Dear Christina:

As Jean noted this mother of twins (MOT) is lucky to have you. I feel so sad
if it is normal in your country to separate a mother from her infant(s) for
1.5 days after birth for no apparent reason. To have a full-term twin
pregnancy and then have to deal with breastfeeding problems quite likely
related to an unnecessary separation and the introduction of another feeding
method is just sad -- especially when so much science says to keep mom and
infant(s) together.

Of course, that doesn't help this MOT and her babies (or you) re:
breastfeeding at this point! Glad the bigger guy is able to breastfeed,
which can really help milk production. I hope she knows to nurse, nurse,
nurse as often as he's willing. If she's feeling coordinated enough, she
could feed him on one breast and pump with the Swing on the other breast --
this can increase the efficiency and effectiveness of both baby and pump!

Re: bigger baby who "spills a lot of milk while bottle feeding" is not
necessarily a sign of disorganized sucking. It's often a sign of a smart
baby trying desperately to protect his airway from too fast of flow coming
in from a fast-flow feeding-bottle nipple. One of the ways babies protect
the airway from fast flow is too get rid of some of the too-large bolus by
drooling/spilling from the mouth the excess fluid. A true slow-flow (and a
label of "slow flow" doesn't guarantee slow flow -- a company can put
anything it wants on a label) allows for wave-like sucking on the
feeding-nipple. More upright positioning of baby during feeding also helps.

Re: The smaller guy who is chomping, chewing seems the more likely suspect
when it comes to flattening mom's nipples. Could be a shallow latch and/or
behaviors related to being bottle-fed with a fast-flow nipple that requires
only compression vs. wavelike sucking movements to get and control flow,
and/or could be related to a structural issue in this baby's mouth. Has
anyone suggested trying a thin, silicone nipple shield (probably about  20mm
for this size baby), e.g. Medela brand for breastfeeding this little one
with instructions per
http://www.medelabreastfeedingus.com/tips-and-solutions/112/nipple-shields?

As per Jean, I'm in total agreement re: skin-to-skin contact, which has been
associated with increased volume obtained with pumping - and also in
assisting with a deep, immediate latch via baby-led latch technique. Does
this mother have a computer with internet at home? I often refer mothers to
the latch video at http://www.ameda.com/breastfeeding/elibrary/videos.aspx.

How much household help does this mother have at home? Can someone else
handle the feedings that aren't at breast, so the MOT has more time for
skin-to-skin, breastfeeding and pumping? Pumping as often as needed is
definitely more complicated when caring for twice as many babies (while also
recuperating from major surgery), which is why pumping one breast when BF on
the other can help -- a real timesaver IF a mother can become comfortable
with it.

Did the Swing pump go home with the mother? What kind of instructions did
this mother receive re: how often to use and what kind of pumping routine?
Do mothers use breast massage prior to and during pumping sessions? Do they
pump each breast once or twice during a pumping session? Was the
mother encouraged to also "run and pump" in between regular pumping sessions
for a few minutes here and there when possible?

Re: BF and Hep C - the CDC has some info at
http://www.cdc.gov/BREASTFEEDING/disease/hepatitis.htm.

Finally, if this MOT has a computer with internet access and reads English,
please encourage her to join the Yahoo group APMultiples. She can get there
via the first link at my web site
http://www.karengromada.com/karengromada/links.htm. She'll have to
"subscribe" but it's free. It may take a couple of days to get on. If there
are any chapters in Mothering Multiples that you think may be helpful for
her now, e.g. Making Up for a Poor Start (with BF twins or more), get in
touch via personal email. I can send via email.

All the best to her -- and thank you for being there for her!

