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 List keyways to help families prepare for premature birth, including establishing 
breastfeeding multiples.

 Describe components of unique care specific to the Late Preterm and Early Term birth 
in establishing breastfeeding multiples.

 Discuss how lactation support professionals can support multiple birth families during 
the different stages of their breastfeeding journey. 

This content will be available on the GOLD Learning Lecture Library until March 29, 2024.

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Mum of 4 boys, twins aged 16, singleton aged 11, singleton aged 7,
IBCLC and Breastfeeding Counsellor
Founder of Breastfeeding Twins and Triplets UK Charity and Facebook Group

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Barriers to breastfeeding multiples,

survey of Breastfeeding Twins and Triplets UK Facebook group

More than one baby - logistics

Prematurity/NICU stay

Early term/late preterm birth

Poor Support from Health Care Professionals

Poor understanding of breastfeeding/milk supply

Mental health and overwhelm

Attitudes of friends and family

Underlying feeding/health problems in baby

Underlying milk supply issues

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 Mikami et al (2018) Breastfeeding Twins: Factors related to weaning. Journal of Human Lactation, 34(4), 749-759

 Randomised control trial Brazil, 128 women pregnant with twins

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 Let’s take them one topic as a time

 And let’s start from pregnancy

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 Shock Sarah:
 Relief
Managing other
people’s feelings,
 Devastated whether positive or
 Anger negative, when they
might be opposite to
 Grief of normal pregnancy your own is bizarre
 Grief for the family they had planned
 So happy
 Cried for weeks
 Ecstatic
 More children than planned!

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 ‘How will you cope?’

 ‘Rather you than me!’
 ‘Twins would be my worst nightmare!’
 ‘Double Trouble!’
 ‘I always wanted twins… until I had one baby!’
 ‘My Sister/ Aunt/ Cousin/ hairdresser had
twins and it was so hard’
 ‘Of course, you will have to have a caesarean’
 ‘Of course, they will come early’
 ‘Of course, you won’t be able to breastfeed …..’

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 ‘Oh no, you’re not going to breastfeed are you?’

 ‘You’ll never make enough milk for more than one baby’
 ‘You will have to give formula because they are small/ big/ early/ full term’
 ‘You should give a bottle so partner can help and bond with the babies’
 ‘Expressing and bottle feeding is much easier because you can see how much
they’re taking’
 ‘You’re being selfish wanting to feed them yourself’
 ‘It’s too just difficult’

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 How are you feeling about this pregnancy?

 Its ok to have concerns and worries
 How lovely that you would like to breast/chest feed your
twins/triplets to give them such a good start
 Here, let me find you some information and signpost you to
some specialist antenatal education and postnatal support
 Help them research, find out what is available locally to you
and what is available online: Breastfeeding support groups,
Twins groups, Facebook groups, WhatsApp groups, buddy up

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 ‘There is a need for well-designed, adequately powered studies of interventions designed for
women with twins or higher order multiples to find out what types of education and support
are effective in helping these mothers to breastfeed their babies.’ (Whitford et al; 2017)

 That it is totally possible to breast/chest feed twins and triplets

 There are some barriers but with good support these can be overcome
 Where to access this support
 A good understanding of how milk production works
 A good understanding of how to get a deep latch
 A good understanding of normal baby behaviour
 A good understanding of early baby behaviour.

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 Multiple births can be a greater chance of needing early supplementation and so

antenatal hand expressing can give them a head start.
 From 36 weeks of pregnancy (Forster et al; 2017) or have a conversation about starting
in the week leading up to planned induction/caesarean section if earlier, risks and
benefits should be discussed
 Hand express 2 to 3 times a day.
 Collect in syringes, label clearly with name, date and hospital number, freeze in lidded
container.

 When its 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, don’t take it all, partner can always pick up more from home if needed.

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 Hand expressing within the first couple of hours after birth, then
continuing every 2 to 3 hours
 Once milk begins to come in the move on to a hospital grade
double pump (Prime et al; 2012)
 Pump 8-10 times a day for around 20 mins
 Massage & Hands-on pumping technique (Morton et al; 2009)
 Correct fitting shields
 Distraction – photos, smells, music, mindfulness, cover bottles
 Warm heat
 Power pumping

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 Amy: “At the moment expressing is one of the only things I can do for my babies who
were born at 25+3. It’s mummy’s unique medicine for them. It’s made me feel useful in
a situation where I otherwise have felt a little useless”

 Becky: “Breastfeeding was the one thing that helped me feel like my little girls’ mum.
Born at 30 weeks I was unable to care for them in any other way than provide milk.”

