There are many reasons why women may not be able to, or simply decide not to breastfeed, ranging from recovery after a caesarean delivery, premature babies born with problems, or dealing with bereavement after losing a child from a multiple birth. Tamba’s survey of maternity services done in 1998 of 576 multiple births (536 sets of twins and 40 sets of triplets, all born in 1997) found that a quarter of mothers did not get the help and understanding they needed with breastfeeding¹.

This article sets out some of the practical considerations of breastfeeding multiples and offers some points of discussion that may help you when advising mothers on breasfeeding their babies.

The breasts are designed to produce an adequate quantity of milk to meet demand; the more milk that is taken, the more milk will be produced. The practical hurdle, of course, is the fact that a woman only has two nipples. This means that it takes more time and energy to feed multiple babies, and the mother may find this very tiring during the first few months. Being generally smaller and more premature than full term babies, twins, triplets or other multiples benefit dramatically from the benefits of breastmilk, making it even more important for mothers to persevere with breastfeeding. It would be unrealistic to suggest that breastfeeding multiples is easy, but you can really help mothers weigh up the advantages and difficulties before she makes her mind up.

We`ve set out some points to discuss below:

Advantages

• Breastmilk is the perfect food, containing nutrients and antibodies, which promote a healthy immune system, and healthy digestion.
• Premature babies benefit greatly from these advantages as their immune systems are more immature and they find digestion more difficult than full term babies. This is especially relevant to multiples as they tend to arrive early.
• Essential fatty acids in breastmilk are essential for brain development, which is even more important for premature babies.
• Breastfeeding brings mothers closer to their babies and one-to-one contact is a premium when you have twins or more, so it is especially important.
• Women who breastfeed regain their prepregnancy shape more easily because it helps the womb contract to its normal size and maternal fat stores deposited during pregnancy are used during the time of breastfeeding.

Difficulties

• If the babies are in the SCBU the mother will have to spend a lot of time feeding in hospital. This may be difficult if mum has other children to look after
• Premature babies may not suck well because their sucking reflex may not be as developed as a term baby.
• The mother may need additional support, to provide critical rest which could be difficult if she has other children and/or no help at home.
• In some circumstances, mother and babies are separated and important feeding cues can be missed. This may have an impact on establishing a good breastfeeding regime.
• The babies are more likely to have been born by caesarean section, making it difficult for the mother to move around and lift the babies.

Although a mother may find the decision difficult, there are ways of making and means of ensuring feeding multiple babies is more manageable. The mother should be encouraged to meet with other breastfeeding mothers in her situation and see how they have coped. Details of some support groups and organisations can be found at the end of this article. If a mother is still undecided, then she can always start by breastfeeding and see how it goes, as it’s extremely difficult to establish breastfeeding at a later stage.

There are some compromises mothers may consider that will help make feeding easier. The following tips are especially useful for triplets, but can be adapted for twins:

• One or two babies could be breastfed while the other is given expressed breastmilk. The mother will have to express at regular intervals to provide sufficient breastmilk for the third baby.
• All babies could be breastfed at different times. This is a good option if the mother has help at home, although can be time consuming and very tiring.
• She could breastfeed one or two babies and formula feed the other(s) on a rota basis so that every 24 hours all get breastfeeds and all get bottles or alternatively she could part breastfeed and top up with formula feed on rotation, so that each of the babies gets some breastmilk.

To maintain any breastfeeding regime, the mother could be advised to keep written notes on which baby has been fed and at what time. This will help her to keep track of feeds and lessen any likelihood of under or over feeding, especially in the early days.

Successful breastfeeding also relies on the mother being in good health, and this is even more important when she`s feeding more than one baby. She`ll need to take plenty of rest, eat a good variety of healthy food and drink plenty of liquids. If she has had a caesarean delivery, she will need even more support while she`s recovering from surgery and unable to move around easily.

