Ina May's Guide to Breastfeeding

Nursing Twins … and More

Nowadays, many people seem to think that having twins is no big deal—we keep hearing about people who are having three, four, or even more babies from one pregnancy with assisted reproductive technologies. People who underestimate the difficulty of having twice as many babies as usual often haven’t raised twins themselves. Having twins and more is a big deal; it requires new mothers to care for more than one helpless infant at once. Add to this the fact that multiples are more likely to be born prematurely, at low birth weights, and are more likely to need extended hospital care. For these reasons, you may have a rocky start with breastfeeding; you could find yourself caring for two or more hospitalized babies.

It’s a good idea to look for a support group for mothers of multiples in your area while you are still pregnant. Listening to the stories of those who have traversed this territory before you will help you prepare better for what is ahead. In case there is no such group near you, try visiting an Internet forum for the mothers of multiples. Your morale will benefit from hearing the stories of other mothers who have managed to breastfeed their twins or multiples, and you will also pick up some useful tips on caring for your babies.

Lots of women can produce enough milk to feed two babies. For you to increase your chances of joining this lucky group, do your best to eliminate any other sources of stress from your life. Realize that you will need plenty of help during the first weeks and months of your babies’ lives, whether or not they are born prematurely. Accept any help that is offered and ask your relatives and friends for more if necessary.

If you plan to give birth in a hospital, find out if there is a lactation consultant on duty at all times. Having the help of a professional lactation consultant will increase the chances that your babies will latch correctly in the beginning. This can do much to prevent later problems. Remember, a woman with only one baby can have trouble getting that baby to latch on right, especially if she is physically exhausted, sore, or left to her own devices. Having two babies to cope with instead of one isn’t going to make things easier. Think of each baby’s need for eight to twelve feedings a day once your milk is fully in and then multiply that by the number of babies you expect. At the same time, realize that thousands of women out there will testify that the rewards are well worth the trouble and persistence attendant to nursing multiples. Approach the challenge of feeding your babies one day at a time.

Find out if postpartum home visits after hospital discharge are part of the maternity-care plan you have. If they’re not, start making plans while you are still pregnant about who (besides your partner, who will also be sleep-deprived) can help you during the first month or two.

Claudia’s story shows how much the support of family and friends can help when caring for and nursing multiples. She faced a surprising challenge when she gave birth to triplets after expecting only twins. Fortunately, and unusually for triplets, her babies were full-term at birth. Here is her story:

 Claudia: My labor was quick. I cannot say that I was in pain. I just felt uncomfortable. When my midwife arrived, I had been in labor for an hour and a half and was already seven centimeters dilated. It was a fantastic labor and delivery. We had a roomful of people, but in the end we didn’t really have a surplus of people, because so many babies came out. Remarkably, each baby weighed nearly seven pounds.

I decided to breastfeed all three. That went really well, mainly because I had good people around me who were supportive of my decision. There was never any question that I would do it another way. Nobody treated me like I was crazy for trying to breastfeed all of them. My friend, my father, and my mother came, and while I breastfed one of the babies, they would cuddle and care for the other two. I had somebody with me most of the first three months. It was hectic. Usually it was me and at least one other adult, which was minimal, and the three babies.

But I got so much strength from doing that birth the way I wanted (I gave birth vaginally) that it carried me through the hard times of that first six or seven months. We’d be so exhausted by evening, and we’d have to take a deep breath, knowing that we would have to get up in the middle of the night with them. But we did it.

  If you have a cesarean, keep in mind that it’s still possible for you to nurse your babies—and doing so will yield real benefits for you and your babies. You will need help from a lactation consultant while you are in the hospital, and you’ll definitely need help once you are settled back in your home after your discharge. If your babies are still hospitalized when you are released, try to have a family member or friend (besides your partner) come to the hospital with you and be with you as you nurse your babies. It is not unusual in cases of multiple births for babies of the same mother to be discharged at different times. In this difficult situation, you’ll need a lot of help to manage the logistics of maintaining your connection with both babies. Again, a supportive friend or a relative will prove invaluable to you. In this case, you’ll almost certainly need a heavy-duty breast pump, so you can nurse the home twin at one breast while pumping the other breast to get milk for your hospitalized baby.

