Feeding twins, triplets and more Feeding twins, triplets and more
Contents
1. 1 s amp L J P L i 14 J MS T l E and more A booklet for parents with advice and information Feeding twins triplets and more A booklet for parents with advice and information This booklet 1s a guide only all babies are different and will have indwidual needs and requirements The information contained in this booklet should be used in conjunction with advice from health care professionals such as your health visitor midwife or breastfeeding advisor You may also contact the Multiple Births Foundation on 020 3313 5519 or mbf unpenal nhs uk for more personal advice Written by Jane Denton Director Multiple Births Foundation Maria Quigley Reader in Statistical Epidemiology National Perinatal Epidemiology Unit Biddy Ridley Trustee Multiple Births Foundation First published in 2011 by The Multiple Births Foundation Hammersmith House Level 4 Queen Charlotte s Chelsea Hospital Du Cane Road London W12 OHS Tel 020 3313 3519 Fax 020 8383 3041 Email mbf a imperial nhs uk Website www multiplebirths org uk Registered Charity no 1094546 Limited Company No 4426289 Copyright 2011 Multiple Births Foundation All nights reserved No part of this publication may be reproduced stored in a retrieval system or transmitted in any form or by any means electronic mechanical photocopying recording or otherwise without the prior written permission of the Multiple Births Found2. 3 EXPRESSING BREAST MILK Why might want to express my milk Your babies are sick or premature One of the most common reasons for expressing your milk is because your babies are sick or premature and cannot breastfeed directly Expressing your milk will provide breastmilk for your babies feeds It will also establish and maintain your milk supply so that you will be producing enough milk when they are able to start breastfeeding directly See the next chapter To increase my milk supply Breastmilk 1s produced on a supply and demand basis the more you express the more milk you will produce If your babies only require small amounts of milk you still need to express fully to establish and maintain your milk supply Remember that the best way of establishing or increasing your milk supply is to breastfeed if your babies are able There is no need to use expressing to establish a good milk supply in babies who are able to breastfeed directly breastfeeding will establish a good milk supply When learning to breastfeed When you and your babies are first learning to breastfeed you may find it helpful to hand express a few drops of milk onto your nipple This will encourage the baby to latch on particularly if the baby 1s hungry and gets frustrated when your milk doesn t flow from your nipple immediately To help relieve breastfeeding problems If your breasts feel full and uncomfortable engorged and the bab
3. or demands to be fed first is fed first Then the second baby is gently awakened and fed individually so that the mother has a reasonable interval until the next feed The main drawback to this approach is that the awakened baby may be difficult to arouse and may not feed so well although most babies usually get into this pattern fairly quickly You will probably find it helpful to establish some kind of pattern as soon as possible This may include a specific type of feeding pattern such as modified baby led feeding or other feeding task such as expressing milk after a particular feed or at a certain time or getting help from others such as someone else feeding or occupying one baby whilst you feed the other Preventing and resolving breastfeeding problems Sometimes problems arise with breastfeeding Once again don t hesitate to ask for professional help the quicker you sort out these problems the better for you and your babies Most difficulties can be solved with small adjustments such as a change in the baby s position at the breast Breastfeeding is uncomfortable Make sure that you are sitting or lying comfortably before you start feeding as poor posture can cause backache If you have backache or breastfeeding 1s not comfortable then try feeding in a different position Sore breasts and nipples Sometimes the nipples become cracked or painful Ask for help and advice on how to
4. and eating a good diet It may only take a couple of days for breastfeeding to be established again and for your energy levels to come back to normal To prevent yourself becoming too exhausted make sure that you have some sleep every night and take a daily rest In the first month at least you should aim to have a day time rest or nap for at least a couple of hours every day All sensible offers of help should be taken up so that this can happen Are my babies getting enough milk You can be sure your babies are getting enough milk if They stop feeding when they are full and then settle and sleep between feeds they should be awake and alert for some of the time They have plenty of wet nappies each day most babies have 6 to 8 wet nappies each day They have normal stools breastfed babies start off with meconium which is dark green brown black and sticky passed frequently and then will have frequent yellow stools by day 4 to 5 e They are gaining weight talk to your health visitor about appropriate weight gain Remember that all babies are different and have different feeding patterns It 1s possible for two or more babies with completely different feeding patterns to each be getting the nght amount of milk This often happens with multiples Don t expect your babies to be the same even if they are technically identical It is more important to assess whether each baby is feeding suffic
