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

Breastfeeding babies born at 36 or 37 weeks

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

https://mariebiancuzzo.com/2018/12/04/cue-based-feedings-for-late-preterm-infants/

https://www.unicef.org.uk/babyfriendly/

Establishing milk supply with a pump

There are several reasons milk supply may have to be established by expressing and not by directly breastfeeding. Mother and baby may have to be separated after birth due to prematurity or illness, or maybe baby just cannot latch on for some reason. Maybe baby is tongue tied, has a cleft palate or is too sleepy to feed effectively.

So how do you establish your milk supply if you are not directly feeding your baby?

After birth you should be encouraged to hand express colostrum within an hour of birth if possible, or at least within the first 6 hours. Ask to be shown the technique by your midwife, or there are plenty of great video tutorials online. This one from Global Health Media is particularly good, click here. It is important to massage the whole breast and the nipple for a couple of minutes before starting. Hand expressing is recommended for the first two to three days until the milk begins to come in as colostrum is very thick and sticky and is in small quantities, so will get lost in a pump. However, if large quantities of colostrum are being expressed, you could move onto the pump earlier. Also there are settings on some hospital pumps designed for expressing colostrum and some mums respond better to this. The pump can also be used just for stimulation.

Babies only need a small quantity of colostrum, so every drop counts. These small drops can be sucked up with a syringe direct from the nipple or dripped into a small cup and then sucked into a syringe. This can then be given directly to the baby. You should be encouraged to hand express 8 to 10 times in 24 hours to mimic the baby’s feeding patterns. This will give enough colostrum to feed and to prime the lactation sites so that you will have the greatest chance to make a full supply or as near as possible. Some mums do struggle to express any colostrum in the first few days. It does not mean it’s not in the breast, we all start making colostrum in the second trimester of pregnancy, but it can be a bit challenging to get it out. If it is proving difficult then maybe ask about donor breast milk until your milk “comes in”. Most mums find they can express mature breast milk much more easily.

 

 

lilli put pumping

Moving on to the pump. Milk begins to “come in” around 3 to 5 days after birth, a process called “lactogenesis II”. It is triggered by the birth of the placenta and will happen whether a mum is breastfeeding, pumping or doing neither. Breast milk gradually changes from colostrum to mature milk over a number of days and volumes should begin to increase. Continuing to pump 8 to 10 times a day will help ensure you establish a full supply.

Top tips to establish a good supply!

Frequency – There really is no better way to get a full supply than to pump frequently; 8 to 10 times a day to begin with is essential. Some mums with large storage capacities may be able to drop a couple of sessions and continue to make enough milk, but for many frequency is the key. Expressing sessions do not need to be equally spaced. And if you miss one for some reason, try to shuffle up the others so you still get the same number over 24 hours.

Efficiency – Using a hospital grade pump is recommended. In hospital the staff should be able to provide one for you to use, normally in the pumping room, sometimes by baby’s cot or incubator. Once discharged, hospital grade pumps can be hired either direct from the manufacturer or from a local pump agent. If baby is in NICU there is often a discount code.

Breast shell size – It is really important to get the pump’s breast shell size correct. This will mean pumping should be comfortable and not cause any damage to the nipples, and it will also help maximise milk production. Just a note to say sometimes a pair of breasts need two different sized shells! And sometimes you need to change size as you go through your pumping journey as breast size changes. Nipple diameter is the key. Check your manufacturer’s information on this and experiment a bit.

Power pumping – This mimics a baby’s natural cluster feeding pattern and can help stimulate milk production. The pattern is as follows using a double pump: pump for 20 minutes, have a 10 minute rest, pump for 10 minutes, rest for 10 minutes and then pump for a further 10 minutes. This can be done once a day to help boost supply. If you are using a single pump then you can power pump by pumping 10 minutes on the left and then 10 minutes on the right, rest 5 minutes, pump 10 minutes on the left and 10 minutes on the right, rest for 5 minutes and then pump ten minutes on the left and 10 minutes on the right again.

 

power pumping

Hands on pumping technique – This is a technique which incorporates massage, hand expressing and pumping all at the same time. Many have found that this can greatly increase output. For a more detailed explanation watch this video

Hand expressing – after the flow has slowed you could try finishing off by doing some hand expressing. Often a little more can be squeezed out by hand

A hands free pumping bra – This can make the above massage much easier, as you use the bra to hold the pump onto the breasts and so hands are free. It also means you can pump and do other things at the same time. This can be essential, especially if you have older children. You can buy them or make your own by cutting vertical slots in an old bra or sports bra where your nipples are, and you can insert the cones through the slits.

Warmth – Applying a warm compress just before you express can help the let-down reflex.

