Breastfeeding Twins - and more!

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AIMS Journal, 2017, Vol 29 No 4

Kathryn Stagg, Breastfeeding counsellor and mother of twins, offers her tips on breastfeeding multiple babies.

So you’re off to your first scan now that you’re pregnant. Such an exciting time! And then the sonographer says: ‘How many babies can you see in there?’ This is how I embarked on my journey to twin motherhood. Shock is an understatement!

Lots of mums of multiples find out this way, and others have an idea that it could be a possibility due to family history or fertility treatment. But it’s still a shock. Then, once it sinks in, the emotions vary from joy to anxiety or even grief for a ‘normal’ pregnancy. Will they be OK? Will they come early? But how will I cope? How will I breastfeed? Will I ever sleep again? Unfortunately the comments from friends and family often do not help the anxiety. The number of times we have all heard ‘Double trouble’ or ‘You’ll have your hands full’, ‘You’re expecting twins? Oh I’m so sorry’, ‘Twins would be my worst nightmare!’ It gets very wearing after a while. What about just a simple ‘Congratulations!’? Or ‘How wonderful!’

Breastfeeding is important to many mothers of twin babies, Being well prepared and informed can make a huge difference to how breastfeeding goes for mothers of multiples.

The language used by Health Care Professionals can either support or undermine parents of multiples. For example, a lot of parents are not reassured that it is possible to breastfeed more than one baby. These are some things said to mums expecting twins by health care providers:

‘It’s logistically unfeasible to breastfeed two babies.’

‘The body is not designed to feed twins’

‘It’s impossible to exclusively breastfeed twins.’

‘It’s much easier to express as you can see what they’re getting.’

What we actually need to hear is ‘Oh that’s fantastic that you are going to breastfeed your babies and give them such a great start. You can do this! Lots of mums breastfeed twins. Here’s lots of information.'

During pregnancy, it is very important that midwives fully discuss feeding options with women, supporting them to prepare for breastfeeding should they wish to. Wouldn't it be helpful if there were a specific multiple birth antenatal clinic with specialised consultants and midwives who have experience of all types of multiple birth? It’s great if twin and triplet mums who are breastfeeding or have breastfed can either help to run it or be invited to take part. Links with the local twins club can facilitate this. It is vital to discuss the implications of birth and pain relief on feeding, and ways to mitigate the effects of pharmaceutical pain relief on breastfeeding initiation. For instance, opiates such as pethidine and diamorphine can make babies sleepy, and they can find it much harder to feed after birth.

How birth goes can influence how easy breastfeeding is to initiate, and with twins there is a much higher chance of a medicalised birth, which can impact on breastfeeding initiation. Interventions, drugs, early or premature birth and instrumental or caesarean birth can lead to a higher chance of babies being sleepy, slower to feed, having an under-developed sucking pattern, being more prone to jaundice, more prone to low blood sugar, weight loss and therefore a greater need for top-ups in the early days. All of these situations can be supported, but knowing in advance what can make a positive difference can really help.

Antenatal Expressing of Colostrum

Some mothers may choose to express their colostrum towards the end of pregnancy. The resulting colostrum can be used as an 'insurance policy' to support the babies after birth if they have trouble latching or if their blood sugar is low. The mother is provided with some small syringes to collect and store the colostrum and is taught how to hand express. More information on this technique can be found on the ABM website (click here).

Active Birth

As the tradition for the last generation or so has been to manage twin birth in a highly medicalised fashion, it can sometimes be challenging to arrange support for a more intervention-free labour and birth. However, the links between a drug-free, low-tech birth and easy initiation of breastfeeding are well established and therefore mothers who are anxious to breastfeed may consider ways to stay upright and active in labour and explore alternatives to pharmaceutical pain relief. To find information on the benefits of upright, active birth, click here.