Karen Gromada
(author Mothering Multiples: Breastfeeding and Caring for Twins or More)



> I would be grateful for suggestions for a case I am struggling with. The
> problem is developing a practical plan of care for a mother of 6 days old
> twins who (the mom) happens to have hepatitis C infection .
>
> A little history - it is a first pregnancy after IVF (no hormonal problems,
> infertility due to endometriosis and male factor). Uneventful pregnancy,
> baby boys born 38 weeks via (planned) cesarean preceded by
> spontaneous rupture of membranes and 4 hours of labor. Birth weight
> 2800 gr and 2600 gr, no complications with the babies.
>
> Mom got to see the babies for a brief second after delivery and again
> only after 36 hours have passed and she was brought to a normal
> postpartum room (it is the norm here, although I know that it is very
> different in your parts of the world). Mom has not expressed all this
> time, babies were being fed formula by bottles. She put both babies to
> breast immediately after she won the battle to get them brought to
> her - and almost immediately got her nipples cracked.
>
> I saw them at their 3rd feeding after mom called me to seek help -
> normal breast and nipples, babies latch is very shallow. We tried
> everything and things improved a bit after 2 days - nipples are not
> terribly pinched anymore, but still lipstick-shaped. No improvement in
> this till now despite every effort made (I know I am not the most skillful
> lactation help, although I've been working with bf couples for 4 years
> now, but I reffered her to the - very skilled and the only one available -
> doctor that we work with and still latch is not optimal). Nipples are
> hurting, small cracks visible, but no bleeding - she applies lanolin and
> some type of nipple cream that the hospital provides.
>
> Babies latch with a very open mouth, good latch technique - but still
> hurting the nipples. No TT visble (but neither myself, nor the doctor are
> able to discover a posterior TT), no palate issues visible.
>
> The bigger twin seems to suck efficiently with gulping (milk transfer on
> day 4 was 10 ml, weighed only at one feeding). I still suspect he has
> some lip weekness, because he sleeps with an open mouth and spills a
> lot of milk while bottle feeding despite proper pacing technique.
>
> The smaller one has a very disorganized suck, chomping and chewing
> action only, almost no gulping to hear or notice. 0 ml transferred at
> breast, although mom feeds them simultaneously and the bigger one
> triggers the MER for him. I am afraid he is not a good candidate for SNS-
> feeding because of his ineffective suck - the doctor tried it with him, but
> it was no success and mom didn't like it. He feeds efficiently from the
> bottle.
>
> Mom is very nervous about bleeding nipples and is afraid she could
> pass the hep C infection to the babies if her nipples become more
> injured. So she is reluctant to put the babies to the breast more often
> than every 3 hours and her plan of action was to put babies to breast
> 8x24h for 20-30 min and supplement with 10-20 ml formula afterwards.
>
> Milk came in yesterday (day 5), breasts fill fuller and hotter, a bit
> enlarged, but no uncomfortable engorgement. No additional breast
> stimulation with milk expression till today (day 6), just what the babies
> could do with their sucking issues.
>
> I am really worried about milk supply with this lack of stimulation. Mom
> is very willing to put the babies to breast every hour and a half, but
> only after nipples are feeling good because of her fear of bleeding and
> infecting the boys.
>
> So the options here - as I see it - are working on the latch, nursing
> every 3 hours (as mom's wishes are) plus more frequent expression
> with the pump and giving expressed milk (or formula if breast milk
> unavailable) by bottle until the situation with the nipples improves.
>
> There are no hospital grade pumps available in our hospitals (and in
> fact not even one at all in the whole country), but today mom is going
> home with the babies and we talked about regularly expressing after
> each feeding with her Medela Swing (it is the best pump available
> here). She prefers the pump - I showed her hand expression, but she
> doesn't feel comfortable with it and thinks the pump is a better and
> faster way for her.
>
> And I am not quite sure about the best way to organize the things -
> mom has 2 babies to care for and feedings could not last forever, so
> she has some time to not only pump and nurse, but get some sleep
> too. She will have help at home (grandma and husband will be home
> for some weeks), so it will be easier. In the hospital she was all alone
> with the babies and was not willing to leave them in the nursery (which
> I admire her for) although she slept only an hour or 2 a day for the
> past 4 days and is now totally exhausted.
>
> What am I missing here - are there other things we could try? Think
> only the basics, we don't have most of the things I read on the list and
> we are the only lactation help available (and surely it is quite visible I
> am not an LC).
>
> Christina in Bulgaria,
> BF Peer Counselor
>
>

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