The breasts are very efficient at meeting the demand of however many babies are feeding (think of wet nurses who used to feed several babies at any one time). But mothers often worry that they cannot meet the needs of their babies. They may require more reassurance than normal, with coaching on what signs to look for to know that their babies are thriving. Women with small breasts may need additional reassurance especially when they begin.

Mixed feeding
Mothers of multiples, who also have other children, often find it difficult to find the time to breastfeed exclusively. In these circumstances feeding formula alongside breastmilk is often a reality. Many mothers will already have been combining breastfeeding with formulas specially developed for premature babies. If they are mixed feeding, it is worth talking to mothers about the availability and benefits of prebiotics within some term formulas, as prebiotics will help support the baby’s natural immune system.

Bottle-feeding multiples
Bottle-feeding multiples, whether with formula or expressed breastmilk, presents its own practical difficulties. It will be harder for the mother to position herself close to two or three babies and keep the bottles in the right position. The mother will need to feed a maximum of two babies at any one time, feeding the third baby separately.The diagrams below show some examples of good positions to bottle-feed two babies. Mothers will also need to be advised on safely preparing feeds and sterilising bottles for either formula or expressed breastmilk. We have developed a useful fact sheet on positioning for all types of feeding which features some helpful tips for you to pass on to mothers. This can be downloaded here.

Breastfeeding in the Special Care Baby Unit
Even when babies are premature, it`s still possible to breastfeed. Breastfeeding gives the babies a huge advantage as they get all the benefits of breastmilk along with the close physical contact of breastfeeding which is known to promote emotional and physical development.

If at first the babies are unable to suckle from the breast, it`s still important for mothers to express their milk straight away because the colostrum produced before the milk comes in will be invaluable for the babies` immunity. Expressing will also stimulate the milk supply and help the mother build up a store of milk for future use. Mothers could be advised to express while sitting by their babies` incubators, as the closeness to them will stimulate the hormones that produce the let-down reflex. Another useful tip is for the mother to have a photo of the baby to hand, as this could have a similar effect.

All SCBUs make provision for pumping and storing breast milk so mothers can supply their own breastmilk, or alternate breastmilk and formula if this is necessary. Some hospitals will also have a store of donor breastmilk too so this is also an option that can also be discussed.

Other considerations

Breastfeeding babies is something only the mother can do, which can have the happy benefit of encouraging others to do essential but less interesting tasks, like laundry and other household chores.

Women who have multiples often have no more babies – the arrival of 2, 3 or more babies effectively completes their family. If they do not take the opportunity to breastfeed now, they may regret it later.

Supporting mothers of multiples

Most mothers expecting multiple babies will already have been introduced to other mothers in the same situation, but it`s important to make sure that these mums continue to meet and give each other support after the births. Organisations such as ‘Tamba’ who run the Twinline helpline and support a network of Twins Clubs, can be extremely rewarding for mothers and are a wealth of information and a source of reassurance. Often just meeting another mother who is successfully breastfeeding her twins or triplets provides the encouragement a new mum finds helpful. If you feel that a mother of multiples may need some additional support you could mention the Sure Start initiative which aims to provide increased support where there is greater need through children’s tax credit, children’s centres and Sure Start local programmes.


Useful contact details:

Tamba (Twins and Multiple Births Association): 0870 770 3305

Tamba Twinline: 0800 138 0509
(Lines open 10am-1pm/7pm-10pm every day)

Multiple Births Foundation: 0208 383 3519

National Childbirth Trust: 0870 7703236

Sure Start public enquiry unit: 0870 0002288

Bliss (Premature baby charity) 0500 618140

To download our useful fact sheet that shows some breast and bottle-feeding positions and some handy tips click here or call us on 08457 623 624.

Cow & Gate Breast is Best Leaflet

Reference

1. Twins Triplets and More Magazine, 1999, 10: 4-6

Useful Reference Material

Leonard LG. Breastfeeding rights of multiple birth families and guidelines for health professionals . Twin Research 2003; 6: 34-45.