Hi Kathleen:
Wanted to offer my thoughts and also ask if the mother has some BF
twins/multiples buddies? If not, the commiseration, support and ideas from
others who have BTDT can be really helpful. She is welcome to contact
(call/email) me, but there are a whole lot of us on the Yahoo group re:
APMultiples -- there's a link (1st on page) via my web site at:
http://www.karengromada.com/karengromada/links.htm

<< I have been dealing with a challenging case and need a fresh perspective,
so any thoughts or suggestions are welcome. The mother has given me
permission to post. I will give her case history below, but want to stress
that HER main concern is repeated plugged ducts.

This mother of twins is also a physical therapist. She contacted me on
1/1/09, when the twins were 6 ½ weeks old because she had been battling
repeated plugged ducts. She had been treated for a breast infection with
Dicloxacillin for 4 days then switched to Cephalexin for 10 days. >>


Do you have any other history related to the plugs? When did the first
occur, where was it located (which breast and where on breast), were repeats
in same or different breast, etc.? When did a plug move into mastitis? You
mention later what she has been doing to treat plugs, but what breast size
is she (approx) and what kind of bra has she been wearing -- and does it fit
appropriately re: not putting pressure anywhere on glandular tissue? What
kind of breast pump has she been using?



<< These fraternal twin girls were born on 11/17/08. Baby A weighed 6 lb. 12
oz., Baby B weighed 7 lbs. 4 oz. >>


So sounds as if they were term -- what week gestation at birth? Did mom go
into labor on her own or was she induced? But congrats to mom on a job well
done re: incubating two!



<< The mother had a fibroadenoma removed in 2000 and her breasts have always
been tender, even before pregnancy. Baby A was born after 4 hrs. pushing,
spontaneous labor, no augmentation or pain medications, followed by Baby B,
13 minutes later. Mother nursed Baby A immediately after birth. Baby B
needed O2 at birth, but the mother thought she also attempted to breastfeed
her, too. The mother
had surgery 2 hours after birth for a cervical tear and received
two transfusions. Her hematocrit was 26. As of 1/2/09 her hemoglobin level
was 13. She has been eating iron rich foods, but no supplementary iron
beyond her prenatal vitamins. I suggested, but am not sure whether further
testing has been done. Lactogenesis II was delayed until Day 6. The mother
developed sore nipples in the first week, which resolved after a visit from
a local LLL Leader. >>


Does mom know whether one or both babies were contributing to the sore
nipples? (Can imagine the delay in lactogenesis after the bleeding
situations. Wonder how her resistance is now and whether low resistance
contributed to mastitis?)

Do you know what kind of fats she gets in her typical diet, since those
appear to be related to plugged duct development?



<< Baby B had been gaining appropriately, although had recently slowed down,
produced 2-3 large yellow BMs/day, along with smaller ones. She had begun
hanging out at the breast almost continuously, spending a lot of time
sucking without much swallowing. Baby A had a green BM after birth and did
not stool again until day 5 when she passed meconium. After that, her BMs
turned to green. When she was still not up to birth weight at 4 weeks,
supplementation of 2 oz. of formula after each feeding was begun. She gained
8 oz. the first week of supplementation, but only a couple oz. the next
week. She was sleeping longer and only feeding 6-7 times a day. I encouraged
the mother to watch for feeding cues, and feed at least every 3 hours. >>


Hmm, something doesn't sound right, does it? Sore nipples resolve yet baby B
should have regained birth weight by 2 weeks or so if BF effectively - and
allowed to BF on cue... Was each baby being BF on cue? DZ twins can have
really different BF needs -- one may need only 8 BF/24 hours while another
may really 10-12 to gain appropriately. Obviously, most sleep-deprived MOT
prefer 8x/24 hours and may try to fit the one with a need to BF more
frequently into the same routine as other.



<< Upon my arrival, Baby B showed feeding cues, despite having been fed a
short while ago. We put her to breast where I demonstrated asymmetric latch
along with breast compression.  After repeated attempts at both breasts,
Baby B appeared satiated.