Nursing for Two

While you are pregnant, you should buy a large U-shaped foam pillow, with a removable cover, that will wrap around you. The best variety has a strap that fastens behind you and an upper side that is angled so your babies are held close to you with their heads in the best position for swallowing. See Resources for more information on buying one of these. With such a pillow, you may be able to feed your twins simultaneously.

Simultaneous nursing with twins

However, in many cases, each baby will need to have developed a good latch and be able to nurse well before you try simultaneous feeding. Getting your twins to feed simultaneously probably won’t be easy the first few times you try it, but it should get easier with practice.

Cara, a first-time mother of twins born at full term, wrote about her feelings the first time she tried nursing both girls at once:

 Cara: All went well until they both began rooting and crying at the same time. I tried nursing one at a time but couldn’t stand watching my other girl turn beet red and scream at the top of her lungs. It was making my head pound fast into a throbbing headache—I was a wreck, and I started to cry too. How was I going to do this? What was I going to do? Get it together! After a couple of deep breaths, I arranged all the pillows that were around me, so that each pillow would support one of my girlsI decided to go for the underarm hold, which meant placing one of my hands under each of their necks for support, with their heads under my breast, ready to latch on. It took a while; they were worked up and thrashing around, and it was hard to get them on the pillows. Once I latched one, I’d have to reach up and try to latch on the other. The first would fall off by the time I got the second one on.

Finally, we made it! Both babies were happily latched on and nursing. At this time the new shift nurse came in. She was quite pleased, and we appeared deceptively calm. She brought me a breastfeeding pillow for use next time—just what I needed.

  Simultaneous feeding stimulates both breasts at once, which is good for increasing milk production to meet the needs of your two babies. Even if one of your babies isn’t as efficient a feeder as the other, the more efficient twin may help to facilitate a good letdown, thus benefiting the less expert feeder. In this case, though, it’s a good idea to alternate breasts with each feeding, so that your breasts are stimulated as equally as possible. This will make it less likely that one of your breasts will be significantly larger than the other.

However nice and efficient simultaneous feeding sounds, some babies simply nurse better when given their mother’s undivided attention. It will also be easier to know if one baby has an early latch problem if you feed them separately. (Sore, misshapen nipples will be a tip-off that at least one twin is having a latch problem.) If you have sore nipples, I recommend that you feed your babies separately for a while, even though it may seem at first that this will take more of your precious time. You may find that, by feeding them separately, you are better able to teach each baby the best possible latch, which will mean a better letdown of your hindmilk and better-satisfied babies.

Keep in mind that there is no one right way to feed twins. You won’t know what works best for you until you get started. It will help you to figure out if you are meeting both of your babies’ needs if you make a chart to keep track of how many wet and poopy diapers you get from each baby over the first few weeks. It’s a good idea to continue this practice until you are sure that both babies are gaining weight at a good rate. (Hint: Prepare the chart while you are still pregnant.)

If your babies don’t nurse well simultaneously, you might want to devise a system for keeping track of which baby you nursed last during the night. Sometimes a mother of twins may wake so many times during the night that she can’t trust her memory about which one she most recently fed.

Quite a few mothers of twins are happy to own a heavy-duty electric double pump that will allow both breasts to express milk simultaneously. Some of the models that work with maximum efficiency are the Avent Isis IQ Duo, the Ameda Egnell Elite, the Medela Pump In Style, or the Medela Lactina. See Chapter 8 for more details on breast pumps.

Positions for Simultaneous Nursing

You may want to practice these positions with dolls or teddy bears while you are still pregnant. Have plenty of water for yourself within reach.

Double Underarm Hold

Putting both babies in the underarm hold works for many mothers. You may need a pillow or two behind you at the same time that each baby is supported on your twin-sized U-shaped pillow.

Double Cuddle or Cradle Hold

In this hold, both babies are cradled “crisscrossed” to your breasts, with their legs underneath each of your arms.

One Underarm and One Cuddle

One baby is positioned under one of your arms, while the other is cradled to your breast.