Early skin to Skin/Kangaroo Care

Once the babies are born, holding the babies in skin to skin contact has a number of benefits. From regulating the babies' temperature, heart rate and respiration to stimulating the neonatal reflexes that result in the initiation of feeding, the power of this close contact is unparalleled. Staff need to be flexible with hospital routines to support as much time with each baby skin to skin as the parents want. Skin to skin helps to increase milk supply by triggering breastfeeding hormones, and depending on the age and gestation of the baby, can really help to encourage initiation and continuance of breastfeeding.¹

Biliblankets

Jaundice in more likely in premature babies, and therefore something to be aware of if your twins are born early. When bilirubin levels reach a certain point, phototherapy will be recommended. Whilst supplementation with formula is often advised, breastfeeding does not need to be interrupted and, in fact, breastmilk can speed up recovery. If the hospital has biliblankets, skin to skin need not be interrupted and the babies can be encouraged to feed frequently. If the babies have to be in a cot, regular breaks for feeds and cuddles should be encouraged and skilled breastfeeding support given. The NICE guidance is clear that jaundice is rarely a reason for formula supplementation.²

Feeding Frequently And As Much As They Need

Breastfeeding twins or more is undeniably quite an undertaking in the early days; it can feel as though just as one baby finishes, the next wakes and wants to feed. It can seem that the only chance of any respite is to put the babies on a strict feeding routine. However, it is helpful for parents to understand that unrestricted time at the breast in the early days builds milk supply, ensures optimal weight gain and guards against breastfeeding problems such as blocked ducts and mastitis. Mothers need consistent, positive support through the sleep deprivation and lots of practical domestic support so that all she has to worry about it feeding the babies and getting as much rest as possible.

Born Too Soon

Prematurity can be a massive barrier to breastfeeding, but it can also be a positive. I have met mums who were not going to breastfeed at all but because their babies came early and they were informed of how important breast milk is for preterm infants, they began expressing. 40% of multiple births need special care and in some situations mothers will not be able to be with their babies as much as they would like to, for instance if the mother is herself unwell or when there are other children or family members needing care. In this case, hand expressing as soon as possible after birth, and encouraging the feeding of every drop of colostrum, will help babies to be as well as they can be.

Once milk volume starts to increase, probably around day 3 or 4, a hospital grade breast pump with a double pump setting may be more efficient and effective for mums who are not able to breastfeed directly for whatever reason, or for mums who are partially breastfeeding and partially providing milk through other means. Every drop of breastmilk is immensely valuable, and breastmilk helps to protect premature babies from serious illnesses such as necrotizing enterocolitis (NEC).³

For mums who are unable to supply enough milk for their babies to start with, screened, processed donor breastmilk from an NHS milk bank should be available for these infants. Parents have the right to choose to request that the hospital provides this to their babies rather than formula.

Learning how to increase milk supply can be important with multiples due to the larger volumes of milk that will be needed. The more milk that is taken from the breasts, the more milk is made.

When expressing, support to find the correct flange size for each woman is important, and can make a difference to the amount of milk which can be pumped, as can supporting her to pump at least 8 times a day, including at least once at night. Mothers often benefit from skilled support to position and attach their babies and to recognise good milk transfer. The use of nipple shields is also sometimes useful, helping premature babies with small mouths to latch on, but these should be used with specialist support and ideally weaned off as soon as possible as they can lead to lowered milk supply in the longer term. Teaching breast compressions can increase milk transfer and staff can also really help mums by arranging or signposting to hospital grade pump hire when the mother is discharged.

When babies are tube fed it’s important that the nursing care is mindful of the need to try each baby on the breast. One mum was told, ‘We have just fed your babies, they won’t need you now’ when she came back from lunch. This was obviously very upsetting. Care needs to be taken that babies have the opportunity to practise at the breast when they are not full from a tube feed or conversely too hungry to latch easily.

