Preparing to breastfeed multiples

Learn about breastfeeding:

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

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

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

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

Learn about normal new-born behaviour:

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

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

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

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

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

Find your support system:

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

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

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

Antenatal hand expressing colostrum:

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

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

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

Kathryn Stagg IBCLC, 2020

Combination Feeding Twins and Multiples

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

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

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

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

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

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

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

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

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

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

Bibliography

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

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

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

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

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

2020, Kathryn Stagg IBCLC

 

Supporting Breastfeeding Triplets

This article is available as a downloadable pdf here:

Supporting Breastfeeding Triplets

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

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

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

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

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

Premature Birth

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

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

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

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

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

Breastfeeding triplets once they get home

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

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

Logistics of exclusively breastfeeding triplets

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

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

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

Tandem feeding

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

Combination feeding triplets

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

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

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

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

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

©Breastfeeding Twins and Triplets UK, 2020

References

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

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

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

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

Supporting Breastfeeding Twins

This article is available as a downloadable pdf here:

Supporting Breastfeeding Twins

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

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

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

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

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

Antenatal Colostrum Harvesting

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

Birth at 36 – 37 weeks

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

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

Premature Birth

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

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

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

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

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

Responsive breastfeeding

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

Tandem feeding

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

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

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

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

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

References

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

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

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

 

 

Surviving fussy periods with beastfeeding twins

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

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

So here are some tips to help cope:

Let them cluster feed

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

Other settling techniques

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

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

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

 June 2019, Kathryn Stagg IBCLC

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

 

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

Breastfeeding Triplets

Twins, I can understand twins, you have two babies, two arms and two breasts. The maths just works. But THREE babies! Where do you start with breastfeeding triplets? Joanne said: “My first thought when I found out I was expecting triplets was: “oh no I won’t be able to breastfeed them.” But after lots of research she found others have breastfed their triplets.

But why one earth would you even contemplate it? Well firstly there is obviously all the health benefits for mum and babies. And triplets are much more likely to be premature so these health benefits are even more important. But once breastfeeding is established, it is so easy. Don’t get me wrong, having triplets is hard, but it’s hard whatever way you feed them! Breastfeeding means feeds are always ready to go, no preparation, you won’t forget your boobs when you go somewhere, you don’t have to get out of bed to do the night feeds, and once they are older it is a really nice way to get some one on one time with crawling babies, and later there is no better way to subdue a tantrum! And it’s free! Although you may have an increased food bill due to how hungry it makes you! The reasons to breastfeed three babies are just the same as the reasons to breastfeed one or two.

I asked some of the triplet families on Facebook what would be their top tips.

Firstly, believe it is possible. Sue said “my body grew three babies, it can feed three babies”. And as with all breastfeeding, believing it is possible and trusting your body to produce what is needed is so important. As is having health care professionals who are on your side. Natasha said “I’d also recommend making connections with the hospital lactation consultant before your babies are due. Mine came and saw me 2 or 3 times a week when the boys were on SCBU and when we returned to our booking hospital 3wks after the boys were born she was there ready and waiting for me. We struck up a real friendship and she had my back the whole time. She was knowledgeable and empowered me to stand up to others who thought it wasn’t possible. She also helped educate me around bottles/dummies/kangaroo care etc which was great and helped me make informed decisions.”

The majority of triplets will be born early and end up in the Neonatal Unit. So mum should be prepared to start your breastfeeding journey with a breast pump, expressing every two to three hours round the clock to establish a copious milk supply. Once mum is discharged home she will need to hire a hospital grade double pump and continue this expressing pattern. We will shortly have a more in depth blog on pumping so watch this space! Once babies begin to feed at the breast, pumping can begin to reduce. Our other blog Transitioning a Premature Baby Onto The Breast is a good read of how to move from expressing for your babies to breastfeeding them when they’re discharged home.

Being educated in how breast milk production works is really important as mum will need to maximize her milk-making potential. For triplets the breasts receive three times the stimulation as from a single baby. This means the breasts are drained three times as often. This in turn promotes them to make three times as much milk. The more you feed the more you make. The hardest thing is finding the time to do this and some time to eat and sleep too! And you will be incredibly hungry. Breastfeeding one baby takes around 500 calories, so we can assume that three babies take 1500 extra calories! Having healthy snacks and lots of fluids will make you feel like you have enough energy to do this, although it probably won’t directly impact your milk supply.

Get support with positioning and attachment i.e. getting a good latch. For small babies it is so important to ensure they are latched on well so they can feed as efficiently as possible. They get tired very easily. Breast compressions can help get a bit of extra milk into them during feeding. Also vital for mum too as this will help prevent sore nipple and blocked ducts. When you are trying to feed three, you need to minimize the chance problems.

Some mums prefer to tandem feed two babies and then feed the third, rotating who gets the individual feed. Others prefer to tandem feed two and give a bottle of expressed to the third, rotating who gets the bottle each time. Or some prefer to breastfeed all three separately to get some individual time with each baby. Or maybe do more expressed feeds and less direct feeding. There is no right or wrong way to do this. It’s whatever suits you and your family best. And you can change what you do for different times of day or for different stages of breastfeeding. So keep an open mind and be flexible.

Many expectant triplet mums wonder how they will get the time to do everything. Will I ever sleep? The truth is you can’t do everything. So prioritize and delegate! If a mum is breastfeeding then she needs to prioritize that over everything else. Get help with all the things that anyone can do! Another pair of hands can be useful for general baby care; nappy changing, baths, feeding top ups, settling when they are cranky! Also help with the housework is a must in the early days. If family and friends can’t help out then it might be worth spending some of the money you are saving on formula on buying in some help. And the rule for visitors is that the must bring food and do one household chore before they are allowed a cuddle of the babies!

And of course if it all gets too much mix feeding is always an option. For example some triplet mums prefer to breastfeed two babies and formula feed the third, and then rotate. Or breastfeed one and formula feed two and rotate. Or use expressed breast milk and formula in bottles. Any amount of breast milk is incredibly valuable and should be celebrated.

To sum up Caroline commented: “All I would say is it takes patience and perseverance. You need a smile for those who say you can’t, and a finger for those who say you shouldn’t!” So if you have just found out you are expecting triplets, why not give it a go and see how you get on?

 

Kathryn Stagg, ABM BFC, 2017