Re: << Hello, my name is Tiffany Baker and I am a nursing student at the University of North Dakota. I have recently had my OB clinical and was fortunate enough to see the delivery of twins! As I was watching, however, I was wondering what she was going to do about breastfeeding. I have learned much about teaching a parent of a singleton to breastfeed, however, I have never had to deal with multiples. >>


Hi, Tiffany. I have probably worked with 100s of mothers of twins (MOT) and a number of mothers of higher-order multiples (MOM) who BF their babies as well as BF my own MZ sons long ago. As a RN your role is to look at/assess BF in context to the mother as an individual, each baby as an individual and the dynamic interaction of the mother-babies together. Although multiples arrive together, their level of maturity and ability to BF initially can be quite different. So, first, each multiple's BF should be assessed -- separately.  Multiples are often born prior to full term and/or are SGA and that often affects early BF. Mothers are more likely to experience pregnancy or peripartum complications with multiples, which also affect early BF. 

If mother is healthy and babies are term and healthy, each multiple should be able to fully BF -- and each should be viewed as an individual re: assessment at breast, BF outcomes, etc.


<< I did some research to back up my knowledge acquired at UND. I was interested in the importance of early breastfeeding. Riordan, Gill-Hopple,
and Angeron (2005) did some research and found that early in the postpartum period, rooting and observed swallowing appear to be important estimates of human milk intake as well as a critical time for the establishment of breastfeeding. This information should be taught to the mom so she would understand the importance of early breastfeeding versus bottle feeding until she was ready to deal with both newborns. In another report, however, I found that when both twins are ready to breastfeed, many mothers during the first few post partum days, do not have enough milk for both children. >>


I'm not quite sure I understand where you're going here. What do you mean re: "until she was ready to deal with both"? Ready or not (and I know few MOT/MOM who truly were ready!) here they are! And MOT/MOM "do not have enough milk for both"? Bull puckies! What quantitative data was this based on? Unless a woman has an underlying health issue affecting lactogenesis, most mothers make enough for both babies -- but yes, she should expect frequent BF. Having twice as many babies means twice as many feedings.


<< Eventually, the mothers supply increases and shouldn't pose a problem. It is recommended for the mother to take at least a three-hour break between feedings as well as to have the twins (or other multiples) feed equally at each breast (R. Hattori and H. Hattori, 1999). >>

Just as with a singleton, BF each term multiple based on feeding cues. More BF = more milk. Ignoring cues, waiting 3 hours, etc. have been shown to be related to lower production. Check info by Daly, Hartmann, Ramsay, etc.


<< I began to think of ways to ensure the babies got enough breast milk, and came across a research report that focused on breast pumps with
multiple births. The reason the study was performed was because the researcher realized that with mothers of multiples there are challenges associated with establishing an adequate milk supply as well as the initiation of more than one infant to the breast after delivery. This study also confirmed my previous research by stating that their data showed that the earlier infants get to the breast the more likely they are to feed on human milk for longer durations. (Geraghy, Khoury, and Kalkwarf, 2005). >>

Are we talking term, healthy newborn multiples or preterm multiples, including those borderline/near term multiples whose suck-swallow-breathe is likely to still be immature and, therefore, result in Ineffective BF (NANDA definition)? Managing two or more newborns is challenging no matter what, but BF and establishing full production for more than one is NOT the issue for term, healthy multiples -- needing more than 24 hours in a day is more of a challenge and it can affect BF.
 
 
<< I was wondering if there was a schedule that could be provided to the mother of multiples that included time at the breast as well as time pumping (if she chooses).  Would the combination of breastfeeding and breast pumping be more beneficial for the mother and what type of schedule should be set for the infants to experience the mothers nipple and the bottle nipple? >>


If a healthy mother wants to fully BF and her babies are term and healthy, her babies -- if demonstrating Effective BF -- are better than any breast pump yet devised. Individual infant cue-based BF is the best way to optimal milk production. If babies are early and demonstrate Ineffective BF or for ANY reason are supplemented, compensatory milk expression should be part of the plan. Either each baby or milk expression should be effectively removing milk a minimum of 8x/24 hours -- and in the case of multiples more is better usually, it's just not always feasible. However, the care plan should be individualized for particular circumstances. 

I've got a slew of refs if you'd like them but it's late and I have to work early so didn't include here.  Also, see the FAQ page at my web site: www.karengromada.com/ The photo section may be of interest to new BF MOT/MOM also.

Karen Gromada (MSN, RN, IBCLC)
author, Mothering Multiples: Breastfeeding and Caring for Twins or More

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