Throughout your pregnancy you will have the opportunity to discuss how you plan to feed your babies with your midwife or consultant. Much of what you will discuss will depend on your birth plan and it may be appropriate for you to start expressing small amounts of your first milk; colostrum from 36 or 37 weeks as it more likely twins and triplets are born early. If you are thinking of expressing before birth, it is important you discuss your options with your healthcare professional.

You will be advised that expressing milk may encourage labour early and to consider putting a ‘feeding plan’ in place so it is clear to the health professionals caring for you if you have a store of expressed breast milk and intend to breastfeed.

Once your babies have arrived it will become a matter of learning your baby’s early feeding cues so your supply becomes established and you feel confident that your babies are getting what they need.

When it comes to feeding your babies directly from the breast, positioning and attachment are key to avoiding sore nipples and poor milk transfer. You may wish to consider if you want to feed your babies together or separately and it is advised that if you choose to feed each baby from a specific breast that you swap sides daily to support their development through visual stimulation.

We have highlighted 6 positions suitable for breastfeeding twins below:

Expressing breastmilk

• Expressing milk can stimulate your supply
• Breastmilk can be expressed by hand or with a breast pump (single or double, manual or battery/electric)
• Your hands should be washed thoroughly before expressing and you should be in a comfortable position with your shoulders relaxed
• You can stimulate your breasts by massaging them or by warming them by using a heat pad to encourage milk flow

Our related products

The Lansinoh 2 in 1 Electric Breast Pump can be used as a single or double pump so you can use it in tandem with feeding your babies from the breast. It offers flexibility in the style and suction level of pumping and can be battery operated if required
Thera°Pearl® 3-in-1 Breast Therapy pads.  Used hot they can encourage milk let-down,  relieve engorgement, plugged ducts and mastitis.  Used cold it helps relieve the pain and swelling caused by engorgement and is adaptable to fit any breast pump.
Lansinoh disposable breast pads to ensure that breastfeeding mums stay dry, night or day,
Lansinoh Breastmilk Storage Bags can be used to create a bank of breastmilk that can be stored until needed

For more information about expressing and storing breastmilk, see our related article here.

1) One of the most important things you need to do is to keep yourself hydrated, have a glass of water before you start pumping and another next to you whilst you’re pumping.

2) Some things that can help encourage your milk flow are having a picture of your baby nearby, keeping something which smells of your baby for example, a blanket from their moses basket and hearing your baby.

3) There are products that can help too, for example Lansinoh’s Therapearl 3 in 1 hot or cold breast therapy, when placed in the microwave for 15 seconds and positioned around your pump can help initiate milk flow.

4) Pump first thing in the morning, this is when your will have the most milk supply.

5) If your nipples become sore while your pumping use Lansinoh HPA Lanolin to soothe your nipples after pumping. Also make sure your nipple is in the centre of the funnel to reduce soreness.

6) You should pump until your milk flow slows down and then switch to the other breast.

And finally don’t forget to relax!

NICE Guidance (2011) advises care for women expecting multiples should be provided by a nominated multidisciplinary team consisting of a core team of named specialist obstetricians, specialist midwives and ultra-sonographers, all of whom have experience and knowledge of managing twin/triplet pregnancies. NICE also advises an enhanced team for referrals which should include a perinatal mental health professional, a women’s health physiotherapist, an infant feeding specialist and a dietitian.

Within the NHS context, this means a good deal of hospital input – although NICE (2011) does recommend that as much care as possible take place as close as possible to the woman’s home, and that hospital appointments be kept to a minimum. Alternative models of care may offer a different balance, and midwives working independently (www.imuk.org.uk) or as part of other organisations such as Neighbourhood Midwives (http://www.neighbourhoodmidwives.org.uk/midwifey-service.php), One to One Midwives (www.121midwives.co.uk) or UK Birth centres (http://www.ukbirthcentres.com/independent-midwives) will need to ensure they have the referral and support networks established that they and the family will need, whilst enjoying the benefit of being able to hold much of the consultation time within the woman’s home.

Discussing infant feeding

Many opportunities will arise to discuss infant feeding as the woman and her family prepare for the new arrivals. It is part of your midwifery remit to ensure she has the information and education she might need in order to prepare for, and to embrace her new breastfeeding relationships, and that her partner and family are well prepared for how they may best support her in that (NMC 2012).

Much of what you discuss with her will depend on her birth plans. She may well have chosen an elective early birth, and it may be appropriate to consider harvesting some expressed milk in anticipation of the babies’ arrival. Mum needs to be aware that expressing her milk (EBM) from 36 or 37 weeks may encourage labour to commence early. She may also want to put a ‘feeding plan’ in place so that it is clear to health professionals at the time of the birth if she has stored EBM, and that she intends to breastfeed. With a ready-established milk supply, the babies may suckle less than health professionals anticipate in the early hours, so it is well worth having a written plan as to what the expectations and plans are.