5. give attention to the older sibling during a feeding time Depending on the age of the child 1t may be possible to involve him or her with the babies care to some extent Indeed some sisters and brothers prove themselves absolutely invaluable Giving 5 minutes of the mother s time now when an older child needs it may be more beneficial than giving them an hour when it is more convenient for you A quick cuddle setting up the favourite toy starting them off doing homework may occupy them sufficiently so that you can look after the babies Feeding time may signal the time for a treat such as being allowed to watch the TV or a DVD Breastfeeding multiples away from home Many mothers have anxieties about breastfeeding in public For mothers of multiples breastfeeding two or more babies in public may be an even more daunting prospect However with good preparation and planning it is perfectly possible to breastfeed twins in public places The box below includes some helpful tips Practical tips for breastfeeding away from home Nursing bras You will need at least 3 or 4 well fitting comfortable nursing bras Clothing You may be worried about revealing parts of your breasts and tummy in public Wear clothes which provide easy and discreet access to the breasts The babies clothes should allow easy nappy changing Separate versus simultaneous feeding Some mothers prefer to breastfeed separately rather than simul
6. in Chapter 2 A manual breast pump this i5 useful for occasional expressing or more regular or long term expressing Suction is created by squeezing a handle Some mothers find this to be quite tiring if they are expressing for a long time Make sure that the pump has the appropriate funnel size for your breasts otherwise expressing may hurt or be less effective An electric or battery breast pump this is useful for occasional expressing or more regular or long term expressing These can do simultaneous pumping of both breasts 1f you wish If your babies are in a neonatal unit you will probably use a hospital grade electric pump Double pumping from both breasts at the same time is quicker than sequential pumping so you may find that a double pump 1s useful for expressing over a long period of me Again make sure that the pump has the appropriate funnel size for your breasts otherwise expressing may hurt or be less effective Electric pumps can be bought or hired from manufacturers or other organisations such as the National Childbirth Trust NCT Staff on the unit should be able to give you this information You should take care to ensure that all expressing equipment is sterilised after each pumping How often to express If you are expressing to establish milk production while your babies are unable to breastfeed directly then the first 2 weeks are really important in establishing the milk supply Your
7. milk production is likely to be increased if feeding and pumping are Initiated early preferably within the first 6 hours after delivery Done regularly approximately the same time each day or night Done frequently every 2 3 hours during the day with a 4 6 hour break at night or an average of 8 times per 24 hours If your milk supply is already established and you are expressing as a longer term feeding strategy then the number of times you need to express will depend on how often you will breastfeed Expressing can be used to supplement breastfeeding For example you may breastfeed one baby directly and then give the other baby ies expressed breastmilk If this is the case it 1s better to breastfeed first and express afterwards How to store expressed breastmilk Take care to sterilise all feeding and expressing equipment see Chapter 7 When you express your breast milk it must be stored in a fridge or freezer Most of its antibodies and nutritional properties are not affected by refrigeration or freezing So expressed breast milk 1s almost as good as direct breastfeeding Expressed breastmilk must be stored under certain conditions For up to 5 days in the main part of a fridge at 4 C or lower For up to 2 weeks in the freezer compartment of a fridge For up to 6 months in a domestic freezer at minus 18 C or lower If you wish to store expressed breastmilk for less than 5 days then the fridge preserves i
8. position your babies correctly Different cushions or pillows may help If you are expressing milk then ask for professional help to check your technique Engorgement This is when the breasts become too full and are hard and painful Placing warm flannels on your breasts before a feed can help or it may help if you express the excess milk see Chapter 3 Mastitis and blocked ducts If you have a hard red painful lump on your breast then this is probably a blocked duct This can be caused by a blockage in the duct and may be solved by checking your babies positioning and attachment Placing warm flannels on the breasts before a feed can help and so can gentle massage You should continue to feed as often as possible from the affected breast Try to massage the lump while you feed If the breast 1s not fully emptied after a feed then express the excess milk but be careful not to over express the breast as your milk supply will increase and this can cause more problems In addition some form of pain killer may help relieve the discomfort ask for professional advice about which one would be most suitable for you You should also check that your bra isn t too tight and try to wear loose clothing If your breasts feel hot and tender you may have an inflammation called mastitis Mastitis can also be a sign of infection so if you feel hot have a temperature and flu like symptoms and if there 1s no improvement with
9. the preparation of formula milk In recent years the recommendations on how to prepare formula milk have changed What is recommended now may be different to what you or friends or relatives did for previous babies Infant formula powders are not sterile Therefore water boiled at a higher temperature than previously thought is required Feeds should now be made just before feeding rather than making up a whole 24 hours worth of feeds The following advice on cleaning and sterilising feeding equipment and preparing formula milk is taken from the Department of Health for England s current guidance which is available at Attp www dh gov uk ens Publicationsandstatistics Publications PublicationsPolicyAndGudance DH 100667 Cleaning and sterilising feeding equipment It 1s very important that all equipment used for feeding and preparing feeds has been thoroughly cleaned and sterilised before use Wash hands thoroughly before cleaning and sterilising feeding equipment Wash feeding and preparation equipment thoroughly in hot soapy water Bottle and teat brushes should be used to scrub inside and outside of bottles and teats to ensure that all the remaining feed is removed After washing feeding equipment rinse it thoroughly under the tap If using a commercial steriliser follow manufacturer s instructions If your bottles are suitable for sterilising by boiling fill a large pan with water and complete
