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

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.

 

 

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.

 

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

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

 

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

When a baby or babies have arrived early, Mum often feel stressed and helpless and feel one of the few things they can do is to provide breast milk. Preterm breast milk is different to that of a mum who delivers at term. It has higher levels of energy, fats, protein, vitamins and minerals, and most importantly it has higher levels of immune factors. It is highly valued in the neonatal unit and mums are usually supported to hand express colostrum within the first 6 hours after birth, and then move onto the pump to provide breast milk for tube feeds. The hospital should be able to advise on renting a hospital grade double pump for when mum is discharged. It is important to pump frequently; we recommend 8-12 times in 24 hours making sure at least one is between 2-5am when hormone levels are at their highest. A more detailed blog on establishing milk supply is available here.

 But what next? How do we go about actually breastfeeding? Is it possible to move to exclusively breastfeeding when you have had such a traumatic entrance to the world? The answer is yes, but it will take time.

Once premature babies hit around 32-33 weeks gestation they often begin to start developing a suck, swallow, breathe pattern in short bursts and may start rooting for the breast. Hopefully you will have already been given the chance to have lots of kangaroo care with your baby before now, but at this point it can really help transition the baby from tube feeds onto breastfeeding.

Learning to breastfeed when you are a premature baby is a long, slow, tiring process and it requires everybody to have lots of patience. To start with babies can have skin to skin time, or kangaroo care, be encouraged to lick the nipple and if they are ready to possibly have a few sucks. A baby can begin with non-nutritive sucking at a recently pumped breast to provide a gentle experience without an overwhelming flow of milk. Then a fuller breast can be introduced. But at this early stage the majority of any feed will still be  expressed milk through the feeding tube. The staff will encourage you to try baby at the breast once or twice a day so as not to tire them out too much. Once they become stronger and start to suck and swallow more efficiently its time to move to more frequent feeds. It can be a good plan to try baby at the breast during their tube feed as they will begin to associate the act of breastfeeding with the feeling of having a nice full tummy. A nipple shield can help the smaller baby to latch onto the breast, especially if they have been given bottles. There is evidence that suggests shields can increase milk intake in preterm infants in the early days. Remember ask for lots of support from the hospital staff during this time. This is actually one of the benefits of having babies in special care.

When the babies appear to be feeding better and getting much more milk we can move on to the next stage. This can be at different ages for different babies. For some it can be around the 36-37 week gestation mark, others need to get to near full term. The hospital staff will help give confidence that it is time to move to the next stage. Whilst some babies will be able to move straight on to exclusive breastfeeding from tube feeding, this new enthusiasm for feeding can be a bit misleading as the suck can still be uncoordinated and inefficient and the babies can still tire easily. If we move on to exclusive breastfeeding too quickly, it can cause problems with babies not taking enough milk, becoming too tired and then starting to reduce their weight gain. So for many babies its advisable to continue to top up with expressed for a while. A lot of mums choose to top up by a different method than tube so the babies can get home. Hospital staff may use a tool like the Breastfeeding Assessment Score below to calculate how much top up to give baby. They will calculate to work out exactly how much milk  depending on baby’s weight, gestation, growth about how much a full feed is.

For twins and triplets it is important to remember that they are individuals. One baby may be much better at feeding than the other. It can be hard not to compare and be worried and frustrated  if one baby is not managing to feed as well. But, with time, it is very likely that they will catch up and both will feed well from the breast when ready. 

Generally hospitals prefer to use bottles to feed babies their top ups, or during the night when mum is not there. They are easier, there’s less waste and staff are pushed for time so go for the easier option. So to minimise the impact of using a bottle on breastfeeding, it is important to use a paced bottle feeding technique. Paced bottle feeding means letting the baby take control of the speed of the feed and when to take breaks and when to finish. Sit baby in an upright position and keep the bottle as horizontal as possible whilst still filling the teat with milk to avoid intake of air. Baby should be encouraged to latch on to the bottle like the breast, so touching the top lip to encourage baby to route and bring baby onto the bottle chin first, teat into the roof of the mouth. Stop frequently and make sure you do not force baby to have a certain amount. With this slower feeding technique, the baby will be able to tell it is full and finish the feed when satisfied. And baby will be more able to transfer  between bottle and the slower flow of the breast.

Mum and baby will hopefully be given the chance to ‘room in’ for a night or two before they are discharged. During this time they’re often encouraged to move on to more baby-led feeding as opposed to hospital routine based feeding. But babies can still be sleepy and not wake for feeds at this stage so its important to make sure that they feed at least every 3 hours as a minimum. 3 hours is measured from the start of each feed.