Expressing Milk

To show her how to hand express and collect her milk in small syringes, and to discuss with her the types of breast-pump available commercially (*) will help support her in making her decisions about feeding, and in having the tools she needs. The Lansinoh 2 in 1 Electric breast pump is a closed system, meaning that the theoretical risk of milk spores accumulating in the tubes or motor is eliminated. It also has a rotary motor with dual controls, meaning that it gives a mother much more flexibility in the style and suction level of pumping, which has been recognised as facilitating a greater yield (Becker et al. 2015). It can be used both as a single or double pump, and can be battery operated if required.

Once babies have arrived

Once the babies have arrived, support and encouragement will be paramount. Parents may need reassurance that bottle feeding would be just as hard, if not harder, and that the benefits of the babies being fully breastfed will be huge, in terms of minimising illness and other artificial milk-related problems.  Well-meaning family and friends can often apply pressure to give a bottle or to express so someone else can feed, so if you haven’t had an opportunity to educate them antenatally, then now is the time!

See *page for supporting a family whose babies are in special care.

When Mum and babies are together, Mum will still need plenty of support and reassurance that her body will produce enough milk for more than one baby, that by responding to baby’s early feeding cues (*link early cues/breast refusal) her supply will be established, and that the babies will get what they need.

Supply

Generally speaking, there will be no need to supplement twins, and any supplementation may disrupt skin to skin and responses to babies’ early feeding cues, or potentially cause confusion. If you or a mother are concerned about her supply, then feeding both babies together will help by increasing prolactin levels.

It may be necessary to express (*link to expressing/pumps) milk in order to stimulate supply if one baby is not feeding so well.

An explanation of the small size of babies’ stomachs when they are born, and that breastmilk begins to be absorbed by the soft mucus membrane in baby’s mouth, even before it arrives in the stomach may help Mums to feel confident that their babies are getting what they need.

Position, positions and attachment

Pay special attention to good positioning and attachment(*link) in order that any difficulties with sore nipples or inadequate milk transfer are avoided. However, it is equally important not to overwhelm a new mother of multiples with strict criteria of how to position and latch. It may be useful for her to understand the ideas of biological nurturing and self-latching (Colson, 2010), which will allow her the flexibility to position herself and the babies in a way that is comfortable for them all. A mother will also come to her own decision as to whether she feeds her babies together, or separately. Either way, the babies get plenty of skin contact and love, and either way, Mum would be well-advised to seek extra help around the house, for her partner to take on more of the household share, and also to ensure she is well-nourished and hydrated.

Some mothers may express a desire to have each baby have their ‘own’ breast. Although this potentially works fine from a supply perspective, it is not necessarily advisable from a development perspective, as baby has visual stimulation from one direction only (Mohrbacher and Stock 2008). If Mum would like each baby to be on one side only, suggest that they swap sides every day or so. Otherwise, there are no hard and fast rules as to which baby feeds from which breast when, as long as they are both thriving.

Sleep

In addition to our usual advice about trying to rest when baby does, the mother of multiples may need some extra information and support in terms of how she manages night feeds. It is important that she understands the risks of asking someone else do give the babies feeds, in terms of her supply, (and the need to express for every feed she misses) and in terms of nipple teat confusion. It may help her to talk to other mums who are co-sleeping, and to ensure she has balanced information about how to safely share a bed with her baby(s) (https://www.tamba.org.uk/Parenting/First-Year/Sleep).

Feeding more than two

With more than two babies to feed, fully breastfeeding is still possible (LLLI 2004), though a little supplementation may be required in the earliest days, while milk supply is being established. It is advisable for Mum to document feeds, dirty and wet nappies of each baby until breastfeeding is well established, in order to ensure each baby is getting what he needs.

Sometimes a baby who is a multiple can benefit from the ‘let-down’ that their sibling creates, and not fully drive their own supply themselves. Observe carefully that babies are sucking and swallowing at the breast, and draining the breast well at a feeding. Improved positioning and attachment may help, or using gentle breast compressions to encourage gulping.

Examples of breastfeeding positions for multiples

PICs. (see p376 of breastfeeding answer book- work in progress c/o Becky)

Tandem Feeding

Tandem feeding is the expression used to describe feeding siblings of different ages at the breast.

There are no hard and fast rules about tandem feeding, although Mum may feel she wants to give the new baby ‘first share’. Sometimes older children will notice a change in their milk during Mum’s pregnancy, and may self-wean at that time. Others will continue to enjoy. It can be very important for siblings to bond with one another over feeding together, or equally, it can be reassuring to the older sibling who is learning to cope with a new younger brother or sister. It is not uncommon for toddlers who have already weaned to come back to the breast, or at least to ask. If a Mum doesn’t feel tandem feeding is for her, then it is worth talking with her about this antenatally, and thinking about other ways to reassure and support the older sibling.

Generally, Mum’s will instinctively find a way that works for them, and milk will be plentiful for both children. It may also help Mum to find other women who are tandem feeding, for support.