Supplemental Feeding

Sometimes supplemental feeding is necessary with twins, particularly immediately after birth. Tamara, a first-time mother of twins, had her babies vaginally at 37.5 weeks’ gestation. Her babies were given formula during the early days because her milk was slow in coming in. Tamara soon learned how much difference a bottle can make during these early days. She wrote:

 Tamara: Not all bottles are equal. Nipples come in a variety of sizes. You want a nipple with a wide base, as latching on to a wide-based nipple is closer to latching on to a breast and helps babies maintain a good latch while your milk supply builds up. Sasha didn’t have jaundice and was better at getting colostrum from me than Cormac was, so for Sasha we used an Avent bottle. Avent bottles are especially designed to help babies maintain a good latch. I do believe the difference in bottles was a factor in Sasha maintaining a good latch and Cormac totally losing interest in breastfeeding by the end of the first week.

  While in the hospital, Tamara was encouraged to pump every few hours and received several consultations from her obstetrician, her labor doula, and others. She wrote:

  Oddly, all this support made me feel like a failure. I could not get more than a few drops of colostrum from the pump—not even a teaspoon after twenty minutes of pumping. I was incredibly sore from the pump and trying to nurse two babies—I even got blisters. I would sit at the pump, crying, thinking of all my friends who had had no problems with breastfeeding and of one of my little babies who so badly needed the breast milk. Things changed quite a bit when we got home from the hospital and were greeted by my postpartum doula. She immediately pointed out that the flanges for my pump were too small, a big factor in the blistered nipples. [Too bad this problem hadn’t been noticed days earlier.] She also advised me to rub the flanges with olive oil, which made a huge difference, and had me cover my breasts with ice packs after each pumping session. More than that, it was her positive attitude that helped. She’d known plenty of women who had to pump for a week or two, and plenty more who had to supplement. She assured me that the tiny drops of colostrum I was able to provide for my babies were doing their job and helped me make an appointment with another lactation consultant.

My postpartum doula also pointed out, on day three after coming home from the hospital, that I had mastitis. I was feeling terrible, had a fever, and my left breast was incredibly sore and hot. I’d assumed this was what I was supposed to feel like. I would have become extremely ill if it weren’t for my postpartum doula. New mothers don’t necessarily know how to diagnose problems like this.

Cormac had a very powerful latch too, but he was hungry and extremely impatient. He wanted his milk! After a few days of trying to nurse, he gave up on nursing and insisted on the bottle. How do you deal with a baby who rejects your breast? Many women throw out the bottle and force them back on. But if your milk isn’t there and your babies are small, you don’t have that luxury. I continued to offer Sasha the breast throughout the day and would offer the breast to Cormac a couple of times each day. He finally took to the breast after a bath. It was his first bath, and I think it took him back to the womb. After that, I noticed he was willing to nurse if it was late at night or early in the morning, when he was in more of a sleep state. At six weeks I finally had a good milk supply. But by then my son would cry and push me away when I offered him the breast—unless it was in the middle of the night.

I’m sure that using a lactation aid would have helped with Cormac, and I did buy one. But I was too tired and overwhelmed with everything (not just breastfeeding) to want to deal with this contraption in addition to everything else. And, to be totally honest, I needed to be able to hand a baby off to a helper so I could have a break. I therefore focused my breastfeeding sessions on Sasha during the day and Cormac at night, when he was more willing. Also, I would always breastfeed first and then supplement with the bottle.

It helped me to learn through online chats with members of a multiples group that my challenges were the norm. They also commended me on my perseverance. Many parents said they quit after a few weeks and felt much happier, as they could then focus on all the other aspects of being good parents. Even those who had successfully breastfed from the get-go were sympathetic and supportive about my need to supplement.

Getting Sleep

One of the hardest parts of being the parent of twins or other multiples during the first year is how much you’ll yearn for more sleep. You’ll want to get your babies to sleep at the same time as each other—so that you can sleep then as well—but getting there will take patience and persistence on your part. There is no one strategy that will work for everyone, and much depends upon the personalities of you and your babies. One way to encourage this sleep pattern is to try putting both babies to sleep in body contact with each other, as many twins have a way of calming when they are in contact. This can be done whether you are co-sleeping or if you put your twins in a crib together. If you find it possible to feed your babies simultaneously, you may want to wake one twin whenever the other wakes so they’ll be on the same eating schedule. Then you can all get some sleep at the same time between feedings. Since most mothers find that feeding twins simultaneously requires sitting up, you’ll want to do what you can to teach your babies to be awake more during the daytime hours than at night. Since newborns are usually on a reversed sleep schedule, you shouldn’t expect them to immediately fall in line with your plan. It’s hard enough to get one baby to do this, let alone two. To change this, you may have to make an extra effort to play with and excite them during the day, keeping the room they’re in well lit. At night, be sure to keep the lights off or dim them as you tend to your babies’ needs.

