As mothers of preemies, we learn that our breastmilk is the perfect food for our babies.

Within hours of giving birth, we are encouraged to begin pumping, so our babies will benefit from our milk. The breastmilk of preemie mothers has special nutrients, is easier to digest, and can reduce the risk of infections.

Although breastfeeding is a natural physiological process, it’s not always intuitive or easy to get our babies latched and nursing.

For mothers of premature twins, it is especially challenging. Often babies become more familiar with bottles in the NICU. While their mothers, in turn, become well acquainted with their hospital-grade double electric pump.

Kathryn Stagg, IBCLC is a U.K. based Lactation Consultant, certified through the International Board of Certified Lactation Consultants. She is also an expert in supporting breastfeeding mothers with multiples.

What makes her unique is, in addition to her professional experience as an IBCLC, she successfully breastfed, and tandem nursed her twin boys.

A while back, I interviewed Kathryn, about nursing twins, this time she’s here to offer guidance for breastfeeding premature twins.

Breastfeeding Premature Twins

Breastfeeding Premature TwinsCould you share your advice for a twin mom who plans to breastfeed and knows her babies are going to be born prematurely? How should she prepare, before, and after the babies are born?

If she has some warning and her health professionals think it’s safe to do so, she could do some antenatal hand expressing and collect the colostrum. This would give her a head start.

What would you recommend for a twin mom whose babies arrive unexpectedly premature, and she didn’t have time to prepare for breastfeeding ahead of time. If she only has the energy to do one thing while her babies are in the NICU, what should it be?

She should be supported to hand express her colostrum preferably within an hour after birth, but certainly within 6 hours after birth. Then to try to hand express every 2-3 hours from then on. Once her milk begins to come in she can move on to a hospital grade pump and continue to express every 2-3, not leaving it longer than 4 hours overnight.

After the Birth

Breastfeeding TwinsWhat should mom do if it’s been 2 or 3 days since her babies were born, and she’s pumping every 3 hours, and she’s just getting drops?

If babies are stable enough for kangaroo care this can really help. Massaging the breast before and during the pumping session can help massively. Having photos of babies, a video, some clothes, or a blanket that smells of them can really help. And trying to relax, not watching amounts, listening to music, watching comedy, chatting to friends or family can improve. Ensuring the pump is efficient (a hospital grade pump is recommended) and that the cones fit correctly will have an impact on yield. If milk volume continues to be low then exploring whether there is a medical issue for this would be a good plan.

Are you a fan of breastfeeding supplements like teas and over-the-counter galactagogues?

There is generally no harm in trying most of them (fenugreek is a little iffy, sometimes reduces supply) but they only work alongside frequent expressing. They are not a magic wand. The only sure-fire way of making lots of milk is the frequent and efficient removal of the milk by hospital grade pump or baby if they are feeding.

NICU

Often in the NICU, preemies aren’t able to open their mouths wide enough to get a good latch, so mothers sometimes come home using a nipple shield to make it easier for the babies to transfer milk. What are your thoughts on this?

Nipple shields can be a very useful tool to establish breastfeeding in premature babies. Research shows premature babies can often transfer more milk with a shield in the early days. Babies can often wean off them fairly easily once past due date and when they are feeding more efficiently.

For babies to come home from the NICU, one of the requirements is they need to be taking all their feeds by mouth. Preterm infants often get tired while nursing, and it’s also not easy for mothers to be at the hospital round the clock for every feeding. This often means babies are more familiar with eating from bottles when they go home. How can a mother get back on track with breastfeeding her twins once they go home?

It is important for mum to be at the hospital as much as possible once trying to establish breastfeeding. It can be preferable to get babies good on the breast first and then introduce a bottle just before discharge. Some do it earlier and it is ok. A period of “rooming in” where the breastfeeding parent stays at the hospital and looks after the babies 24 hours a day before the babies come home can be useful. Many Neonatal Units (NNU) offer this.

Breastfeeding Premature Twins

Most NICU mothers I know, including myself, who’ve had micro-preemies, have had their babies introduced to bottle-feeding first. From what I know and hear from my NICU families, the NICU wants to establish that they can handle oral feedings, and with preemies born on the earlier side of prematurity, they would have to wait super long before introducing the breast nutritively.

I do know that non-nutritive breastfeeding can be done, at any point, once a baby is stable. It’s something that I and many other NICU mothers I know were able to do, even before a bottle was introduced for feedings.

So for twin mothers of micro-preemies who aren’t able to primarily breastfeed in the NICU, and have been doing more non-nutritive nursing, how can they get back on track once they go home?

That’s interesting. Here we tend to introduce breastfeeding first, sometimes with a shield, which helps them to be more efficient at transferring milk from the breast in the early days. Then once that is going well, tube feeds are discontinued and top-ups may be given by bottle. So we do it the other way round if a mum wishes to breastfeed long term.

But if a baby is mainly bottle fed when discharged from NICU you can begin to introduce the breast starting with trying to latch every feed and then topping up. Shields can help them to latch if they are not able to do so directly on the breast. Then once the baby becomes more efficient you can gradually decrease the top-up volume, and once it’s down to a small amount, begin to stop some altogether.

I have a whole article on dropping top-ups.

Breastfeeding at Home

If babies aren’t emptying the breast or falling asleep while nursing, should mom continue to pump as needed?

Breast compressions are a great way to get a bit more milk into a baby when they are a bit sleepy at the breast. Breasts are never fully empty, they make milk all the time. But if the baby has fallen asleep before they have taken enough milk, then pumping and topping up can be a good plan in the early days. As babies approach due date their feeding efficiency often improves and the top-ups can be gradually phased out.

Should mom start by trying to nurse one baby at a time to get the hang of it, or should she just nurse both babies together?

It’s totally up to her. If tandem feeding is working and comfortable then no harm in using it. If mum prefers to single feed so she can concentrate on the latch, then that is also fine.

Breastfeeding Premature Twins

Bottlefeeding

When my son was discharged from the NICU, we had our ups and downs with nursing. Sometimes I was tired, my nipples were sore, or the feeding just wasn’t going well, and I would use a bottle. Is breastfeeding still successful if a mom utilizes bottles for some feedings?

Of course. Breastfeeding is successful if the baby is getting any amount of breast milk. Even one feed a day has massive health benefits. If mum is wanting to move towards exclusive breastfeeding then any time she uses a bottle it is important to pump so her breasts get the stimulation. But if she’s happy combination feeding then her breasts will make the amount of milk they are asked to make. For long term combination feeding to work well, it can be a good plan to have a couple of set bottle feeds a day and breastfeeding responsively in between. This lessens the risk of just increasing the formula during fussy periods, which can mean a gradual decline in breastfeeding

Support for Breastfeeding Twins

Kathryn Stagg IBCLCCould you share more about the virtual lactation support you’re able to provide twin breastfeeding mothers worldwide?

Since Coronavirus (COVID19) hit, I have been ding a lot of online support and it is working particularly well. Parents book a session on my online booking system. Once they are booked in I encourage them to send some photos/videos of the babies latching or any behavior they are worried about, just in case they don’t behave on the day! They will need a camera person helper to maneuver the device so I can get the best view of feeding possible during the session.

For more with Kathryn, please follow her on Instagram, Facebook, and contact her through her website.

This advice is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health care providers for specific questions you have regarding your situation.