10. you are in any doubt about when to wean your babies or how to do it ask your health visitor for advice In addition you can get excellent information on weaning from the Department of Health for England at hitth www dh gov uk en Publicationsandstatistics Publications Publications PolicyAndGuidance DH_ 4117060 and in Scotland at hitth www healthscotland com uploads documents 8807 FunFkirst 20 FoodsEnglish pdf If your babies were premature your health visitor will be able to give you advice about when to start to introduce solids Information relating specifically to preterm infants 1s available on the Bliss website the charity for premature and sick babies where a booklet can be downloaded http www bliss org uk page asp section 58 4 amp 8 section Title Weaning your premature baby Support Groups Useful Organisations 10 SUPPORT GROUPS AND USEFUL ORGANISATIONS Multiple Births Organisations Multiple Births Foundation MBF Twins and Multiple Births Association Tamba Breastfeeding Support Groups Baby Friendly Initiative UNICEF UK Baby Friendly Initiative Breastfeeding Network Contact details Address Hammersmith House Level 4 Queen Charlotte s amp Chelsea Hospital Du Cane Road London W12 OHS Phone 020 3313 3519 Email mbf imperial nhs uk Website www multiplebirths org uk Address 2 The Willows Gardner Road Guildford Surrey GU1 4PG Phone 0870 770 3305 Email en
11. 70 C Water at 70 C will kill most of the bacteria present in the powdered formula This is the most important step in making up powdered infant formula as powdered infant formula cannot be guaranteed to be free of bacteria Why should made up formula be cooled quickly Bacteria mul ply most quickly between 7 and 63 C The longer formula is at this temperature the greater the increase in the bacterial content and so the risk of infection for the baby will increase Why should storage times of made up formula be minimised Even when formula 1s made up with water at more than 70 C it may still contain some bacteria which will continue to multiply during storage At less than 5 C the rate of multiplication of the bacteria will reduce but will not completely cease How long can made up formula be stored in a fridge Made up formula can be stored for a maximum of 24 hours but this 1s no longer considered ideal particularly for young babies because the bacterial content continues to increase during storage This increases the risk of infection for the baby Once a feed is ready for feeding how long before it should be discarded Discard any feed that has not been used within 2 hours All left over feed should be discarded and never saved for later If you are out and cannot boil water how do you make up a feed Mothers should be advised to fill a vacuum flask with boiling water If the flask 1s full and se
12. It usually takes about 4 to 6 weeks to get breastfeeding fully established though some mothers may manage it sooner Some newborns are easier to feed than others and there may well be a difference between your babies but don t give up on a baby who seems difficult It is usually best to let feeding be baby led on demand in the first few weeks But with more than one baby it s often wise to adapt your approach so that you don t spend your whole time feeding and can get more rest This means that you feed the baby who wakes first and then wake the second one afterwards so that feed times are kept together As your milk supply increases the length of time between feeds should get longer and a pattern or routine which suits you and the babies will emerge Can produce enough milk to feed my babies Mothers can produce enough milk to feed not just twins but even triplets and quads That s because milk is produced according to supply and demand the more you breastfeed or express the more milk you will produce So if you feed your babies as often as they want and for as long as they want to begin with you will produce enough milk for them If your babies are too small or ill to breastfeed and you have to give them expressed breastmilk it 1s still valuable to have direct skin to skin contact with them where possible Not only does this help you bond with them it also stimulates your milk production Some
13. aled the water will stay above 70 C for several hours This flask can be safely transported and used to make up a feed when necessary Do vacuum flasks need to be sterilised if they are used to store boiled water for making up a feed later No the vacuum flasks do not need to be sterilised but they should be washed thoroughly and rinsed with boiling water before being filled with boiling water intended for the feed The boiling water should kill bacteria present in the vacuum flask If water is boiled and put into the sterilised feeding bottles can it be stored in the fridge like this until the powder is added No the water must be above 70 C when the powder is added otherwise the bacteria in the powder will not be killed Going back to work 8 GOING BACK TO WORK If you want to return to work and carry on breastfeeding you can do it but it needs careful planning Here are some helpful tips Keep supplies of expressed breastmilk in the freezer Before going back to work you can build up supplies which can be fed to your babies during the day while you re at work This store of breastmilk could be from when you had too much milk or from choosing to express so that you could feel confident you were still giving your babies the best when you returned to work Prepare your babies It s a good idea to introduce the occasional bottle in plenty of time before you go back to work so that the babies get used to fe