Skin to skin with baby – Skin to skin, or kangaroo care as it is often referred to, helps boost oxytocin and encourages the milk to flow. Oxytocin is one of the key hormones involved in the production of breast milk and, amongst other things, stimulates the let-down reflex, meaning milk flows more easily when pumping.

Look at baby – Photos, videos, pictures, pumping next to the cot, listening to your baby. All these remind the breasts what they are supposed to be doing! They also stimulate oxytocin and help with supply.

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!

Latch baby – If baby is beginning to latch on to the breast, pumping straight afterwards can make it much easier for the milk to flow as the baby will have stimulated the let-down reflex.

Distraction – “A watched pot never boils”. It’s the same with pumping. If you watch what you get, you will likely not get so much. Distracting with listening to music, relaxation recordings, mindfulness, watching comedy, chatting to other mums or friends and family all have been shown to increase milk production. Stress can inhibit the let down reflex so these techniques can help keep you relaxed.

Eat and drink – Good for health and energy of the mother, not necessarily for milk production.

Rest – It is really essential for mums to rest. Yes we also want them to wake once or twice a night to pump, but getting a good amount of sleep is so important to cope with the stresses and strains that you feel when a baby who is latching. Get help with all the usual household chores, looking after older children and cooking. Mother the mother so the mother is able to mother the baby.

Galactagogues – There are many foods or medications out there which either have some scientific evidence behind them or have anecdotal evidence that they can increases milk production. However, none of these work unless the milk is being removed frequently from the breast. They are not a magic wand. For more info on galactagogues have a look at this link
pump Sophie De Sousa expressed stash

It is important to look at 24 hour output, not necessarily what is expressed in each session. This is because there is often a wide variation in amounts from different times of day, and also each breast often gives a different amount. Over the first few weeks, we hope to see a gradual increase in volume in each 24 hour period.

Once babies are strong enough or well enough they should be able to move gradually on to breastfeeding directly. Make sure you seek some support from a trained breastfeeding specialist to help you achieve this.

Kathryn Stagg IBCLC 2018

 

Tandem feeding twins

You have two babies, you have two breasts. Many twin mums like to feed their babies together to save time and to try to maximise sleep!

But should you try straight away or should you single feed first whilst you are all practising?  The answer is it really depends on your babies and you. Some babies struggle to latch in the early days so trying to juggle two babies and latching both on with one hand each can be quite stressful. And they often take a few goes each to latch. So sometimes its preferable to wait until they have practised a bit feeding singly. Other babies, especially if they are full term, a good size and nice and alert, can tandem feed straight away. So you will really have to wait and see. Some mums try tandem feeding and just don’t enjoy it. And that’s fine too. But I think its always a good idea to be able to tandem feed if you need to, even if you don’t do it all the time.

So how do you go about tandem feeding? The most popular position is the “double rugby hold”, or “double football hold” if you are American. The babies lie one down each side of you. Start nose to nipple, so the babies need to be quite far back with their legs curled round your waist; you may need an extra cushion or two behind you to make room for their legs, especially as they grow longer! Support the baby with your hand behind their shoulders with thumb and fingers round the neck behind the ears. Tickle top lip with your nipple to stimulate baby to open her mouth wide, and bring on to the breast chin first with nipple going up into the roof of the mouth. A twin feeding pillow can help to support the babies in a good position. You can read my blog about different twin feeding pillows here. If you have your feeding pillow set up well you should be able to let go of the babies and feed hands free (meaning you can eat ice-cream!).

Many mums are worried about how they will be able to tandem feed without help when their partner goes back to work. The most important thing is to keep everything nearby within reach. Then get your feeding pillow ready. Pick up one baby and put on sofa or bed next to you. Ensure baby cannot roll or push themselves off. It is surprising how early babies can move themselves! Then pick up the second and place next to the first. Get settled and make sure the feeding pillow is in position. Lift one baby onto the pillow, ensure they can’t roll off, you can either use your arm to support it or some prefer to roll up a muslin and just prop them up. Lift second baby onto the cushion. I usually advise mums to start with the fussier feeder as you can concentrate more on the latch and use both hands. Then once the first baby has settled into a deep feeding rhythm and the milk is flowing, latch on the second baby. Sometimes this knocks the first baby off the nipple and you have to start again! But with practice, you will get there.

But you don’t have to be constrained by the double rugby hold and needing to use a pillow to tandem feed. There are several other positions you could try. And especially as the babies get older, more able to control their heads, and faster at feeding, you really can be quite creative.

Commonly called “The Stack” you can feed one baby in cradle hold and one in rugby hold. This is quite a good position for feeding out and about as you can do it either without a feeding pillow or with just a couple of cushions to support your arms. Or you can sit cross-legged on the floor and have your legs support the babies.

