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

 

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