14. always using the scoop provided with the powdered formula by the manufacturer Adding more or less powder than instructed could make the baby ill Re assemble the bottle following manufacturer s instructions e Shake the bottle well to mix the contents Cool quickly to feeding temperature by holding under a running tap or placing in a container of cold water Check the temperature by shaking a few drops onto the inside of your wrist it should feel lukewarm not hot Discard any feed that has not been used within two hours The following Questions and Answers are also copied from the Department of Health s guidance and may help to answer your questions Question and Answers What is the safest option for feeding babies Breastmilk 1s the safest way to feed a baby Ready to use liquid feeds are sterile until opened and are the safest option if using infant formula Powdered infant formula 1s not sterile and should be made using water that is hotter than 70 C Continued overleaf gt Why is powdered infant formula not sterile The bacterium enterobacter sakazaku 1s ubiquitous in the environment and may contaminate powdered infant formula during manufacture It 1s impossible to be sure of avoiding this contamination Bacteria may also be present on work surfaces in homes and nurseries and can contaminate feeds while they are being prepared by parents Or Carers Why should the water be
15. anisation than feeding one it should be just as enjoyable and fulfilling It can be a family event too Mothers of newborn babies often feel very isolated and their partners can feel shut out at a time when they want to get involved With twins or more there s no risk of that Your partner can be of real help especially during the night and so could your mother or sister or a close friend This booklet aims to set your mind at rest It should help to answer the many questions you may have before the birth as well as serving as a practical guide once your babies are born Our aim is for you to feel confident about feeding and caring for your babies in whatever way you choose so that you can enjoy them to the full Remember whatever your worries or problems the professionals nurses midwives health visitors breastfeeding counsellors and advisors are there to help you Don t hesitate to ask You may also contact the Multiple Births Foundation on 020 3313 3519 or mbf imperial nhs uk Feeding options 1 WHAT ARE THE OPTIONS Breastfeeding Breastmilk 1s best for babies and that includes multiples Not only does breastfeeding provide all the nutrients your babies need it also contains antibodies from you which help them fight infections Colostrum produced by the breasts during pregnancy and the first days after the babies are born 1s thicker and richer than breastmilk and especially valuable to new born babies It co
16. ation Images by Gaby Jeffs www magnetofilms com Available from The Multiple Births Foundation ISBN 978 1 902068 17 6 Contents I troducton to this DOG NC costars dans atontcsuennanetgaieenino ie Mastaeptauldu rivo npa Foren eur isasi 4 The OIHOFOHETOOCHDS OTS essiensa bacc ivto eo mese e Pan bn nas gus pen pos 5 Picas OCIS i T E e Eo Eu et epled nuPE 6 Bey FC ASI Ate oaceae eune ra AE eTe raana 15 Feeding sick or premature D3DIGS o eacaveninescinmoriargosnnen nda rines arbi tiber d nsu dnas 18 Feedin tople o and guad essasi Seo bivio eda btont dong ariana 24 Torra a a a 22 Sterilisation and preparation of feeding equipment eee 24 and formula milk Goin pae kto Sueno eRe ER er Rien MIRI NOR tM eMe iit MEE 27 rodi ne Sod TOO S oaa intt un Ii Pato INE RUND SUI M MEME 20 Support groups and useful organisations eeesseecceceeeeeeeeseneeeeeeeeeeeeeeeeneeeeeeeeees 30 Introduction How on earth am going to feed more than one baby This 1s probably one of the thoughts uppermost in your mind as you await the birth of twins triplets or more You re quite right to think about 1t and to start gathering information and advice to help you plan ahead Not only are the nutritional aspects important there are also practical implications However you needn t be anxious about this While it s obviously true that feeding two or more babies takes more time and org
17. ays for instance to pass the second baby to you when you are feeding both at once or to look after the other baby ies when they are fed separately Both in hospital and once you are back home don t forget to ask for professional help As well as hospital and community staff you may also find the organisations E listed in Chapter 10 helpful Some suggested positions for simultaneous breastfeeding several commonly used positions are shown on the facing page Remember there are no rules on how to do this Try different positions and do whatever is comfortable for you and your babies You may find that one position works really well to begin with but you find another position works better a few weeks later for example as the babies grow or when your tummy stops feeling tender Again ask a midwife health visitor or a breastfeeding counsellor to help you try these positions Try to involve your partner or any family support you have so that they can help when there are no health professionals around See pictures on facing page Same side or swap sides In general it s better to alternate breasts when feeding multiples as each breast may have a different milk production and storage capacity This ensures each breast receives equal stimulation from all babies It also allows additional healing time if your nipples become sore If your babies have very different birth weights or growth patterns then the
