I've seen a great case of triplets recently and she's done a better job than
many moms of twins I've seen. Moreover, she is not one of those
overproducers that just gush milk, she did it through sheer determination,
some skin to skin, some nursing at the breast & a lot of pumping. She even
managed through some pretty serious health problems right after delivery.

In terms of the Reglan, I'd be very nervous about its use.  If your triplets
lived in Manhattan I'd send her straight to the breastfeeding medicine
specialist in our area who is great with low supply for a full workup. I
have never seen a single case of side effects when she's screened women
carefully and put them on domperidone.  I don't know if you have someone
similar in your area.

I do have a vague memory of the breastfeeding medicine specialist mentioning
some things about triplets that I think are worth looking into.  Any MDs out
there PLEASE correct me if I have misremembered it because this is NOT
something I've read up about.  First, if I remember correctly, she mentioned
a greater tendency towards gestational diabetes and insulin resistence.  The
other was from an endocrinologist who I talked to at length about milk
supply.  He did not know a lot about milk supply, but his impression is that
many more women suffer from hypothyroidism in the postpartum period than is
commonly believed (and this can also mimic postpartum depression).  Again, I
could be misremembering this, but I seem to remember something about
postpartum hypothyroidism being more common with multiples.  Now, this could
be one of those coincidences, perhaps it is because more of the mothers who
have multiples now are those who have fertility problems (such as PCOS) and
are therefore more likely to have problems getting to full supply?  So, if
there is any MDs in the area that are ammenable, I'd have her screened for
insulin resistence & thyroid levels at the very least.

As for the benefit of baby on the breast versus the pump - this is one of
those time management, effectiveness issues.  Definitely skin to skin is a
big help and often forgotten or not done as frequently with multiples.  In
terms of actual breastfeeding, I would definitely do pre and postfeeding
weights to make sure the babies are not just sucking away not taking
anything.  Based on the pre and postfeeding weights, I would come up with a
manageable plan for "skin-to-skin" time, "practice feeding time", or if
they're doing well at the breast, "effective feeding time", and "pumping
time".  While I hate "schedules" finding a manageable routine where the most
efficient breast drainage technique is given priority, while making sure the
other methods are not neglected can be really helpful.  AND I never prejudge
which is the most effective for a particular women, I measure with the scale
(given the odd shape of the botles for pumping, I even sometimes weigh the
pumped milk). Moms of triplets often need some specificity to the advice
about getting into a routine.

The trick with pumping (and making mom feel more comfortable not
exaggerating what she is really doing) is examining all the barriers.  More
and more, I watch women pumping.

1) I have found one way to eliminate discomfort is determining the most
appropriate diameter for the breast pump flanges.  It makes a huge
difference watching mom for at least five minutes on the pump because of the
expansion that can occur. I'm convinced that the so-called "large"  27 mm
flanges are really "medium" not "large", and the so-called "extra-large" 30
mm flanges are really just plain "large.  BUT, I have also had the
ocaissional mom with very stretchy breasts that rub significantly who feel
better with those extra small inserts from the old Pump N Styles.  Sizing
can make a huge difference.

2)  Also, for many moms I have found that a touch of olive oil can make an
enormous difference in comfort as well.  I'd say I suggest it for about 75%
of the moms I see who need to pump to increase their supply.

3) Just as it is important for mom to get comfortable while nursing, it is
important for her to get comfortable while pumping. I see many moms who jam
the pump flanges deep into their breasts, elbows sticking out like chicken
wings, and backs curled over so they can look at their breast while pumping
(or because they've been told they have to lean over to pump).  No wonder
its a miserable experience.  I prop them up in a comfortable spot with
adequate pillows and have them lean back.  I swear, I have not seen any
difference in expression when mom is leaning back and comfortable than
leaning forward and getting an aching back.

4) My cheap trick which I think really makes a big difference is a homemade
hands free bra.  A stretch sports bra or a yoga top with an internal shelf
bra with two holes cut out is great for hands free pumping.  Its amazing
what a difference it can make for mom to be able to eat, drink, scratch her
nose or click on the TV remote while pumping. It also keeps her from curling
up in an uncomfortable ball to watch what comes out of her breasts.

5) From having to work with the baby nurse moms (who would have hired wet
nurses 100 years ago), I've learned some sneaky tricks to get rid of that
AIM during the middle of the night, straight out of Paula Meier's work.  I
tell them that they should pump when they wake up on their own (and they all
do!). I mention that this works better than setting the clock because they
are waking on their own natural light, deep cycle.  I tell them that pumping
is a safe sleep drug - it will put them back into a deep sleep and if they
feel very tired that this is a very good thing.  This approach tends to work
better for most of the moms I've seen than putting them on a strict schedule
for pumping at night.


Finally, I also have seen some moms take a while for their milk to increase
for no explicable reason.  For some moms it just takes time and patience.

So, hope a few of these tricks work for your mom!

Best, Susan E. Burger, MHS, PhD, IBCLC

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