We then woke Baby A. Since starting bottle supplementation, Baby A would
suck a short time at the breast and then begin to fuss. Suspecting that
mom's milk supply was low and that Baby A was having difficulty extracting
the milk, I suggested an SNS. Baby A nursed
contentedly while taking 2 ½ oz. of milk via the SNS. >>


Since you didn't mention any deviations, I'm assuming you observed WNL
latch/suckling patterns for both A & B with no c/o maternal nipple or breast
pain? Were you able to do test-weighing re: pre/post-BF weights during the
consult? What had mother been doing differently re: BF/supplementation prior
to your consult with her? Is mother monitoring the individual babies'
feedings (breast and otherwise) on a checklist chart of some kind? What kind
of feeding bottle system was mother using for supplements prior to SNS --
and was she using an effective breast pump to boost milk production?

Since there were signs of some ineffective milk removal by one or both
babies, I wonder if inadequate milk removal played a role in plugged duct
development (earlier) and/or decreased production (now).


<< The mother had purchased More Milk Plus tincture, but took it
infrequently so I encouraged her to be more diligent in taking it, and to
find time to pump, as increasing her milk supply would make it easier for
both babies to nurse. Using the supplementer with both babies would ensure
they received adequate amounts of milk in a reasonable amount of time. The
mother tried the SNS for a short time, but then reverted back to bottles for
Baby A and allowing Baby B to hang out at the breast, as that is the only
way to keep her happy. Both babies sleep 5 hours at and she is loathe to
wake at night either to nurse or pump as she is so busy during the day. >>


The SNS can be overwhelming for mothers of singletons, and more so for
MOT/MOM, so I can understand her reverting to the bottle. Is she bringing A
to breast at all now? Would it be better to have both BF for 5-20 min (more
or less related to infant response at breast) and then complement both --
may give her some time to pump also. If you/she have a 2007 ed of Mothering
Multiples, the chapter re: Making up for a Poor Start may be of use.

Not all slow-flow bottles are created equal. Another LC (who's also a SLP)
and I tested a gazillion of them. If you'd like an abstract with our info,
let me know. When I'm at my other computer, I'll send a sheet with the
technique and bottle types we've found to be more compatible with BF oral
behaviors. I will say that a lot of MOT find the Dr. Brown (level 1,
newborn, slow-flow) better and it was one we found to be more compatible.

Does this mom have some family, friend or paid household help, e.g.
postpartum doula? Having extra hands around may really help preserve BF for
both babies...


<< Baby A 's tongue had little extension and a pronounced upper labial
frenulum. Baby B's tongue extended, but did not fully elevate. Both babies
had frenotomies performed on 1/17. Mother reported little change in
breastfeeding habits for either girl. >>


Hmm, less common for both of DZ twins to have short/tight lingual frenulums!
(Sure they aren't MZ??) Has labial frenulum interfered with maintaining a
good seal at breast? Has a nipple shield ever been tried with either/both?



<< Mother and babies have been prescribed Nystatin for thrush. Mother
reports she has trouble applying it as frequently as needed, as the babies
keep her so busy and although tender, sore nipples are the least of her
concerns. >>


I assume thrush is related to maternal antibiotics for mastitis? Because of
this MOT's lack of time for treatment, I wonder if gentian violet -- less
frequent application and shorter course -- may be helpful. Can be very messy
but is effective!



<< The doctor was comfortable with their progress at their 2 mo. appt. last
week, although baby A is below the 3%ile for weight and baby B is below the
10%ile. Mother and father are both long, lean people. Baby A is still
receiving 2 oz. of formula after every feeding. Mother reports that she has
been very content. Baby B receives 3 oz. of formula before bedtime. She is
only happy while at the breast.>>


Do you know whether growth percentiles are based on WHO, CDC or freebie pedi
growth standard charts? Hmm, baby A only gained 2 oz but is very content?
And B is happy only at breast -- needs more contact or never satisfied?


<< Mother tried wearing baby B in a sling yesterday, so she could keep her
content at the breast and get things done around the house. She believes
that the pressure of the sling during the ½ hour she was wearing the baby
has caused her latest plugged duct. She reports that any kind of pressure on
her breast causes a plugged duct. Manual therapy performed on her thorax by
a physical therapist set off her first plug. >>


What does mother mean re: manual therapy "set off" her first plug? And what
kind of sling was she using and was she using it correctly?

I have a feeling "two baby" issues may be somewhat intertwined with actual
BF issues... Not sure if any of this will help...


Karen Gromada
Mothering Multiples: Breastfeeding and Caring for Twins or More
www.karengromada.com/

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