The “double clutch” can be another good way of tandem feeding without a pillow. It is especially useful when babies are a bit older and can feed in a more sitting up position.

You can even tandem feed in the car. Just make sure you are not actually driving at the time!

And you can feed walking around if you can master the “tandem twin sling feed”. The ultimate food on the move.

And most importantly, there are ways you can tandem feed lying down, so you can lie back and relax whilst you feed. These positions can be used from birth when babies like to feed very frequently, or later on during the long, cluster feeding sessions during growth spurts.

 

And when the babies become toddlers, they can feed any old how.

 

Kathryn Stagg, IBCLC, Jan 2018

 

Night Weaning Toddler Twins

Babies wake in the night. We know that. Babies like to feed a lot in the night. That’s a given. But sometimes it all becomes too much. Sometimes its exhaustion, sometimes its nursing aversion, sometimes work commitments and sometimes it’s just that mum has had enough. Night weaning is generally not recommended until after 18 months by most Gentle Parenting experts. At this age they have some understanding of what is going on. Sleep is a developmental stage, like walking and talking, and babies and toddlers will do it when they are ready. Some will have large chunks of sleep from an early age and that’s fine, but others continue to wake frequently well into their second year.  There are definite genetic factors at play. And twins do not necessarily do it at the same time. Often one is ready much sooner than the other. Breastfeeding is by far the easiest and fastest way to settle a baby back to sleep when they wake. But there may be a point where mum needs to stop it. This should be for the mum to decide and nobody else. She will know if she is ready to night wean. If she is not sure whether she should, then it probably is not the right time yet. It is nobody else’s decision; not the health visitor, grandmother or even the partner. And just to make sure you understand, night weaning will not necessarily make them sleep any better. They may still wake, and you will have lost the easiest way to get them back to sleep. However with lots of consistent alternative reassurance they will begin to be able to transition from one sleep state to another. Toddlers not being too over tired during the day will also help with this.

tandem feeding in bed

Breastfeeding at night is not so much about nutrition for toddlers. There is a big emotional context to it. Breastfeeding is helping them feel safe, to deal with all the big emotions of being a toddler, to deal with the pain of teething, to reconnect after being separated due to work and child care. There’s a whole load of stuff going on. So it’s important not to take away the other comforts that they are used to whilst you try to night wean. Co-sleeping, bed-sharing, cuddles, using a comforter like a toy. These can help the transition away from relying on the breast to settle back to sleep.

Should you night wean both together? Or should you deal with them separately? This is a difficult one as it really depends on your own individual situation. Is one more settled than the other? Or are they both equally as wakeful? Is either of them happy to settle for your partner?  Are you bed sharing? Do they share a separate bedroom? Do they have separate rooms? There are all sorts of factors to take into account. If one baby is more settled, able to settle for a partner, or they are in separate rooms, then it may be easier to try separately. Otherwise it is probably easier to do both together.

Find other ways to settle your toddler at night. There are many different things you can try as a replacement for breastfeeding; cuddling, stroking, patting, singing, use of a special toy or blanket, music, white noise, whatever works best for you. Some will work better than others and everyone is different. You will find the best option for your family.

One thing to try is to cuddle or stroke back to sleep whilst they’re stirring before properly awake. Toddlers go through sleep cycles from deep, slow wave, sleep to light REM (rapid eye movement) sleep regularly and it is during the REM sleep that they often fully rouse and need help to resettle back into a deeper sleep again. Unfortunately a toddler’s sleep cycle is much shorter than an adult’s. This only really works if you are bed sharing as you will need to be in close proximity to be aware when they are about to wake. But if you can cuddle or rest your hand on their body and settle before they are completely awake, you may find they go back into another deep sleep without fully waking and demanding to be fed. I found turning baby away from me and cuddling tightly from behind worked fairly well.

Try with just one of the night feeds. Try the first wake-up of the night and see if you can settle them in a different way. This is the most likely night feed to be able to drop more easily. As the night progresses and morning approaches, sleep often becomes lighter and toddlers are more difficult to settle back to sleep. They often like to get up very early at this age. The most likely thing to help you stay in bed for a bit longer is to continue to breastfeed in the early mornings!  

Find another comforter. Toddlers often like to have a comforter in bed and these can really help to transition away from breastfeeding being the major comfort. The comforter can be anything your toddler is attached to. It can be a toy or blanket, or sometimes physical touch can replace breastfeeding; my toddler would slide his hand up my sleeve for comfort. The replacement comforter should be introduced well before the night weaning process is begun as it should not be seen as a replacement for breastfeeding but a separate comfort. Then slowly you can encourage your toddlers to become more dependent on this and less dependent on breastfeeding.