18. ding techniques and sterilisation of feeding equipment in Chapter 5 Some mothers opt for formula feeding from the word go but others start to consider it because they have difficulties with breastfeeding or expressing milk If you are having difficulties but would prefer to continue breastfeeding read the next chapter before you give up 1t might be possible to solve your problems If you definitely want to stop discuss it with your midwife health visitor breastfeeding counsellor or advisor They can advise you about stopping gradually so that you don t get a problem such as blocked ducts Of course there is a third option used by many parents of multiples at some stage Mixed feeding This is when you feed your babies using different combinations of breastfeeding expressed milk and formula milk This allows the advantages of breastmilk to be combined with the advantages of others being able to help with feeding Breastfeeding 2 BREASTFEEDING It is perfectly possible to breastfeed twins triplets and even quads There are many different ways to do it In this chapter we answer some of your questions How do get started Breastfeeding 1s a skill that needs to be learnt Most mothers even if they ve only got one baby need support and advice from professionals to help them get going As the mother of twins or more you should be offered extra help both in hospital and once you are back at home
19. e fed formula milk Donor breast milk is also easier for them to digest than formula milk How will my babies be fed Babies who are sick or born prematurely may have special nutritional needs In some babies milk feeding may have to be delayed for a short period after they are born and the babies may receive only total parenteral nutrition IPN through an intravenous infusion drip Once milk feeding starts 1t may be done through a thin tube that either goes via the nose nasogastric or mouth orogastric into the stomach Ideally this milk will be the mother s expressed breast milk although if this is not available then donor breastmilk or formula may be used Sometimes expressed breast milk is fortified with protein energy vitamins and minerals to help promote growth in the preterm baby Helpful information The following booklet gives information about feeding premature babies It describes the special feeding situations for sick and premature babies including skin to skin contact how to express your milk how to breastfeed and how to continue feeding after discharge from hospital The booklet is called Jones E Spencer A Breastfeeding your premature baby Bliss the premature baby charity 6th Edition 2009 It may be downloaded free of charge from the Bliss website www bliss org uk The Bliss booklet provides much of the information you need about feeding premature babies But there are some extra points to conside
20. ed attention from both parents Two issues you should bear in mind are Making up formula feeds fresh for each feed as currently recommended by the Department of Health rather than several hours in advance may require careful co ordination and help from somebody else If your babies are being fed at the same time particularly triplets and quads the bottles cups etc should be clearly labelled for each baby This enables the mother to keep a record of how much each baby takes Type of formula milk If your babies are in special care and donor breast milk is not available and maternal breast milk 1s not available in sufficient quantities then your babies will be given formula milk There are a range of formulas available to meet the special needs of sick and premature babies The hospital staff will advise you about these If your babies are not sick or premature then standard formula milk will be appropriate Simultaneous versus separate formula feeding If you have help it 1s generally recommended that your babies are fed separately so as to maximise the interaction with the carer If both all your babies wake together it is possible to feed two babies at once using one of the following positions Older babies may be positioned in an infant seat and you can sit near both of them holding a bottle in each hand You can prop one baby in an infant seat or support pillow and hold one baby in your lap aga
21. eding from a bottle Make sure replacement feeders are fully informed Carer s who are feeding the babies your milk need to know the rules for storing expressed breastmilk or making up formula and sterilisation They also need to know of any issues specific to feeding multiples twins may have their own labelled bottles and may have different feeding patterns Expressing at work If you want to express at work your employer must find a suitable room and allow you sufficient time to do it Your employer should be aware that expressing for multiples will probably take longer and require more equipment bottles storage space than for singletons Breastfeeding before and after work Many working mothers breastfeed directly before going to work in the morning and in the evening on their return although other patterns suit other working mothers for instance some mothers may work night shifts Your health visitor or breastfeeding counsellor can give advice about this This needs careful timing you will need to allow enough time to feed the babies and get them yourself and any older children ready for the day before going to work Introducing solid foods weaning 9 INTRODUCING SOLID FOODS WEANING Weaning is the word used to describe the introduction of foods other than milk into a baby s diet Most people refer to it as introducing solids When should it start TA At around six months both breastfed and
