Dear Jennifer,
I see lots of twins in my practice, and while this experienced mom may do
just fine, there are some red flags in her situation that would make me
watchful:

The gestational age of the twins and the fact that multiples are SGA means
that they will have thin cheeks, lack of fat pads, and resultant poorer
facial tone than an older singleton.  Given immature neurological maturation
and immature facial development, the work of feeding is increased.  Such
infants have all the risks for poor feeding that Kramer describes in his
paper on the  "just a little early" babies.  (Refs to all issues cited below
at the end of this message).

Secondly, the mother had pre-eclampsia and tx with mag sulfate.
Hypertension is a risk factor for lactation difficulties in the Hall study,
and the Peds in Review ref. cites exposure to mag sulfate as a risk factor
for somewhat floppy babies.  I would monitor the mother for normal time of
onset of copious milk production, because hypertension with edema or
recovery from physical illness may depress milk supply until the mother
recovers.  The babies may not be physically strong enough to overcome the
effects of the suppressive effects of the mother's situation.  Early
observation of her engorgement pattern, and observation of feedings (with
weights) may tell you if the kids are really moving milk.  I've been fooled
before by vigorous (but little) twins, who started to fade due to lack of
stored fat if the mom's milk supply was even slightly delayed by stress or
illness. The mother may need to use a pump for a few min. after the babies
feed to enhance the degree of breast stimulation.  If there is residual
milk, supplementing the babies with it will speed their growth and increase
their strength.  Monitoring diapers would be appropriate for the parents to
do.

These early, immature feeders often need more, not less postural stability
to protect the efficiency of their feeding.  While experienced moms can
often manage getting good latches while nursing simultaneously, sometimes it
works better in the early days to feed twins sequentially to make sure each
baby gets a good intake.  Mom should be taught to distinguish nutritive from
non-nutritive feeding.  These pre-term infants feed with what MM Palmer
calls a "transitional" feeding pattern that is characterized by too many
pauses and too-short sucking bursts.  They often close their eyes very
quickly and drop into a light, flutter suck pattern that neither transfers
milk nor stimulates the breasts.  When the mother sees the change from
nutritive to non-nutritive suck take place, she can either switch nurse or
employ some other "stop and rouse" strategy, or assume the baby has had it
and use the pump with a top off of pumped hind milk to the baby.  Otherwise,
some moms literally feed for hours and the reward (in terms of real breast
stimulation and transfer of milk to the baby is marginal.)  If the mother's
own milk is delayed coming in, which it may well be, then other decisions of
how to feed the twins in the meantime obviously have to be made.

Kramer M, Demissie K, Yang H, Platt R, et al:  The Contribution of Mild and
Moderate Preterm Birth to Infant Mortality, JAMA 2000, 284:843-849.



Hall, R, Mercer, A, Teasley, S, et al:  A breast-feeding assessment score to
evaluate the risk for cessation of breast-feeding by 7 to 10 days of age, J
Pediatr 2002; 141:659-64.



Hypotonia In Infants,  In Brief Column, Peds in Review 1996, 17(3):104-5.



Palmer,M.  Identification and management of the transitional suck pattern in
premature infants, J Perinat Neonatal Nurs  1993, 7(1):66-75.



Barbara Wilson-Clay, BS, IBCLC
Austin Lactation Associates
LactNews Press
www.lactnews.com

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