 Emma: “I was so proud walking into hospital each day with my cool bag of milk. The
nurses called it ‘mummy’s magic milk’. Now they are beginning to breastfeed
everything feels less medical and we are developing a bond like no other.”

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 Kangaroo care as soon as babies are stable

 32-33 weeks gestation begin to develop suck swallow breathe
 May start rooting
 Non-nutritive sucking on a pumped breast
 Fuller breast can be introduced
 Majority of feed will be given by tube
 Try once or twice a day to begin with
 Try during tube feed to associate feeding with full stomach
 A nipple shield can increase efficiency of feed in early days

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 Research has shown that premature babies often transfer a

lot more milk if breastfeeding with a shield (Meier, 2000)
 More efficient feeds in the short term
 Can affect milk transfer in the long term
 Have to balance getting babies to take more milk at the
breast against the fact that shields are not ideal.
 Can be a good option for parents who are struggling with
pumping
 Babies are usually able to wean off the shields once past
due date

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ACOG, 2013

 Late preterm – 34+0 to 36+6 weeks gestation

 Early term – 37+0 to 38+6 weeks gestation
 In the UK the majority of twins are born between 36 and
38 weeks gestation due to NICE guidelines
 In many other countries hey have similar guidelines
 Many premature babies are discharged home at this
gestation

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 Often well enough to stay on postnatal ward

 Often treated the same as a full term baby
 Often sleepy and difficult to rouse
 Can have a weak or uncoordinated suck
 Short sucking bursts
 Inefficient at the breast
 Can lead to weight issues, jaundice, low milk supply
 Skilled breastfeeding assessment to assess milk transfer
 Late preterm/early term birth is significantly associated with sub optimal
breastfeeding (Dewey et al, 2003)

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 Encourage babies to latch frequently and deeply

 Use breast compressions
 Do not let babies go longer than 3 hours from the start of each feed (Nyqvist; 2008)
 Encourage hand expressing of colostrum after each feed
 Help prime the prolactin sites
 Ensure babies have some colostrum to be given if they need a little extra energy or
any blood sugar issues
 Syringe feed colostrum, finger feeding is incredibly effective but not widely used in
UK hospitals

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 Alina: “They pressed so hard on giving formula due to low blood sugar. I wanted
some support with hand expressing my colostrum but none was given. I was so
disappointed I got so little support even though there were posters everywhere on
how vital breastfeeding is”

 Shanice: “I had a lady come in and help as I had requested to breastfeed, she showed
me how to hand express and caught it in a cup, she popped in every day I was in
hospital”

 Charlotte: “I was offered donor milk but I did not realise that it would be better for my
babies and so declined and gave them formula”

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 Puts pressure on the milk glands causing them to release more milk and increases flow
 Encourages baby to keep sucking
 Keeps baby feeding at the breast for longer
 More thoroughly drains breast
 Can extend short sucking bursts when baby is inefficient
 Increases milk supply

 Gently squeeze the breast between thumb and fingers during a feed
 Far enough back not to disturb the latch
 Watch for when baby stops sucking
 Squeeze and hold for a few seconds, baby should start sucking
 Can also be used to increase length of sucking bursts
 Repeat until no active swallowing

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 A lot of babies of this gestation are discharged topping up

 Breast/chest feed both babies, top up, pump, every 3 hours!
 ENSURE parents realise this is temporary
 It is very intense and exhausting
 Try to get the whole feed finished in one hour
 Tandem feeding makes it easier
 Top ups can be given by syringe, cup, finger feeding, supplementary nursing
system or paced bottle feeding
 Ongoing breastfeeding support throughout the process and as we begin moving
away from top ups

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 Breast/chest feed both babies, watch for active feeding,

use breast compressions
 If 2 helpers take one baby each and top up whilst nursing
parent pumps
 If 1 helper, take one baby each to top up, or 1 helper
tandem bottle feeds (this is hard to pace feeds so not
ideal)
 If no helpers, tandem bottle feed top ups (pace feeds as
best you can)
 Double pump for 15-20 min with a hospital grade pump

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 Breast/chest feed one baby, watch for active feeding,

use breast compressions
 Pass baby to helper to top up, breast/chest feed
second baby
 Pass second baby to top up, double pump with a
hospital grade pump
 If no helpers then trying to keep the babies on
separate schedules is probably necessary, but it will
be very time consuming

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 Nurse babies every feed

 Reduce volume of top ups gradually
 Put babies back on the breast after top up if necessary
 This triggers another let down, even if only after a short time
 Put babies back on the breast for seconds before top up, remember most singletons
feed from both sides, babies will trigger a second let down of milk.
 Begin to remove one or two top ups
 Morning and night top ups are easier to stop
 Late afternoons and evening more difficult due to cluster feeding fussy baby behaviour
 Reassure cluster feeding is normal
 Reassure that babies may want to feed more frequently and that this is a good thing!