22. em in a shorter tme such as at night If you think you might want to feed them together at some stage it s a good idea to try it when a midwife nurse or breastfeeding counsellor is around to help you try different positions and provide an extra pair of hands Should sit or lie for breastfeeding And how do support my back Most mothers of multiples find it easiest to sit in a chair at least during the day Identify a comfortable chair and put the phone a drink and something to eat within easy reach you may be sitting there for some time Try using pillows and cushions You may need extra pillows to support your back when you start breastfeeding It 1s also helpful to position pillows on your knees to take the weight of the babies Some mothers find a V or U shaped special feeding cushion helpful while others prefer to use additional ordinary pillows The pillows should support the babies allowing you to move your hands freely Take care not to make them too high as the baby may not be able to attach correctly to the breast You may find it easier to feed your baby es when lying down particularly if you are feeling tired ill or have had a caesarean section Some mothers prefer to feed lying down so that they can for instance feed one baby while cuddling the other Even when you are confident that your babies are breastfeeding happily you may still need someone to help you at least in the early d
23. er or at the same time Ask the midwives or nurses how to do this Skin to skin contact may also be done with fathers and other family members but that obviously doesn t produce the breastfeeding related advantages Express or breastfeed often This will establish a good milk supply and enable you to have enough milk to breastfeed your babies If you are very worried about your babies it can affect your milk production It is important to ask for help Your partner family and friends can be very supportive at this difficult time It may help to talk through your feelings with them They may also provide practical support such as helping organise the home for the babies arrival or help look after siblings or with domestic duties The midwives and nurses can help you with skin to skin contact expressing breastfeeding and anything else in the hospital There are many support groups and other organisations who may be able to advise on feeding and other aspects of caring for your babies These are listed at the end of the booklet Deciding which baby gets your milk If there isn t enough of your expressed breast milk to feed all of your babies the staff on the neonatal unit will help you decide which baby receives it e g the sickest or whether it should be given to a different baby at each feed A step by step process towards direct breastfeeding For sick and premature babies there is often a gradual stead
24. formula fed babies will be ready for solids to be introduced to their diet It s better to rely on your judgement rather than a rigid age rule to determine if your babies are ready to start solid foods There are a number of cues that show babies are ready for weaning and we list them in the box below They are not essential indicators and they should not be considered as cues if they occur before 4 months 17 weeks of age in full term babies or 5 months 21 weeks in babies born prematurely Signs that your babies are ready for solids Remember assess each baby separately When the baby can sit up e When the baby wants to chew and is putting toys and other objects in his her mouth When the baby reaches and grabs accurately Taken from the Department of Health information leaflet Weaning How to introduce solids The literal definition of the term weaning is to accustom to When it is used to refer to the process of transferring from an all milk diet to a mixed diet it suggests a gradual process not all milk today none tomorrow In general parents may find the period of weaning quite stressful as they are responsible not just for the amount of nutrition their infant receives but also for the balance of foods Although nutrition is a science feeding should be a pleasurable experience for all parties so you should apply a relaxed interpretation of the available evidence As ever use your common sense If
25. iently and growing adequately rather than to assess how s he 1s feeding and growing compared with his her sibling If you are unsure as to whether your babies are getting enough milk or you have any concerns about their growth then you should talk to your health visitor Feeding multiples when there are older siblings around The birth of even one new baby may cause sibling rivalry They are no longer the sole focus of their mother s attention as they suddenly find themselves having to compete with two or more other little people whose care seems to take up every moment of the day In order to gain attention they may well resort to behaving badly at the most inconvenient moments such as feeding times The box on the facing page includes some helpful tips for feeding multiples when there are older siblings around Practical tips for feeding multiples when there are older siblings around A breastfeeding mother with an older child may find it more convenient to feed her babies separately as she will still have a free arm for another child e g to read a story or reach out to the child Breastfeeding can be made into a positive time for other siblings e g 1t might signal story time when a young sibling can crawl up beside the mother and have a story Fathers and other carers can help occupy the older child while the mother concentrates on feeding It may be helpful occasionally to invite a visitor specifically to
26. ies are having trouble attaching then 1t might help to express a little milk before attempting to breastfeed The milk should flow a bit easier then and the babies may find it easier to attach to a softer breast Expressing can also help relieve a blocked duct or mastitis see Chapter 2 To allow other people to feed the babies You may want to express milk so that someone else can feed your babies This may be something you do occasionally for example when you will be away from your babies for a few hours orlonger It may be something that you do regularly for example if you are returning to work As a long term feeding strategy Some mothers choose to exclusively feed their babies expressed breast milk rather than to breastfeed Sometimes mothers choose to feed their babies expressed breast milk in combination with breast and or formula feedings This 1s particularly common in multiples especially higher order multiples so that other people can help with feeding How to express There are several different ways to express your breastmilk and mothers often have their own preference Hand expression this is useful for expressing small amounts of milk from the breast for example before the milk comes in when the babies are on the neonatal unit NNU and you need to collect the colostrum when encouraging your baby to latch on or for reheving uncomfortable breasts see Engorgement and Blocked ducts