Debra's twins cudding

Twins also have a built in comfort; each other! One of the plus points of having more than one baby is that they do give comfort to each other. In the early days many parents co-bed their twins or triplets and find this can help with settling them to sleep. However a lot of mums separate them later as they start to disturb each other. But sometimes as they get older, they may like to sleep together in a large cot or floor bed or even just in a standard toddler bed. I often found mine had climbed in bed together when they had gone to bed separately.

Shortening feeds. This can be especially effective if you are experiencing nursing aversion. Nursing aversion is a negative feeling some mums get when feeding. It is often hormonally driven, ovulation and menstruation can be a trigger, and pregnancy is a major culprit. So in order to continue being able to breastfeed, shortening the feeds can work well. You can talk to your toddlers about having “a little bit”. To start with, tackle the bed time feed, pull off the breast by sticking in your little finger and breaking the seal just before your toddler is about to drift off to sleep and encourage them to do that last bit on their own. You can always re-latch them if it doesn’t work. Once the toddler is used to this you can gradually unlatch sooner and eventually they may settle to sleep from awake on their own. Some mums like to sing a song during this feed and when the song is finished, the feed is finished. If you are having a particularly bad day you can sing faster! Once they are good at settling to sleep without the breast they may be more able to move between their night time sleep cycles without feeding. They may settle for the song. Or they may settle with just a few of sucks.   

Talk to your toddlers throughout the day about how boobies will be asleep tonight and how they can have some in the morning. Let them choose which comforter they would like to use. Remind them again just before bed time. Try to keep it positive. When will they be able to feed again, you can feed once the sun shines, boobies have gone to bed and will be back in the morning. Try not to focus on rejecting them. On saying no, not now. Some parents find a Gro-clock can be a great visual aide for this method. The Gro-clock can be set to go from day to night at a certain time and you can explain to your toddler that they can breastfeed once the clock says it is morning. You can set an early time to begin with and extend it later on, once they get the concept. There is also a lovely book called “Nursies When The Sun Shines” by Katherine C Havener which focusses on night weaning and explains to the toddler that she will be able to nurse when the sun comes up.  

Dad sleeping with babies

The partners in a twin or triplet family are often much more hands on than your average family, as there is much more to do! If your toddlers are happy to settle with your partner, and they must be truly happy, sometimes this can be a good technique to night wean. Your partner can go in first and see if they can settle them. If it doesn’t work then you can go in and breastfeed back to sleep. Some babies are more receptive to this than others. You may find one of your babies is fine with your partner and so this may help night wean one of them easily and you can concentrate on the other. Sometimes you can split them up and the non-breastfeeding parent take one of the toddlers and sleep with them and the breastfeeding parent can sleep with the other. But often only the breastfeeding parent will do and if this is causing further distress it may be a good idea to stop.  Remember for a toddler breastfeeding is a way to connect with you, their mum. So keeping the connection is important.

Night weaning is often a very gradual process. Aim for small goals and baby steps. And don’t be afraid to stop if it does not feel right. Teething, illness, changes of circumstances, can all increase night waking and sometimes it may just be easier to go back to breastfeeding in the night again. Then once the unsettled period has passed you can try again. Also don’t be afraid to stop at a certain stage if you are all happy. Sometimes mums find that one or two night feeds are actually quite doable and continuing with these can actually make night times easier. Each journey is very personal between mum and her toddlers and what will work for one family will not necessarily work for another.d and j in bed

www.isisonline.org.uk/twins/

www.parentingscience.com/baby-sleep-patterns.html

www.feedsleepbond.com/how-to-stop-breastfeeding/

www.emmapickettbreastfeedingsupport.com/twitter-and-blog/weaning-toddler-bob-and-pre-schooler-billie-how-do-you-stop-breastfeeding-an-older-child

“The No-Cry Sleep Solution”; Elizabeth Pantley

“The Gentle Sleep Book”; Sarah Ockwell-Smith

 

Kathryn Stagg, IBCLC and ABM Breastfeeding Counsellor, Dec 2017

Specialist Twin Breastfeeding Pillows. Are they necessary and which one do I buy?

 

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

Transitioning a premature baby onto the breast – a step by step guide for parents

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

References

Breastfeeding and Human Lactation, enhanced 5th edition, Wambach & Riordan, 2016

The Breastfeeding Atlas, 6th edition, Wilson-Clay and Hoover, 2017

 

Dropping top ups gradually – a step by step guide for mum.

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

References:

http://kellymom.com/bf/got-milk/supply-worries/enough-milk/

http://kellymom.com/hot-topics/milkproduction/