The transition from highly structured routines in NNU with sleepy premature babies to taking home alert, frequently-feeding babies can feel scary and overwhelming. Staff need to discuss cluster feeding, tandem feeding, unsettled behaviour and developmental leaps so that parents understand normal newborn behaviour. It is also important to reassure parents that it is OK to ask for help, especially as many babies are discharged from NNU on the absolutely exhausting ‘breastfeed, express and top up’ cycle. Parents need support with how to manage this, and reassurance that it is temporary, as well as skilled guidance on when to start moving towards exclusive breastfeeding if that is what the mother wants.

NNU can be an immense support, with parents being able to access breastfeeding support for a lot longer than those on the ordinary the postnatal ward. However, rooming-in before discharge can feel a bit like a test, with some parents feeling like the staff are judging whether they are capable of looking after their babies alone. But it can also be a positive time with more freedom to parent with the continued support of staff.

Parking costs can be a real issue when babies have a long stay in hospital. It can prevent mums from seeing their babies every day and therefore spend less time establishing feeding. Some hospitals will provide a free parking permit for parents whose children are in hospital – just ask the ward staff.

Term Babies

For full-term babies, getting a good start is even more important because their stay in hospital, if they are born at home, will be a lot shorter. Skin to skin and early feeds are just as important, especially after a cesarean birth, and can make a big difference to breastfeeding success. Sometimes parents may be advised to top up their babies with formula – perhaps for low blood sugar, or weight loss. In this situation, babies must be treated as the individuals that they are and “because they’re twins” is not a valid reason for this to be suggested. Many parents report that their babies are often topped up with artificial milk for no reason, and some parents even feel threatened if they do not agree to supplementary feeds. One mum was told, ‘We will remove your babies from your care if you do not consent to give top ups.’ This is coercion – and in most cases unlawful.

And, of course, there is more than one baby to care for. Balancing the needs of two or three very demanding individuals with differing needs can be challenging. Babies don’t always learn to feed at the same time. Often one will get it before the other. Mothers often need a lot of reassurance that the second baby will get there in the end.

Midwives and Health Visitors need to understand smaller or premature babies’ weight gain, and how to plot percentiles with adjustment for prematurity, and know how to support tandem feeding. Many parents will also need support to work out how and when to top up with expressed breastmilk or formula if that has been necessary, and how and when to move on to exclusive breastfeeding. Unfortunately, not all midwives and health visitors will have detailed training in these areas, and it might be necessary for parents to approach breastfeeding counsellors or IBCLCs for additional support.

Everyone involved in the care of the babies also needs to make sure that the babies are treated as individuals and not compared, especially for weight gain but also for developmental milestones. Health Visitors offering as many home visits as they possibly can make an enormous difference as it is very difficult to get out to appointments with more than one baby, and mothers often need to find a friend or family member to help.

Peer Support

Signposting to specific breastfeeding support, both face-to-face and online, can help with the technicalities of breastfeeding. Peer to peer support is often absolutely vital for mums of multiples. The reality is that nobody truly understands what it is like to have twins or triplets unless they have done it themselves and this is where twins clubs can play a large part. There are also excellent online support groups like the Breastfeeding Twins and Triplets UK Facebook group.

All mothers deserve to have support in establishing breastfeeding but it is especially important for mothers of multiples. There are some very simple steps which could improve outcomes, both in hospital and the community. Breastfeeding my twins was by far the most challenging and intense thing I have ever done, but it was also the most rewarding. And once I got over the first few weeks it was just so easy. I cannot imagine having to get out of bed to do night feeds, to wash and sterilize 16 bottles a day, to spend over £1000 on infant formula or to have to go home because I had not taken enough milk out with me. It’s so important to me to be able to offer support to other mums the chance to have the same fulfilling experience.

Kathryn Stagg

References

1) www.unicef.org.uk/babyfriendly/baby-friendly-resources/guidance-for-health-professionals/implementing-the-baby-friendly-standards/further-guidance-on-implementing-the-standards/skin-to-skin-contact/

2) www.nice.org.uk/guidance/cg98/chapter/Recommendations#management-and-treatment-of-hyperbilirubinaemia

3) www.ncbi.nlm.nih.gov/pmc/articles/PMC4025624/