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Breastfeeding Multiples

Karen Kerkhoff Gromada, MSN, RN, IBCLC
Cincinnati OH USA
From NEW BEGINNINGS, Vol. 23 No. 6, November-December 2006, pp. 244-249.

Hannah was thrilled that her pregnancy had lasted for 36 weeks since many health professionals, relatives, and friends had warned her that twins often arrive even earlier. "The babies were almost full-term," she said with pride during our initial phone conversation. She had called to ask about two-week-old Ian, who rarely latched onto the breast no matter how long she worked with him. Hannah also asked what to do with his twin sister, Emily, who was able to latch on, but usually drifted to sleep after suckling for only a minute or two.

"I feel so lucky that my babies didn't have to spend any time in the intensive care nursery," she said, "But I'm getting frustrated. Both seem to do better when offered my milk in a bottle. I wonder if they'll ever get it, and I'm not sure how long I can keep working at breastfeeding while also pumping and bottle-feeding. Do you think I should give up and just pump?"

Like many new mothers of multiples, Hannah and her boy/girl twins, Ian and Emily, had gotten off to a slow breastfeeding start. In spite of avoiding a stay in the neonatal intensive care unit (NICU), the twins' different breastfeeding difficulties reflected the immaturity of their "near term" birth. Chronologically, Ian and Emily may have been two weeks old, but at the time of Hannah's call, they had barely reached a full-term gestational age of 38 weeks. They were still a week shy of the average age when most "singleton" infants are born.

I then learned that Hannah had been on strict bed rest for several weeks before her babies' birth. Her doctors had delivered her babies surgically at 36 weeks because she had developed preeclampsia. Not surprisingly, her energy level was low.

"My mother-in-law was here until yesterday, but she couldn't take any more time away from her job," she told me. "I know I should be able to take care of the babies by myself, but I'm feeling really overwhelmed and scared." I suddenly understood why her breastfeeding concerns had assumed a new level of urgency.

After congratulating Hannah on her healthy babies and the terrific job she was doing, I reassured her that Ian's and Emily's ability to breastfeed were typical for babies of their gestational age and would likely improve with a few more weeks of maturity. Then we talked about the impact of adding twice the usual number of new babies to a family, and the need for some form of ongoing household help -- no matter how those babies were fed. After suggesting a few possible sources of help, we worked together to develop a breastfeeding plan she thought was "doable" for the next week.

In addition to brief "practice" breastfeeds, until each baby showed Hannah that she or he could sustain suckling at the breast, the plan included as much separate or simultaneous Kangaroo Care (KC), or mother-baby skin-on-skin contact, as possible between feedings. We discussed options for supplementary feedings. Hannah felt most comfortable with bottle-feeding, so we talked about the kind of feeding-bottle nipple/teat and an infant cue-based bottle-feeding technique that were less likely to interfere with their development of breastfeeding oral behaviors. I also suggested she allow helpers to bottle-feed Ian and Emily when available so she had more time for pumping sessions and KC time with her babies. After reviewing her breast pumping routine and whether the pump equipment she was using "fit" her situation with two babies still learning to breastfeed, she said she would call back in a week with an update -- or sooner if her confidence needed a boost!

Later that week I heard from Barbara. Her triplet daughters, Maya, Anna, and Dana, were now 10 months old. She lived in another state and had gotten my phone number from a La Leche League phone line. She told me it had taken months for her girls to learn to breastfeed after their preterm birth at 31 weeks gestation, and Dana had needed significantly more time to learn to breastfeed than her sisters. Barbara usually breastfed two of her daughters simultaneously while her husband or a live-in helper gave a bottle of her milk or infant formula to the third baby; she then rotated which babies breastfed so each received a bottle only every third feeding during the day. Dad and the helper gave all three girls a bottle for one late evening or nighttime feeding to give Barbara a few hours of uninterrupted sleep. Even after all of her triplets could breastfeed well, She had continued to pump so her babies would get her milk for most of their bottle-feedings. Also, all three girls had recently begun to show enthusiasm for the solid food they were offered.

