot latch, who need support and advice about expressing to maintain a supply until baby begins to feed efficiently. I am currently training to be a Breastfeeding Counsellor. Exclusively expressing, for however long you need or choose to do it, is hard work and requires determination and dedication – mothers need support during this time, I hope I am able to provide some of this support to them and let them know they are doing a fantastic job.
Sam Osborne, ABM Mother Supporter and trainee Breastfeeding Counsellor
So you have had the news that you are expecting twins. Once you’ve got over the shock it’s time to think about the practicalities, and what you need to buy. Many mums wish to tandem feed their babies in order to save time and deal with two hungry babies! But are the twin breastfeeding pillows necessary? And if they are, which one is the best one to buy? They are not cheap so it is important to get it right. When you have the correct one they can make tandem feeding so much easier, especially in double rugby hold (one baby under each arm) but they can be used for other feeding positions too. If the babies are held at the correct height on the cushion you can actually feed hands free, meaning you can actually and drink your tea warm! But which one you buy is a very personal choice and often you need to think about your body shape before deciding. Your lap to nipple measurement (I bet you didn’t think you’d ever be measuring that!) makes a lot of difference. And this depends very much on the length of your upper body, and how your breasts fall. If you are tall with perky, small boobs, you may find you need a lot of extra cushions to make some of the lower brands work. We did a survey on the Breastfeeding Twins and Triplets Facebook group to see if we could glean any useful information.
There are five main brands available. The first four are the traditional U shape, (listed from thinnest to highest) and the last one is M shaped.
Harmony Duo. (£79.95)
This feeding pillow has been a mainstay of the twin feeding world for a long time now. It has a breastfeeding side and a bottle feeding side. On the breastfeeding side there is quite a big slope from outside to inside which helps prevent the babies from rolling off. However this pillow is the lowest of all sloping from 15cm down to 11 cm on the inside. Many mums find they need to add extra cushions to raise it up high enough. It is also the smallest on the inside diameter of the U, so not so good if you’re on the larger side. This pillow suits shorter mums, or those with droopier boobs. A lap to nipple measurement of 15-17cm seems to work best. Some find it’s difficult to use as the babies get older as it is quite narrow. It comes with detachable back cushion and a wipeable surface, although this can be a bit sweaty in hot weather. You may find you need extra cushions behind as babies get longer.
My Brest Friend Twin Cushion. (Currently US import only)
This pillow is a little higher. It has a nice soft feel and is comfy for the babies. It is a little wider which makes it feel more secure and less likely for the babies to roll off. It also has quite a large inner diameter so is good for larger ladies. This pillow slopes from around 15cm on the outside to 12 cm on the inside and suits a medium height, or medium boobs. A lap to nipple measurement 17-21cm and a larger frame would probably suit this cushion. It has washable covers and comes with attached back cushion but you may find you need extra support behind as it’s quite narrow.
San Diego Bebe Twin Cushion. (Currently US import only)
This is another sort of medium height feeding pillow. Lovely brushed finish and comfy for the babies. It is a slightly wider pillow so lots of room for bigger babies. You can use it with an “apron” attached for modesty, although sometimes the babies are not so keen to be covered up. It has washable covers and a back cushion that is removable. The pillow slopes from around 15cm outside to 12cm inside. Again this pillow would suit a medium height or medium boobs. A lap to nipple measurement of 17-21cm would suit this cushion.
Peanut and Piglet. (£85.00)
This is a firm high feeding pillow. It is still around 15cm high above the knees but is higher at the back and so keeps the babies more horizontal. Because of its firmness the babies are held at a slightly higher height, so this pillow suits taller ladies or small perky boobs. A lap to nipple measurement of around 22-26cm would suit this pillow. Taller ladies may still need to lift it a little.
**newsflash** Peanut and Piglet now have a petite version of their feeding pillow. This will be much more suited to the shorter-bodied or danglier-boobed mum!
Twin Z. (US import only)
It took me quite a while to work out how this M shaped pillow from the USA worked. So the official way of using it is to start with the cushion standing vertically in the W position, then fold down the two outer prongs, the middle “prong” of the M becomes a back support. Then the two outside prongs are where the babies lie. There is a strap to pull the two prongs together to prevent there being a big gap for babies to fall into. It is a fairly low pillow, 20cm at the back but only 12cm at the front. Unless you are short or have droopy boobs you will probably find you need extra cushions to raise it up. There are bootlegs available in the UK but they do not have the front strap to hold it together.
