Hi Katherine: 

Re: << I am very interested in information about breastfeeding with multiple births, especially triplets, and the role nurses play in education and the role nurses play in education and support >>

I am very excited that you've found this topic of special interest. It has been a special interest of mine since I gave birth to my 3rd & 4th children 10 minutes apart! Since then I've worked with 100s (possibly more than 1000 by now) breastfeeding mothers of twins (MOT) and higher-order multiples (MOM). I'd love to be able to help you in any way I can. For info on what an expectant MOT/MOM can do to prepare for BF and why it’s especially important with multiples, please check out the FAQ pages at my web site: www.karengromada.com/ Feel free to email directly as well.

<< I realize that many mothers may chose not to breastfeed because of multiple infants, but I feel that with the proper education and instruction, breastfeeding could be performed effectively with multiple infants. >>

Actually several surveys have found expectant MOT/MOM plan to BF at about the same rate as women having singletons (Geraghty et al, 2004; Bleyl, 2001; Gromada & Spangler, 1998).  I’ve worked with a fair number of mothers BF triplets and several mothers BF quads. The literature includes case studies (Auer & Gromada, 1998; Mead, Chuffo, Lawlor-Klean & Meier, 1992) as well as the Saint, Maggiore and Hartmann (1986) classic article on the ability of women to produce enough milk for multiple infants. 

<< According to Moxley and Haddon (1999), with the increase in multiple births, there is a greater need to provide this group of parents with accurate information and anticipatory guidance about breastfeeding. >>

Fortunately, the increase incidence of higher-order multiples, including triplet births, has stabilized since 2002 and may begin to decrease as reproductive medicine improves techniques to enhance conception for couples dealing with fertility issues. But you are 100% correct that these couples (and their infants) not only need accurate – and may I add “realistic” – info and guidance re: BF during pregnancy but have the right to receive it (Leonard, 2003). I am too often astounded by not only the lack of info they are given but the negativity they receive when they say they want to BF. (There is a lot that astounds me about the medical community’s approach to multiple pregnancy and birth, but we won’t go there now!) 

<< Parents need to understand that breastfeeding is not only nutritional, but builds a maternal-child relationship and decreases the chances of viral and bacterial infections for the infant.  Many mothers believe that breastfeeding is a life-line to their newborn infants and provides the child with emotional security and nurturing (Leonard, 2002). >> 

You’ve hit the nail(s) on the head! Many women fully BF (or express-breast-milk/EBM-feed) twins, and I’ve met a number of mothers of triplets and a few with quads who did as well. But because of both infant and maternal complications that are more common with multiple births, partial BF is more likely. For the mother who must form attachments with 2 or more infants at once, ANY BF is better than none in terms of the closeness it provides. (And don’t forget to promote kangaroo mother care for post-discharge also!) Partial BF still has a positive impact on a number of infectious diseases, although impact appears to be related to the amount of BF (Scariati, Grummer-Strawn & Beck Fein S, 1997).

<< Several mothers felt that the CHN, although accessible and provided quality information, was unable to understand what it was like to have triplets... The study stated that it is important for nurses and lactation consultants to follow-up with new parents, because new parents may become overwhelmed or too exhausted to contact lactation and support services after they have left the hospital if they run into problems. My questions are what your agency=92s guidelines/policies for informing or teaching a mother with multiple newborns how to breastfeed, how many nurses are lactation consultants at your agency, is there a guideline for follow-up visits/calls, and how I can be supportive of a mother, in a hospital setting, with multiple newborns to start/continue to breastfeed. >>

I think Linda Leonard is correct. It is difficult to appreciate what it is like to care for 2, 3, 4 or more times the number of newborns that the typical new mother brings home – and she is often bringing home preterm babies while recuperating from the effects of pregnancy complications! Because of this and related factors, even mothers that initiate BF/lactation with multiples BF for shorter periods than those with single-born infants (Damato et al, 2005; Geraghty et al, 2004). 

In all honesty, I think this is an issue for many LCs and BF support group leaders. BF multiples is so much more than BF mechanics. What works with a singleton does not always work with multiples because of the logistics and the fact that there are still only 24 hours in one day. Beck (2002a & 2002b) has some additional insight on this. Besides LCs and BF support services, it is very important for these mothers to be put in touch with multiples-specific BF resources. The “been there/done that (BTDT)” factor can go a long way re: credibility and appreciation for the reality factors.

The hospital affiliate org where I work as a LC sponsors a “special” childbirth education class for parents expecting multiples, which includes a BF class – although the instructor has not had or BF multiples. Our out-patient LCs follow up via phone. They refer MOT/MOM to me p.r.n. Also, we have a La Leche League multiples group in our area that is especially for these mothers and totally adapted to the realities of this situation. (And I’m sometimes astounded but other leaders do not always tell MOT about us!) There is wonderful online support via Yahoo Groups for mothers BF multiples. The group is AP (attachment parenting) Multiples. And try my web site – FAQ, Articles (birth plan for MOT and some expecting triplets), Photos.

Let me know if there is other info you are interested in on this topic…

Karen Gromada, MSN, RN, IBCLC
Author: Mothering Multiples: Breastfeeding and Caring for Twins or More (LLLI); coauthor: Keys to Parenting Multiples (Barron’s); coauthor, nurse CE modules re: Care of the Multiple Birth Family (I & II) (March of Dimes)
 
Auer, C. & Gromada, K.K. (1998). A case report of breastfeeding quadruplets: Factors perceived as affecting breastfeeding. Journal of Human Lactation, 14(2), 135-141.

Beck, C.T. (2002a). Releasing the pause button: Mothering twins during the first year of life. Qualitative Health Research, 12(5), 593-608.

Beck, C.T. (2002b). Mothering multiples: A meta-synthesis of qualitative research. MCN: The American Journal of Maternal Child Nursing, 27(4), 214-221.

Bleyl, J.L. (2001). Breastfeeding triplets: Personal reflections. In I. Blickstein & L.G. Keith (Eds.), Iatrogenic multiple pregnancy: Clinical implications. New York: The Parthenon Publishing Group.  

Damato, E.G., Dowling, D.A., Madigan, E.A. & Thanattherakul, C. (2005). Duration of breastfeeding for mothers of twins. JOGNN, 34(2), 201-209.

Geraghty, S.R., Pinney, S.M., Sethurman, G., Roy-Chaudbury, A. & Kalkwarf, H.J. (2004). Breast milk feeding rates of mothers of multiples compared to mothers of singletons. Ambulatory Pediatrics, 4(3), 226-231.

Gromada, K.K. & Spangler, A. K. (1998). Breastfeeding twins and higher-order multiples. JOGNN, 27(4), 441-449.

Leonard, L.G. (2003). Breastfeeding rights of multiple birth families and guidelines for health professionals. Twin Research, 6(1), 34-45. 

Mead, L.J., Chuffo, R., Lawlor-Klean, P., & Meier, P.P. (1992). Breastfeeding success with preterm quadruplets. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 21(3), 221-227.

Saint, L., Maggiore, P. & Hartmann, P.E. (1986). Yield and nutrient content of milk in eight women breast-feeding twins and one woman breast-feeding triplets. British Journal of Nutrition, 56(1), 49-58.

Scariati PD, Grummer-Strawn LM & Fein SB (1997). A longitudinal analysis of infant morbidity and the extent of breastfeeding in the United States. Pediatrics, 99(6), e5. Available [online]: http://pediatrics.aappublications.org/cgi/reprint/99/6/e5

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