Barbara called because she was tired of pumping and wondered if she would have enough milk to continue breastfeeding if she "got rid of" the breast pump. Pumping and keeping breast pump parts ready to use was consuming too much of her already limited time each day, yet she felt torn because she wanted her babies to have her milk.

Being patient and persistent enough to give three different premies the time to learn how to breastfeed is an amazing accomplishment! And I told Barbara so. I then asked about the individual development of each of her daughters, since their 10-month chronological age was likely to need some adjustment to better reflect what their age would be if born at full term. Based on that information, each appeared to be closer to their "full term age" of eight months. Thinking of her babies more as eight months instead of 10 months was an "aha moment" for Barbara, who then decided to slowly decrease pumping so her milk would still be available for at least some of her "younger" babies' other feedings. To help stretch available mother's milk, I suggested that a baby's every third feeding, when baby was not at breast, might be the time to offer any solid food. Barbara liked that idea. We bounced around a few ideas for gradually cutting back on pumping sessions based on her babies' continued development and their responses to other foods. By the end of our conversation, Barbara had a plan she thought she could live with for the next few weeks. She promised to keep in touch, especially if the plan required a bit of tweaking.

Jen called a few days later. She had come to our La Leche League Multiples Group while pregnant with her girl/boy twins, Taylor and Tyler. Her older daughter, Riley, had breastfed for more than two years, weaning during Jen's twin pregnancy. She looked forward to a similar breastfeeding relationship with each of her twins. All went well with her babies' birth at 39 weeks, and each baby had gotten off to a good breastfeeding start. Within a few days of their birth, Jen was producing plenty of milk and she had found a comfortable position to breastfeed both babies at once. But she'd also learned that Taylor had a heart defect that would require surgery.

"The cardiologist says Taylor is not gaining enough weight so I have to give her some formula," Jen told me with tears in her voice. "I've noticed she tires quickly while nursing, but she seemed all right and I was changing dirty diapers every day. I feel awful that I didn't realize she was having a problem." Taylor's cardiac condition increased her nutritional requirements but left her with less energy for feeding. Although her twin, Tyler, often triggered a strong milk let-down that allowed Taylor to get more milk with less work, the increased milk flow with let-down sometimes overwhelmed her ability to coordinate sucking and swallowing with breathing -- another aspect of her medical condition. And, to Jen's surprise, the time involved in taking Taylor to her many doctor appointments created the biggest obstacle to breastfeeding during her twins' first weeks.

Jen also expressed concern about the emotional toll Taylor's condition was taking on each member of the family. Meeting Taylor's needs led to less of her time available for Tyler and her firstborn daughter, Riley. "I feel ripped apart," she said, "And I'm really afraid. I had postpartum depression with Riley and I'm starting to have the same feelings I had then."

What an awesome job Jen was doing in spite of so many unexpected adjustments and obstacles. I told her I hoped she could feel the hug I sent to her through the phone line, although she deserved far more than a hug. We discussed feelings first. It is difficult to be pulled in so many directions by several little persons, each having a strong need for mother's constant care, yet knowing one is in a situation that demands compromise. Jen cried and said she wanted to call her physician after we hung up to discuss whether her feelings may be a recurrence of postpartum depression. We then discussed ways to maximize her time with Riley while also letting her family members and friends pay special attention to her, too. I reminded Jen that breastfeeding already provided Tyler with a great deal of her time, and we looked for ways her time with Tyler could be used to enhance Taylor's weight gain. To avoid Taylor's response to the first strong let-down and to provide her with more fat-enriched hindmilk, Jen decided to begin feedings by placing Tyler at one breast while pumping the other breast just until her milk let down. Once milk flow slowed again, Taylor could take over at the second breast. The milk she collected during the initial pumping phase could be given to Tyler when he couldn't accompany her to one of Taylor's doctor appointments. I provided Jen with the number of a lactation consultant at a children's hospital who worked with one of their dietitians. Jen hoped they could develop a plan that would allow her to give Taylor any required supplement during a breastfeeding by using a tube system taped to the breast. Jen and I hung up after figuring out a time to follow up in a few days.

