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.

 

 

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

 

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