Babies who once nursed well together may interfere with each other’s nursing when they’re older, by interacting enough to be distracting during a feeding. Some mothers find that everyone gets more rest if the babies sleep on either side of Mom, who turns from side to side to feed each. You’ll probably need a king-sized bed for this, and you might want to put the mattress on the floor. Even though this arrangement will probably mean several wake-ups during the night, you will eventually learn to nap as you nurse the babies. There are also mothers who like to leave the room with the baby they’re feeding so they don’t wake the second baby.

Many mothers find that they have one calm twin and one who is needier. While you may feel compelled to pay more attention to the one who’s needier, don’t forget to give your calm baby plenty of loving attention too. In this situation, it may be a good idea to swaddle the needy twin (or both of them) during the night, making sure that the covers over them (and you) can’t accidentally be pulled over their faces. Swaddled babies can, of course, be placed side by side.

Nursing While Pregnant

One morning, years ago, my seven-month-old son abruptly refused to nurse anymore. He had seemed hungry and eager to nurse, but as soon as he tasted my milk, he pulled away, as if it didn’t taste the way he expected it to taste. I soon realized that the reason for his behavior was that I had become pregnant. Apparently the flavor of my milk had changed in a way that was not palatable to him. Fortunately, he was good at drinking from a cup by that time, and he was able to make a smooth transition to other foods that agreed with him.

Many mothers become pregnant while they are still nursing a baby. For those whose babies don’t wean themselves, as my son did, the question often becomes whether to wean or to continue nursing while pregnant.

In order to make this decision, there are several things you should know:

·   It’s not unusual to experience some nipple soreness when you are nursing while pregnant. This can either be caused by the hormonal changes that come with a new pregnancy or by a diminished milk supply, which may be triggering your baby to suck harder at your breasts to stimulate more output.

·   As long as you are eating well, you needn’t worry that your continued milk production will damage your unborn baby in any way.

·   Don’t worry that uterine contractions, which can be stimulated by nursing, will tip you into premature labor. (However, if you have a tendency to go into premature labor, and you worry about another premature birth, it would probably be a good idea to go ahead with weaning.)

If your new pregnancy turns out to be a difficult one, though, I would advise that you wean. How do you feel when you nurse during early pregnancy? Do you dread a nursing session because you are nauseous or more fatigued than you were before conceiving? Do you feel irritable? Most mammals probably would wean, given such signals from the body. But this is a decision that’s up to you. You may have some strong reasons for wanting to continue nursing your older baby while your new one develops inside. Try not to have too many preconceived ideas, and take it one day at a time.

Tandem Nursing

Let’s say that you’ve decided not to wean your older baby and to go on with what is popularly called “tandem nursing.” When your new baby is born, your milk will switch to colostrum, ready for your new baby’s arrival. From this time forward, your new baby must be given first priority at your breast. You may notice that your older child is affected by the laxative effect of colostrum if she nurses from you during the first two days after her sibling’s birth. Looser, more frequent poop is common in such a case.

If you decide that tandem nursing is the best choice for you and your children, you are the one who is in the best position to decide whether it makes more sense for you to feed them both at once or separately. It’s important for you not to feel bullied by your older child. You may need the support of other family members or friends to deal with any conflict that arises if your older child becomes jealous or wants to nurse whenever the new baby needs to.

You may have talked to many women who loved nursing their older children during pregnancy and beyond and have no regrets about their decision to go on with it. Others continue nursing because it seems the gentlest way to deal with their older child, who was not a self-weaner. Yet others find that the reality for them is less pleasant than they thought it would be. Gradual, gentle weaning may turn out to be the best course in such a situation. Whatever you do, try to be true to your own feelings.