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 Sometimes one baby takes longer to latch

 Tandem feeding can actually help the weaker feeder
as the other baby does all the work!
 Sometimes one baby never gets it and will not latch
 Some manage to get around this by expressing for one
and nursing the other directly
 This can take some serious multitasking!
 Second baby often latches eventually if given the
opportunity

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 Maximise time and sleep for mother  More difficult to latch babies on
 Mother feels she can cope when both  Need to use both hands
babies cry at the same time
 Overwhelming
 Can help the weaker feeder as the
 Nursing aversion
stronger feeder stimulates the let
down  Feeling trapped in the feeding
 Milk is fattier?
cushion
 Can’t get up whilst you are feeding
 You can let go and feed hands free if
you can support the babies on a  Can’t settle babies easily after a feed
feeding cushion or pillows

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 Baby-led feeding maximises milk  Scheduling means that a mum can

supply and makes sure each baby maximise the time between feeds
gets what they need, and gives each and can predict when feeds may
baby some individual attention. happen but risks unsettled babies
and reduced milk supply

 Compromise: Follow the hungriest baby and either

tandem feed, or feed separately straight after each
other. Gives maximum gap between feeds whilst still
being baby led.

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 Tandem nurse two, single feed third, rotate

 Tandem nurse two, expressed milk third, pump,
rotate
 Tandem nurse two, formula third, rotate
 Single feed all three
 Single feed one, express for two, rotate
 Single feed one, formula two, rotate

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 Jessica: “Breastfeeding my twins was our calm amongst the chaos and our much
needed ‘down time’. Breastfeeding twins has been my proudest achievement and has
given me a lot of confidence, which is something I’ve always lacked”

 Laura: “It’s the easiest and quickest way to get them back to sleep- critical for twin
mums!”

 Ira: “I believe breastfeeding is designed by Mother Nature to make us just stop and sit
down, feed and relax, nap with the babies, especially in those early weeks”

 Lainie: “The ability to comfort, sooth, feed 2 screaming babies at the same time was
absolutely worth all the hard work at the start”

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 Twins and triplets are just normal babies with all the same feeding issues as any
singleton
 They are more likely to be a bit sleepy and inefficient on the breast in the early
days due to being a born a bit early or a bit smaller.
 Twin and triplet babies still have the same shallow latches, tongue tie, high palate,
their parents still get blocked ducts, mastitis, blebs, thrush etc
 However, it is important to remember that these feeding issues can seem even
more insurmountable when you have more than one baby to deal with.
 Trying to encourage parents to access support as quickly as possible to catch any
problems early really helps them manage them more effectively

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 Full term, healthy twins can generally exclusively breast/chest feed without any
supplementation, many triplets can also do this once they are feeding effectively
 More pregnancy hormones may lead to more milk making tissue
 Twice as many babies = twice as much breast stimulation = twice as much milk
 3 times as many babies = 3 times as much breast stimulation = 3 times as much milk
 The key is frequent and effective feeds
 Tandem feeding can help maximise milk supply as it means babies are less likely to
have to wait to be fed. This makes responsive feeding easier.

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 Look after siblings

 Housework
 Manage visitors
 Provide food, snacks, drinks, packed lunch
 Change nappies
 Take babies for a walk for an hour
 Settle babies, skin to skin, baby-wearing, bath, massage
 If top ups are necessary, give those
 Learn about breastfeeding, support, defend the decision
 Find specialist breastfeeding support
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 Research shows parents that fulfil their breastfeeding

goals are far less likely to suffer from post natal
depression (Borra, 2014)
 Multiple birth parents have been shown to be at higher
risk of developing post natal depression. (Choi, 2009)
 Often breastfeeding is the one thing that parents think
they are doing well.

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 When I was going through the darkest time of my life after having the twins, even
though I was constantly told I would feel better if I stopped breastfeeding to let other
people “take some of the load”, I knew this wasn’t going to help at all. I knew that
continuing to do what brought me immense joy and the only thing that was creating a
bond between us, was going to be the single thing that kept us all together and me
from jumping off that edge.