For a lot of preemie mums, their first experience of being at home with their early baby is to be in an intense breastfeed, top up, express routine, every 3 hours or more, day and night. This is utterly exhausting and overwhelming and mums can often not see past this stage. However with good feeding support from health visitors and breastfeeding specialists and the discharge team from NICU, mums can move on to exclusive breastfeeding.

Whilst the baby still needs top ups it is imperative that there should be somebody to look after mum. This routine is so full on that there is not much time for anything else, especially sleep! Somebody to do the top up whilst mum expresses can be a life saver as this can save time and could give mum half an hour extra break before she has to start the process again. Breastfeeding makes you hungry and for mum’s energy levels it is important that she eats properly, so having someone to feed her whilst she feeds the babies is a great idea. Every single breastfeed given and every single drop of expressed milk should be valued and encouraged. Emotional support reassuring her that she is doing a brilliant job and that soon it will become much easier can keep everyone going through this incredibly tough time.

Support can be invaluable at this time but a lot of mums feel unsure about taking their preterm baby out to groups due to risk of infections. This is where home visits from well informed health care professionals and good online support can step in. Online support especially can be great, as long as it is properly moderated, as mums can make contact with others who have been in the same position or are going through it at the same time. Peer to peer support is incredibly important. There is also often somebody around at 3am during the night feeds to sympathise!

So how do we know when a baby is feeding well enough to move on from this routine? Often around due date or just after, babies suddenly ‘get’ feeding. Their suck becomes more coordinated and they can remove more milk from the breast. You can watch for the full term feeding pattern of sucking fast for a minute to stimulate the let down, and then move on to deep slower jaw movements with pauses in between. You may be able to hear swallowing. Breast compressions can help to get a bit more milk into the baby if they are still seeming a little inefficent or sleepy at the breast. They often have a big feeding frenzy at around due date and sometimes want to cluster feed. This can be very unnerving for a preterm mum who is used to having a sleepy baby who needs to be woken for feeds. Cluster feeding should be encouraged and explaining to mum that it is completely normal behaviour and will help baby get lots of milk. However it does not necessarily translate in to weight gain immediately. It can be very discouraging when baby has been feeding all night and only put on a small amount the next day. However you often find a day or two later and it pays off.

For twins or triplets it may be a good plan to get some support with tandem feeding. Tandem feeding maximizes the time spent feeding as there’s less waiting time for babies and it is a more efficient use of time. It helps synchronize the babies’ feeding times and more importantly sleeping times! A strong feeder can help a weak feeder by stimulating the let down and getting the milk flowing. It also increases milk supply and the milk has a higher fat content.

Dropping or reducing the top ups gradually can make it a bit less stressful. For more detailed info in reducing top ups see our other blog here

But here’s an overview: Mums can reduce the volume of top ups and put babies back on to the breast if not settled. Mums often find that babies are more settled during certain times of day or night and these can be the first feeds to just breastfeed. Encourage mums to allow the baby to have a second or third go on the breast if they do not settle after the first feed. Offer the other breast so baby gets a nice fast flow of milk. For twins or triplets you can just put them back on the same one and mum will get another let down of milk.

Aiming for maybe 3 top ups of expressed a day and being baby led in between is a good starting point. Mum can keep an eye on nappy output during this time to give her peace of mind and she may prefer to weigh the baby before moving on from this stage to give her confidence that everything is going well. Sometimes when babies move on to more direct breastfeeding, their weight gain can flatten off a little bit. This can be really discouraging but it can take a bit more energy to fully breastfeed and they can tire themselves out and burn more calories. As long as they are still gaining this is usually ok and they will set off following their curve again given a bit of time. This may be a good time to get some reassurance from a breastfeeding specialist.

Once mum is feeling confident and babies are feeding well it is relatively easy to drop the last few top ups. Mum can either stop them all at once or drop one at a time. It is often a relief to have the relative simplicity of just breastfeeding without all the faff of expressing and washing bottles. Some prefer to still keep an expressed feed in their routine so that they can have a break.

 Breastfeeding is so important for babies, but even more so for premature babies. But establishing breastfeeding in the neonatal unit is like a marathon, not a sprint. It is a slow process taking every ounce of patience and determination. But it is worth every bit of stress.

Kathryn Stagg ABM BFC, Updated Nov 2019

References

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

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