It is important to remember that all mums and babies are different and some cushions will not suit some situations. Some mums prefer to just use a V shaped pillow, or a beanbag style pillow or a combination of normal pillows from the bed. Others find they can still use a single feeding pillow. Other mums prefer to find other tandem feeding positions for which you don’t need a pillow at all, like a double laid back position for example. Other mums just don’t like tandem feeding or their babies don’t like tandem feeding! So the point is am trying to make is that you don’t really know what will suit you until the babies actually make an appearance.
There is also a very healthy twin breastfeeding pillow second hand market. So if you do buy the wrong one you will find you can sell it on very easily. Or if you would prefer not to risk so many pounds, then buy second hand in the first place and save money. Many pillows are barely used and are in great condition. There are often For Sale posts on Breastfeeding Twins and Triplets UK Facebook group, also on the TAMBA for sale forum for members, local twins clubs and of course auction and second hand websites. And if you don’t get on with the pillows or don’t get on with tandem feeding, they make a great support for babies learning how to sit up.
Kathryn Stagg, ABM Breastfeeding Counsellor, Nov 2017
Twins, I can understand twins, you have two babies, two arms and two breasts. The maths just works. But THREE babies! Where do you start with breastfeeding triplets? Joanne said: “My first thought when I found out I was expecting triplets was: “oh no I won’t be able to breastfeed them.” But after lots of research she found others have breastfed their triplets.
But why one earth would you even contemplate it? Well firstly there is obviously all the health benefits for mum and babies. And triplets are much more likely to be premature so these health benefits are even more important. But once breastfeeding is established, it is so easy. Don’t get me wrong, having triplets is hard, but it’s hard whatever way you feed them! Breastfeeding means feeds are always ready to go, no preparation, you won’t forget your boobs when you go somewhere, you don’t have to get out of bed to do the night feeds, and once they are older it is a really nice way to get some one on one time with crawling babies, and later there is no better way to subdue a tantrum! And it’s free! Although you may have an increased food bill due to how hungry it makes you! The reasons to breastfeed three babies are just the same as the reasons to breastfeed one or two.
I asked some of the triplet families on Facebook what would be their top tips.
Firstly, believe it is possible. Sue said “my body grew three babies, it can feed three babies”. And as with all breastfeeding, believing it is possible and trusting your body to produce what is needed is so important. As is having health care professionals who are on your side. Natasha said “I’d also recommend making connections with the hospital lactation consultant before your babies are due. Mine came and saw me 2 or 3 times a week when the boys were on SCBU and when we returned to our booking hospital 3wks after the boys were born she was there ready and waiting for me. We struck up a real friendship and she had my back the whole time. She was knowledgeable and empowered me to stand up to others who thought it wasn’t possible. She also helped educate me around bottles/dummies/kangaroo care etc which was great and helped me make informed decisions.”
The majority of triplets will be born early and end up in the Neonatal Unit. So mum should be prepared to start your breastfeeding journey with a breast pump, expressing every two to three hours round the clock to establish a copious milk supply. Once mum is discharged home she will need to hire a hospital grade double pump and continue this expressing pattern. We will shortly have a more in depth blog on pumping so watch this space! Once babies begin to feed at the breast, pumping can begin to reduce. Our other blog Transitioning a Premature Baby Onto The Breast is a good read of how to move from expressing for your babies to breastfeeding them when they’re discharged home.
Being educated in how breast milk production works is really important as mum will need to maximize her milk-making potential. For triplets the breasts receive three times the stimulation as from a single baby. This means the breasts are drained three times as often. This in turn promotes them to make three times as much milk. The more you feed the more you make. The hardest thing is finding the time to do this and some time to eat and sleep too! And you will be incredibly hungry. Breastfeeding one baby takes around 500 calories, so we can assume that three babies take 1500 extra calories! Having healthy snacks and lots of fluids will make you feel like you have enough energy to do this, although it probably won’t directly impact your milk supply.