27. in 12 24 hours you should get advice from a healthcare professional Breastfeeding after a caesarean section If your babies were delivered by caesarean then you may not be very mobile to begin with and will possibly need help picking up the babies and positioning them at feed times Your tummy will feel sore and painful for the first few days It 1s advisable to feed the babies separately using the underarm method which avoids the babies lying on your tummy If you are breastfeeding your babies together you will find the double underarm hold see page 9 helpful If you are exhausted or breastfeeding takes too long It 1s vital for mothers of multiples to get plenty of rest especially during the early days This 1s particularly important if you are breastfeeding a well rested mother is more able to cope with the demands of establishing breastfeeding in multiples If the babies are not satisfied at each feed they will require more frequent feeds This can become a vicious cycle as the mother has even less time to rest and becomes even more exhausted Family members may pressure you to introduce a bottle at this point so that you can get some sleep If you are keen to continue with breastfeeding then it 1s not advisable to do this since less breastfeeding would further reduce your milk supply A better strategy would be to concentrate on only feeding the babies as often as they require then resting between feeds
28. in holding a bottle in each hand Bottle propping should be avoided and a baby should never be left alone with a bottle Hands free feeding systems should not be used The tubes are narrow and hard to clean properly It is important that you or the person doing the feeding holds the bottle If the babies are left alone to feed themselves they could choke Different people helping with feeding If more than one person is involved in feeding the babies it is generally recommended that babies are rotated between these people so that there 1s interaction and stimulation between each baby adult pair Exhaustion Feeding multiples is a time consuming experience whether the babies are breastfed or formula fed The mother particularly will need help and support One way is to let someone else help with feeding or preparation of formula The father or anyone else may be able to help with night time feeding For example it is possible for both mother and father to have periods of uninterrupted sleep e g the mother can feed both all babies at the first night time feed while the father sleeps and then the father can handle the second night time feed by himself Preparation of Feeding Equipment 7 STERILISATION AND PREPARATION OF FEEDING EQUIPMENT Introduction This chapter covers the sterilisation and preparation of all feeding equipment including bottles teats cups and breast pumps It also includes
29. ly submerge all feeding equipment ensuring there are no air bubbles trapped cover the pan and boil for at least 10 minutes making sure the pan does not boil dry Keep the pan covered until equipment is needed Wash hands thoroughly and clean the surface around the steriliser before removing equipment It is best to remove the bottles just before they are used If the bottles are not being used immediately they should be fully assembled with the teat and lid in place to prevent the inside of the sterilised bottle and the inside and outside of the teat from being contaminated Guidance for Preparing Feeds in the Home Preparing a feed using powdered infant formula Important Normally each bottle should be made up fresh for each feed Storing made up formula milk may increase the chance of a baby becoming ill and should be avoided Clean the surface thoroughly on which to prepare the feed Wash hands with soap and water and then dry Boil fresh tap water in a kettle Alternatively bottled water that is suitable for infants can be used for making up feeds and should be boiled in the same way as tap water Important Allow the boiled water to cool to no less than 70 C This means in practce using water that has been left covered for less than 30 minutes after boiling Pour the amount of boiled water required into the sterilised bottle Add the exact amount of formula as instructed on the label
30. ntains proteins and antibodies from the mother which increase the babies own resistance to illness Many twins and triplets are premature Breastmilk 1s particularly good for them because it is more easily digested and tolerated than formula milk and helps the underdeveloped gut to mature But these babies may not be able to breastfeed at first so you may need to express your milk and have it fed to your baby ies through a fine tube which goes into their tummy or by a bottle or cup We give you more information about expressing milk in Chapter 3 and about feeding sick or premature babies in Chapter 4 Giving your babies some breastmilk each day even for a short time is better than no breastmilk at all The next chapter of this booklet will describe the many ways of breastfeeding twins and how the supply of milk always a worry for prospective mothers of more than one baby actually increases in response to demand Breastfeeding your babies for at least six months is recommended However there 1s no need to feel guilty or inadequate if you can t or don t want to do it For a variety of personal physical or medical reasons some parents of twins triplets and quads opt for Formula feeding You might choose formula milk because you wish to share the task of feeding with others If both parents are involved for instance each baby will receive undivided attention We deal with formula feeding preparation of milk fee