Hannah, Barbara, and Jen's breastfeeding stories are not unusual for mothers of multiples. In fact, their stories are rather typical of the mothers I work with as the Leader of the La Leche League of Cincinnati, Ohio, USA Multiples Group. Breastfeeding multiples is not merely about breastfeeding two, three, four, or more babies, although that certainly adds up to a lot of daily feedings with more night wakings and interrupted sleep. However, more often than not, breastfeeding multiples is also complicated by other factors. Preterm birth, from extremely premature to near term, is more common than full term birth for multiples. In addition to early arrivals, these new mothers are frequently recovering from pregnancy and birth complications, such as gestational diabetes, preeclampsia, weeks of strict bed rest, and surgical delivery, followed by postpartum depression and so on. Infant health problems, such as those related to Taylor's heart defect, are also more likely to occur with multiple births. Whether due to a complication itself or related medical intervention, more common breastfeeding "problems," such as sore nipples, plugged ducts, concerns about milk production, infant weight gain, or reflux are also common.

As La Leche League International observes its 50th Anniversary, this year also marks the 30th anniversary of our special LLL Multiples Group. I feel blessed that for 30 years these wonderful mothers have allowed me and my co-Leaders, all of whom have also breastfed multiples, to become a part of their families. Their stories, struggles, and creative breastfeeding solutions have provided the material from the first to the latest edition of MOTHERING MULTIPLES: BREASTFEEDING AND CARING FOR TWINS OR MORE. Over the years via meetings, phone calls, and now email, I've witnessed hundreds (or perhaps thousands) of mothers of multiples persist and overcome countless odds in order to breastfeed their babies. They often leave me feeling humbled and in awe.

Incidentally, Hannah's twins are now busy breastfeeding toddlers, and neither shows signs of weaning any time soon. Ian and Emily simply needed a few more weeks of maturity after their birth and plenty of "kangaroo" access to the breast to become breastfeeding pros. They and their mother are now "regulars" at our group meetings.

Barbara and her family moved to another country, but she occasionally sends me an email update. Her girls recently celebrated their second birthday. Anna weaned abruptly at 16 months, and her response to "nursing strike" strategies let her mother know she really was ready to wean. However, Maya and Dana continue to enjoy a few brief breastfeeds each day.

Taylor and Tyler are now energetic toddlers who follow their big sister everywhere. Watching them, it is hard to believe Taylor ever had a health problem. She did well after the surgery to correct the heart defect, and within weeks of surgery Jen was able to breastfeed her without supplement or the need to wait until after the first milk let-down. Jen did require treatment for postpartum depression; she continues to take medication for it but her doctor recently decreased the dose. Both toddlers love their "nummies," including during the night.

The night nursing is the reason I received a phone call from Jen today. She wondered if we had any ideas for "gentle" night weaning or whether there were any books that covered this topic. While I was gathering thoughts and a resource list together in my head, she asked, "Do you think they'll ever sleep without each waking a couple of times to breastfeed?" Then she added with a laugh, "Oh, I know they will before long, and this is so much easier than those first months after they were born. That situation taught me that I can handle anything!" And that is a wonderful life-long lesson to learn!

Tips for Breastfeeding Multiples

It can be a shock to learn that you are pregnant with twins. Suddenly many of your expectations, plans, and former decisions are changed. Your decision to breastfeed, however, does not have to change. Human milk is especially important for twins, who are often small at birth and need all the health advantages human milk provides. And breastfeeding can help you create that special and necessary bond with both babies. Many mothers have nursed their twins with wonderful results; you can enjoy nurturing your babies in this special way, too!