Get support with positioning and attachment i.e. getting a good latch. For small babies it is so important to ensure they are latched on well so they can feed as efficiently as possible. They get tired very easily. Breast compressions can help get a bit of extra milk into them during feeding. Also vital for mum too as this will help prevent sore nipple and blocked ducts. When you are trying to feed three, you need to minimize the chance problems.
Some mums prefer to tandem feed two babies and then feed the third, rotating who gets the individual feed. Others prefer to tandem feed two and give a bottle of expressed to the third, rotating who gets the bottle each time. Or some prefer to breastfeed all three separately to get some individual time with each baby. Or maybe do more expressed feeds and less direct feeding. There is no right or wrong way to do this. It’s whatever suits you and your family best. And you can change what you do for different times of day or for different stages of breastfeeding. So keep an open mind and be flexible.
Many expectant triplet mums wonder how they will get the time to do everything. Will I ever sleep? The truth is you can’t do everything. So prioritize and delegate! If a mum is breastfeeding then she needs to prioritize that over everything else. Get help with all the things that anyone can do! Another pair of hands can be useful for general baby care; nappy changing, baths, feeding top ups, settling when they are cranky! Also help with the housework is a must in the early days. If family and friends can’t help out then it might be worth spending some of the money you are saving on formula on buying in some help. And the rule for visitors is that the must bring food and do one household chore before they are allowed a cuddle of the babies!
And of course if it all gets too much mix feeding is always an option. For example some triplet mums prefer to breastfeed two babies and formula feed the third, and then rotate. Or breastfeed one and formula feed two and rotate. Or use expressed breast milk and formula in bottles. Any amount of breast milk is incredibly valuable and should be celebrated.
To sum up Caroline commented: “All I would say is it takes patience and perseverance. You need a smile for those who say you can’t, and a finger for those who say you shouldn’t!” So if you have just found out you are expecting triplets, why not give it a go and see how you get on?
Kathryn Stagg, ABM BFC, 2017
When a baby or babies have arrived early, Mum often feel stressed and helpless and feel one of the few things they can do is to provide breast milk. Preterm breast milk is different to that of a mum who delivers at term. It has higher levels of energy, fats, protein, vitamins and minerals, and most importantly it has higher levels of immune factors. It is highly valued in the neonatal unit and mums are usually supported to hand express colostrum within the first 6 hours after birth, and then move onto the pump to provide breast milk for tube feeds. The hospital should be able to advise on renting a hospital grade double pump for when mum is discharged. It is important to pump frequently; we recommend 8-12 times in 24 hours making sure at least one is between 2-5am when hormone levels are at their highest. A more detailed blog on establishing milk supply is available here.
But what next? How do we go about actually breastfeeding? Is it possible to move to exclusively breastfeeding when you have had such a traumatic entrance to the world? The answer is yes, but it will take time.
Once premature babies hit around 32-33 weeks gestation they often begin to start developing a suck, swallow, breathe pattern in short bursts and may start rooting for the breast. Hopefully you will have already been given the chance to have lots of kangaroo care with your baby before now, but at this point it can really help transition the baby from tube feeds onto breastfeeding.
Learning to breastfeed when you are a premature baby is a long, slow, tiring process and it requires everybody to have lots of patience. To start with babies can have skin to skin time, or kangaroo care, be encouraged to lick the nipple and if they are ready to possibly have a few sucks. A baby can begin with non-nutritive sucking at a recently pumped breast to provide a gentle experience without an overwhelming flow of milk. Then a fuller breast can be introduced. But at this early stage the majority of any feed will still be expressed milk through the feeding tube. The staff will encourage you to try baby at the breast once or twice a day so as not to tire them out too much. Once they become stronger and start to suck and swallow more efficiently its time to move to more frequent feeds. It can be a good plan to try baby at the breast during their tube feed as they will begin to associate the act of breastfeeding with the feeling of having a nice full tummy. A nipple shield can help the smaller baby to latch onto the breast, especially if they have been given bottles. There is evidence that suggests shields can increase milk intake in preterm infants in the early days. Remember ask for lots of support from the hospital staff during this time. This is actually one of the benefits of having babies in special care.