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 Once breast/chest feeding is established many multiple birth families find it the
easiest and quickest way of feeding their babies. And also the quickest and easiest
way to settle them to sleep! If parents can push through the difficult early weeks
they are often rewarded with a simple and easy feeding solution.

 Sara: “It made life easier in terms of no sterilising and washing and I saved an
absolute fortune on formula”
 Jessica: “Breastfeeding my twins was our calm amongst the chaos and our much
needed ‘down time’. Breastfeeding twins has been my proudest achievement and has
given me a lot of confidence, which is something I’ve always lacked”
 Laura: “It’s the easiest and quickest way to get them back to sleep- critical for twin
mums!”
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 Medical reason for low milk supply – IGT/mammary

hypoplasia, PCOS, thyroid, breast surgery/trauma, diabetes,
ovarian cysts
 Poor breastfeeding management – separation from babies,
infrequent feeds, scheduled feeds, delaying feeds, topping up
 Baby’s nursing skills – prematurity, shallow latch, tongue tie

 Psychological, mental health, overwhelmed

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 Early combination feeding for weight issues etc is often in the

form of nursing and topping up with formula every feed
 This is not really sustainable long term as parents have to do a bit
of everything, and there is greater risk of breast rejection
 Try having one or two set bottle feeds in 24 hours with
responsive nursing in between often work better and protects
breastfeeding
 Make sure bottle feeds are at a time that is actually helpful! So the
breastfeeding parent can have a rest, sleep, or spend time with
older children
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 Positive conversations
 Signposting to specialist feeding support
 Evidence based information
 Informed choice
 Respect parents’ wishes
 Encourage babies to nurse frequently
 Protect milk supply
 Emotional support
 Practical support
 Joined up support between hospital staff, neonatal outreach team, community midwives,
health visitors and breastfeeding support

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 Multiple birth parents often find themselves having LESS good quality feeding
support
 Firstly because society in general and many health care professionals do not
believe it is possible
 And secondly, sometimes breastfeeding supporters do not know how to support
multiple birth families effectively
 So multiple birth families can feel discriminated against. And this is what we are
trying to address with this session.
 Multiple birth families deserve the best support available so they can have an
equal chance to reach their breastfeeding goals.
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Borra C., Iacovou, M., Sevilla, A. (2014) New evidence on breastfeeding and postpartum depression: The importance of understanding women’s intentions. Maternal and Child Health
Journal., 19(4):897-907.

Choi, Y., Bishai, D., Minkovitz, C. (2009) Multiple births are a risk factor for postpartum maternal depressive symptoms. American Academy of Pediatrics, 123(4):1147-1154

Leonard, L Denton, J. (2006) Preparation for parenting multiple birth children. Early Human Development, 82: 371-378

Nyqvist, K.H. (2008) Breastfeeding preterm infants. In: Genna, C.W. (Ed.) Supporting Sucking Skills. Boston: Jones and Bartlett:153-180.

Dewey, K.G., Nommsen-Rivers, L.A., Heinberg, M.J., Cohen, R.J. (2003) Risk factors for suboptimal infant breastfeeding behaviour, delayed onset of lactation, and excess neonatal
weight loss. Pediatrics, 112(3):607-619.

American College of Obstetricians and Gynecologists. ACOG committee opinion no. 560: Medically indicated late-preterm and early-term deliveries. Obstet Gynecol. 2013
Apr;121(4):908-10. doi: 10.1097/01.AOG.0000428648.75548.00. PMID: 23635709.

*P Meier, L. B. N. H., 2000. Nipple Shields for Preterm Infants: Effect on Milk Transfer and Duration of Breastfeeding. Journal of Human Lactation, 16(2), pp. 106-114.

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):442-7.

Morton, J., Hall, J.Y., Wong, R.J., Thairu, L., benitz, W.E. (2009) Combining hand techniques with electric pumping increases milk production of mothers with preterm infants. Journal of
Perinatology, 29(11):757-764.

HM Whitford, SK Wallis, T Downswell, HM West, MJ Renfrew (2017) Breastfeeding education and support for women with twins or higher order multiples. Cochrane Database of
Systematic Reviews

Forster, D.A., Moorhead, A.M., Jacobs, S.E., Davis, P.G., Walker, S.P. (2017) Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and
Antenatal Milk Expressing [DAME]): A multicentre, unblinded, randomised controlled trial. Lancet, 389(10085):2204-2213.

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