Combination Feeding Twins and Multiples

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

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

Around 40% of twin babies and nearly all triplet and higher order multiples are born premature or unwell and have to go to the neonatal unit (TwinsTrust, 2020). In this situation the breastfeeding journey is started via expressing colostrum and breast milk and feeding via a tube. Frequent pumping with a hospital grade double pump will give the best chance of establishing a copious supply (Hill, et al., 2005) But as the babies grow and become more efficient feeders, milk supply is easier to establish. There seems to be little research into whether there is a window of opportunity to establish a full milk supply. It is certainly possible to increase milk volumes several months into their breastfeeding journey.

The majority of twins are born around 36 to 37 weeks gestation. This can mean they struggle initially as even though a twin pregnancy is deemed as “full term” at 37weeks, the babies are not full term babies! They can be quite small, sleepy and inefficient on the breast to begin with (Ayton, et al., 2012). These babies sometimes need topping up with expressed milk or formula after a feed to start with, often called triple feeding. Parents start by breastfeeding the babies, topping up with expressed if they have it, or formula if they don’t by cup, syringe or bottle, and then double pumping with a hospital grade pump. And they should be doing this 8 times a day, every 3 hours. This is a very intense regime and many struggle, especially with the pumping element. But again as the babies approach 40 week gestation, they are often feeding more effectively and top ups can be gradually phased out. Sometimes one baby may establish breastfeeding more quickly than the other and this can prove a bit of a juggle.

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

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

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

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

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

For triplet families, as well as the twin related scenarios discussed above, there is also the issue that there are more babies than breasts! Various patterns of breastfeeding, expressing and formula feeding can be adopted. Some triplet families prefer to breastfeed each baby individually. This becomes more doable as the babies become more efficient on the breast and feeds shorten. Many exclusively breastfeeding triplet families tandem feed two babies together and single feed the third, and rotate the pattern. Some prefer to tandem feed two babies and express milk feed the third, pumping after for the next feed and rotating the pattern. Or they can single feed one baby and express for two. Some prefer to combination feed with formula. They can tandem two babies and give formula to the third, and rotate. They can single feed one baby and formula feed the other two. Some prefer a similar pattern to twins where they exclusively breastfeed for some of the day and give a couple of set bottle feeds. There are all sorts of combinations. And for higher order multiples, similar patterns can be adopted.

Bibliography

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

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

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

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

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

2020, Kathryn Stagg IBCLC

 

Supporting Breastfeeding Triplets

This article is available as a downloadable pdf here:

Supporting Breastfeeding Triplets

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

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

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

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

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

Premature Birth

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

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

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

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

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

Breastfeeding triplets once they get home

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

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

Logistics of exclusively breastfeeding triplets

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

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

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

Tandem feeding

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

Combination feeding triplets

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

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

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

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

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

©Breastfeeding Twins and Triplets UK, 2020

References

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

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

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

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

Supporting Breastfeeding Twins

This article is available as a downloadable pdf here:

Supporting Breastfeeding Twins

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

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

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

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

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

Antenatal Colostrum Harvesting

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

Birth at 36 – 37 weeks

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

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

Premature Birth

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

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

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

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

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

Responsive breastfeeding

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

Tandem feeding

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

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

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

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

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

References

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

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

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

 

 

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 of 36 or 37 weeks gestation

A baby born between 34+0 weeks and 36+6 weeks gestation is defined as a late preterm baby. A baby born between 37+0 weeks and 38+6 weeks is defined as an early term baby. The average length of a twin pregnancy is 36+4 weeks. Many twin babies are born between 36 and 38 weeks gestation due to the NICE guidelines.

For babies who are born at this time, establishing breastfeeding can be quite difficult. They are often well enough to remain on the postnatal ward with their mothers, which is great as they do not have to go to special care. But as such they often get treated the same as a full term baby and are left to “demand feed”.

The problem is that these babies often do not “demand” enough and prefer to sleep, although I prefer the term “cue-based feeding” or “baby-led feeding”. They are often too sleepy for the mother to be able to follow their lead completely. And if they do not feed enough, they get even sleepier and harder to rouse to feed. Also a lot of slightly early babies are not physically strong enough or coordinated enough to fully breastfeed, often until around due date or even a bit after. They have a few sucks, take on a little milk, and then fall asleep before they have had their fill.

This can lead to real problems! Babies can lose weight, or jaundice can set in. Mum’s milk supply may not be stimulated enough, or she may lose her hard-earned milk supply if she was pumping in NICU. After a week or two it is decided the babies need supplementing, but the lack of breast milk may mean they need to use formula.

These problems are also experienced by parents of more premature babies as they are often discharged around what would have been 36-37 weeks gestation with minimal breastfeeding support. They are often given the chance to “room in” for a couple of days to practise feeding and looking after their baby or babies full time, and this is often the first time the breastfeeding mother is allowed to follow her babies’ lead.

These families need lots of support. They need good quality face-to-face breastfeeding support after discharge. They need to be shown the subtle cues their baby makes to show that they need a feed; stirring, mouth opening, turning head from side to side, and the later cues including stretching, moving arms and legs, trying to bring hand to mouth. Crying and agitation are late cues. (Maria Biancuzzo, Dec2018) They should be encouraged to feed their babies frequently. Dr Tena Fry said in her interview with Maria Biancuzzo: “If a baby’s eyes are open they should be offered food”. Parents also ned to be supported to understand when their baby is not cueing frequently enough. We would suggest not to let a baby of this gestation go longer than 3 hours from the start of each feed to ensure they have a minimum of 8 feeds in 24 hours. 

Parents should also be shown how to ensure the babies are latching on well to feed. And tandem feeding positions can be discussed to help with the intensity of breastfeeding new baby twins. Also breast compressions are a very useful tool to help transfer a bit more milk to the babies during the feed, and to remind them to keep feeding when they get a bit sleepy towards the end of the feed. Sometimes a baby of this gestation may have trouble latching directly on to the breast. Babies who are a little early sometimes latch better and feed more efficiently when using nipple shields. Close attention should be paid to milk weight gain and nappy output if shields are used as they can inhibit milk transfer.


Parents may need support with continuing to pump for top ups if the babies are not ready to fully breastfeed. And they need to be shown how to tell that their baby is developmentally ready and feeding efficiently enough to move away from 3 hourly feeds and on to baby-led, cue-based feeding. The problem is each baby is different. Some will be ready to fully breastfeed at 36 weeks, others at 42 weeks, and everything in between. But mums often continue to supplement and schedule far longer than they need to. We would normally look for each baby to be putting on weight as expected, generally waking themselves for feeds before the 3 hour schedule, and having a good proportion of “active feeding” during a breastfeed. Then if mum is pumping for top ups this can be gradually phased out. They will be safe to move on to baby-led feeding. If parents are using formula to top up this can be gradually phased out. See our guide here 

Ideally each family would be guided by somebody highly qualified such as an IBCLC or experienced breastfeeding counsellor. This is a scenario that deserves specialist breastfeeding support in the home on discharge from hospital, to ensure they can maximise the breast milk intake of their babies.

 

Kathryn Stagg IBCLC 2019

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

The Baby Friendly Initiative