When the babies appear to be feeding better and getting much more milk we can move on to the next stage. This can be at different ages for different babies. For some it can be around the 36-37 week gestation mark, others need to get to near full term. The hospital staff will help give confidence that it is time to move to the next stage. Whilst some babies will be able to move straight on to exclusive breastfeeding from tube feeding, this new enthusiasm for feeding can be a bit misleading as the suck can still be uncoordinated and inefficient and the babies can still tire easily. If we move on to exclusive breastfeeding too quickly, it can cause problems with babies not taking enough milk, becoming too tired and then starting to reduce their weight gain. So for many babies its advisable to continue to top up with expressed for a while. A lot of mums choose to top up by a different method than tube so the babies can get home. Hospital staff may use a tool like the Breastfeeding Assessment Score below to calculate how much top up to give baby. They will calculate to work out exactly how much milk depending on baby’s weight, gestation, growth about how much a full feed is.
For twins and triplets it is important to remember that they are individuals. One baby may be much better at feeding than the other. It can be hard not to compare and be worried and frustrated if one baby is not managing to feed as well. But, with time, it is very likely that they will catch up and both will feed well from the breast when ready.
Generally hospitals prefer to use bottles to feed babies their top ups, or during the night when mum is not there. They are easier, there’s less waste and staff are pushed for time so go for the easier option. So to minimise the impact of using a bottle on breastfeeding, it is important to use a paced bottle feeding technique. Paced bottle feeding means letting the baby take control of the speed of the feed and when to take breaks and when to finish. Sit baby in an upright position and keep the bottle as horizontal as possible whilst still filling the teat with milk to avoid intake of air. Baby should be encouraged to latch on to the bottle like the breast, so touching the top lip to encourage baby to route and bring baby onto the bottle chin first, teat into the roof of the mouth. Stop frequently and make sure you do not force baby to have a certain amount. With this slower feeding technique, the baby will be able to tell it is full and finish the feed when satisfied. And baby will be more able to transfer between bottle and the slower flow of the breast.
Mum and baby will hopefully be given the chance to ‘room in’ for a night or two before they are discharged. During this time they’re often encouraged to move on to more baby-led feeding as opposed to hospital routine based feeding. But babies can still be sleepy and not wake for feeds at this stage so its important to make sure that they feed at least every 3 hours as a minimum. 3 hours is measured from the start of each feed.
For a lot of preemie mums, their first experience of being at home with their early baby is to be in an intense breastfeed, top up, express routine, every 3 hours or more, day and night. This is utterly exhausting and overwhelming and mums can often not see past this stage. However with good feeding support from health visitors and breastfeeding specialists and the discharge team from NICU, mums can move on to exclusive breastfeeding.
Whilst the baby still needs top ups it is imperative that there should be somebody to look after mum. This routine is so full on that there is not much time for anything else, especially sleep! Somebody to do the top up whilst mum expresses can be a life saver as this can save time and could give mum half an hour extra break before she has to start the process again. Breastfeeding makes you hungry and for mum’s energy levels it is important that she eats properly, so having someone to feed her whilst she feeds the babies is a great idea. Every single breastfeed given and every single drop of expressed milk should be valued and encouraged. Emotional support reassuring her that she is doing a brilliant job and that soon it will become much easier can keep everyone going through this incredibly tough time.
Support can be invaluable at this time but a lot of mums feel unsure about taking their preterm baby out to groups due to risk of infections. This is where home visits from well informed health care professionals and good online support can step in. Online support especially can be great, as long as it is properly moderated, as mums can make contact with others who have been in the same position or are going through it at the same time. Peer to peer support is incredibly important. There is also often somebody around at 3am during the night feeds to sympathise!
So how do we know when a baby is feeding well enough to move on from this routine? Often around due date or just after, babies suddenly ‘get’ feeding. Their suck becomes more coordinated and they can remove more milk from the breast. You can watch for the full term feeding pattern of sucking fast for a minute to stimulate the let down, and then move on to deep slower jaw movements with pauses in between. You may be able to hear swallowing. Breast compressions can help to get a bit more milk into the baby if they are still seeming a little inefficent or sleepy at the breast. They often have a big feeding frenzy at around due date and sometimes want to cluster feed. This can be very unnerving for a preterm mum who is used to having a sleepy baby who needs to be woken for feeds. Cluster feeding should be encouraged and explaining to mum that it is completely normal behaviour and will help baby get lots of milk. However it does not necessarily translate in to weight gain immediately. It can be very discouraging when baby has been feeding all night and only put on a small amount the next day. However you often find a day or two later and it pays off.