Getting Started

  • Nursing early and often is the best way to get a good start breastfeeding. However, if you or your babies have a health problem that necessitates separation, this doesn't mean you have to give up the idea of breastfeeding.
  • If it is necessary to pump your milk because one or both babies cannot nurse, use a full-size automatic electric pump on both breasts every two to three hours during the day and at least once during the night.
  • Milk supply is regulated by the amount of sucking (or pumping) that stimulates the breasts. That's why mothers of twins almost always produce enough milk for both babies.

Coordinating Nursings

  • Once the twins are healthy and at home, most mothers of twins find it easiest to nurse both at once. Use pillows to support the babies so your hands are free to help each one latch on correctly.
  • It's a good idea to switch babies from one side to the other at alternate feedings. For example, Baby A takes the left breast at 7 am and Baby B takes the right breast. At the next feeding, Baby B takes the left breast and Baby A takes the right breast.

Night Nursings

  • Night nursings will be easier if you can learn to nurse lying down. One position that allows simultaneous nursing of twins lying down is to lie nearly flat on your back with one baby lying next to you, his head at your breast and his feet pulled in close to your body. Let the second baby lie across your body, head at your breast and feet tucked in under the other baby's knees.

Mothering the Mother

Above all, a mother of twins needs to take good care of herself, eating well-balanced meals and drinking to thirst. Get as much rest as possible by sleeping whenever the babies sleep. Accept all offers of help with meals, laundry, and older siblings.

Ambivalent Feelings

Before, during, and after the birth, some mothers of twins have mixed emotions about their "double blessings." Unfortunately, they are often isolated from others because of bedrest or fatigue, or their negative feelings are not understood by those around them. These feelings are a normal reaction to a very stressful situation and should not be ignored or discounted. It often helps to talk to another mother of twins.

 

Help!

Mothers of twins need help if they are to survive the first year. This may sound dramatic, but it is true. The biggest problems for mothers of twins are getting enough sleep, keeping up with minimal housework, finding outlets for negative feelings, and isolation. The help and support of friends, relatives, and spouses can mean the difference between making it and falling apart for a new mother of twins.

Many times people want to help, but they don't know what to do. Friends or family members who try to help can actually make things worse. Here is a short list of tips for anyone who wants to help a mother of twins.

What You Can Do

  • Bring food when you visit.
  • Change the babies.
  • Give her a back rub or a foot massage while she nurses the babies.
  • Bring her water or juice.
  • Watch the babies while she sleeps.
  • If a baby needs to nurse in the middle of the night, change him, then bring him to the mother while she is in bed. When the next baby wakes up, switch them.
  • Watch the babies while she takes a 15 minute walk or a bubble bath.
  • Listen if she is feeling scared, tired, or overwhelmed.
  • Hold her if she needs to cry.
  • Do laundry, fold the clothes, and put them away in the dresser.
  • Prepare lunch or dinner and serve it to her.
  • Tell her you love her.
  • Bring over current magazines, catalogues, or video tapes.
  • Help her find another mother of twins to talk to.
  • Clean up the kitchen, do dishes, vacuum, pick up.
  • Tell her what a good job she's doing with her babies.

Other Things to Keep in Mind

  • When you visit, help the mother feel relaxed; don't expect to be entertained.
  • She needs support and encouragement; don't give advice when she complains or seems tired.
  • The mother may be feeling vulnerable; do not undermine her confidence by asking negative questions like, "Are you sure those babies are getting enough to eat?" or "Why aren't they sleeping through the night yet?"
  • Concentrate on "mothering the mother" and helping with household chores rather than trying to take over the care of the babies.
  • A mother of twins needs extra help at least throughout the first year; don't disappear after three months.

What if there is no help?

If the mother of twins is living far away from family and friends, or they are working during the day, hiring a mother's helper may be the answer. Even if the cost is high, the mother's physical and emotional well-being are worth it. Some mothers have hired high school students to help after school. Some churches or community groups provide volunteer mother's helpers for mothers of twins. Retirees or stay-at-home mothers with school age children may also be willing to work for a lower wage.

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