For twins or triplets it may be a good plan to get some support with tandem feeding. Tandem feeding maximizes the time spent feeding as there’s less waiting time for babies and it is a more efficient use of time. It helps synchronize the babies’ feeding times and more importantly sleeping times! A strong feeder can help a weak feeder by stimulating the let down and getting the milk flowing. It also increases milk supply and the milk has a higher fat content.
Dropping or reducing the top ups gradually can make it a bit less stressful. For more detailed info in reducing top ups see our other blog here
But here’s an overview: Mums can reduce the volume of top ups and put babies back on to the breast if not settled. Mums often find that babies are more settled during certain times of day or night and these can be the first feeds to just breastfeed. Encourage mums to allow the baby to have a second or third go on the breast if they do not settle after the first feed. Offer the other breast so baby gets a nice fast flow of milk. For twins or triplets you can just put them back on the same one and mum will get another let down of milk.
Aiming for maybe 3 top ups of expressed a day and being baby led in between is a good starting point. Mum can keep an eye on nappy output during this time to give her peace of mind and she may prefer to weigh the baby before moving on from this stage to give her confidence that everything is going well. Sometimes when babies move on to more direct breastfeeding, their weight gain can flatten off a little bit. This can be really discouraging but it can take a bit more energy to fully breastfeed and they can tire themselves out and burn more calories. As long as they are still gaining this is usually ok and they will set off following their curve again given a bit of time. This may be a good time to get some reassurance from a breastfeeding specialist.
Once mum is feeling confident and babies are feeding well it is relatively easy to drop the last few top ups. Mum 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 expressing and washing bottles. Some prefer to still keep an expressed feed in their routine so that they can have a break.
Breastfeeding is so important for babies, but even more so for premature babies. But establishing breastfeeding in the neonatal unit is like a marathon, not a sprint. It is a slow process taking every ounce of patience and determination. But it is worth every bit of stress.
Kathryn Stagg ABM BFC, Updated Nov 2019
Breastfeeding and Human Lactation, enhanced 5th edition, Wambach & Riordan, 2016
The Breastfeeding Atlas, 6th edition, Wilson-Clay and Hoover, 2017
A lot of 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 baby is gaining weight steadily, has plenty of wet and dirty nappies, and is generally settled between feeds. A breastfeeding specialist 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.
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 1 week and 4 or 5 weeks old we should see 3 to 4 dirty nappies a day and at least 6 wet nappies. For older babies they can go for days 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 then milk should be expressed instead. Also if baby is fussy at the breast an not feeding well, expressing should be encouraged to start boosting 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 specialist 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 (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. Baby can be put back on to the breast to settle if necessary. This will increase the amount of stimulation for 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 mum can pump instead and replace some top ups with expressed. We want to start increasing your 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 mum should wake baby every 3 hours or more and feed at least 8 times in each 24 hours as a bare minimum. We measure the 3 hours from the start of each feed. It is good to clear the diary, get a feeding station set up with everything she needs; 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, basically hand expressing whilst baby is latched on, can help increase the amount of milk the baby is getting whilst feeding 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 the top ups. 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 will be necessary and get some further face to face breastfeeding support. It may be a case of waiting a bit longer to start decreasing.
If the baby is growing well and has a good nappy output, a good halfway house is to aim to top up 3 times a day. Pick times of day when baby is more fussy and is less willing to go to the breast to keep 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. But it is good to spread them fairly evenly over 24 hours. Take a section of the day and let the baby 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 the baby 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 baby 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.
Once you have 3 top ups a day with baby led 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!
For twins or triplets all of this still applies. It may be a good plan to get some support with tandem feeding. 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 strong feeder can help a weak 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 baby led 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 breast milk is so important for baby and for mum. 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 dropped then and breastfeeding can continue for as long you and baby enjoy it.
Kathryn Stagg IBCLC, updated Nov 2019