31. or you or your partner to write down details of every feed at least in the early days e g which baby was breastfed and on which side for how long or how much expressed milk or formula was given If you are using bottles you may also want to colour code them This will enable you and the health professionals advising you to make sure that all of the babies are being fed adequately and ensure that the feeding methods for the babies are rotated where appropriate e g breastfed for one feed and bottle fed for the next Parents may find this particularly useful for the night feeds when both parents are exhausted and it s easy to forget who got what Storage Remember for babies receiving expressed breastmilk or formula in bottles a lot of bottles and fridge space will be required Formula Feeding 6 FORMULA FEEDING i Introduction This chapter refers to formula feeding The preparation of formula milk and the sterilisation of feeding equipment are covered in Chapter 7 and should be read first If you are combining breastfeeding and formula feeding you should read the earlier sections on breastfeeding and expressing breast milk too You may choose to feed your babies formula milk for a variety of personal physical or medical reasons You might be choosing formula milk because you wish to share the task of feeding with others If both parents are involved with feeding then each baby will receive undivid
32. p a rota of who is available to help and when before the babies are born Breastfeeding triplets there are many ways to breastfeed triplets depending on what suits the mother and the babies For example mothers can breastfeed one after another breastfeed two together and then one on their own or breastfeed two and give expressed milk or formula to the third Breastfeeding quads again there are many ways to feed quads depending on what suits you and the babies One approach is to feed them approximately every 4 hours 1 e two together every two hours The babies will need more milk during growth spurts and this will be a tiring time for you while your milk supply adjusts especially if all the babies have growth spurts together However this will settle down after a couple of days Expressed breastmilk Some women find that they prefer to breastfeed two babies while someone else can give expressed breastmilk or formula to the other baby ies Formula feeding The formula used will depend on whether the babies are born prematurely and if so whether they are in hospital or at home see Chapter 6 the hospital will advise you Combinations Mothers of triplets and quads who want to breastfeed may choose to use a combination of breast and formula milk When considering different feeding options for triplets and quads remember to take the following into account Records and diaries t might be useful f
33. quiries tamba org uk Website www tamba org uk Tamba Twinline Helpline 0800 138 0509 10am 1pm 7pm 10pm every day Contact details Address PO Box 207 Bridgewater TA6 7YT Phone Helpline 08444 122 949 open 9 30am 10 30pm every day Email counselling abm me uk Website www abm me uk Address 30a Great Sutton Street London ECIV 0DU Phone 020 7375 6052 Email bh Qunicef org uk Website www babyfriendly org uk Address PO Box 11126 Paisley PA2 8YB Phone General 0844 412 4664 Phone Helpline 0300 100 0210 Email email breastfeedingnetwork org uk Website www breastfeedingnetwork org uk La Leche League Great Britain National Breastfeeding Helpline National Childbirth Trust NCT United Kingdom Association for Milk Banking UKAMB Other Useful Organisations Bliss The special care baby charity Homestart UK Address PO Box 29 West Bridgford Nottingham NG2 7NP Phone General 0845 456 1855 Phone Helpline 0845 120 2918 Website www laleche orguk Phone Helpline 0844 20 909 20 Website www breastfeeding nhs uk The National Breastfeeding Helpline is a helpline run in collaboration with the Breastfeeding Network BEN and the Association of Breastfeeding Mothers ABM Address Alexandra House Oldham Terrace London W3 6NH Phone General 0300 3300770 Phone Helpline 0300 330 0771 8am 10 pm 7 days per week Email enquiries nct org uk Website www nct org uk Addre
34. r when you have more than one sick or premature baby First if you have more than one baby in the neonatal unit NNU then it is likely to be even more stressful for you as parents Second your babies may be at different stages of establishing feeding or have different complications or illnesses For example it is not unusual for multiples to have very different birth weights Your babies may even be in different places for example one may be in the neonatal unit and one on the ward or at home with you In fact you may have two three or four very different babies and their feeding pattern or ability to breastfeed may be very different too Try to think of them as individuals rather than comparing them with each other The practical advice on the following page may be helpful Look after yourself Iry to eat healthy and regular meals drink plenty of fluids and rest whenever you get the chance Try to spend as much time as possible with each of the babies especially if one is in a neonatal unit and one on the ward with you Try having skin to skin contact with your babies This may also be called kangaroo care and involves direct skin to skin contact with the baby lying on the mother s chest It can be done with all babies including those who are sick or premature It will help facilitate milk production and help stop your babies crying Skin to skin contact with multiples may be done separately one after the oth
35. ry Some mothers prefer simultaneous feeding because It saves time and gives you more time to rest especially at night when you want to get back to sleep If one of your babies has a stronger suck than the other that baby will stimulate the let down reflex which means that the other baby gets more milk with little effort If your babies are good at latching on and suckling it 1s relatively easy Babies may respond positively to their brother or sister feeding at the same time as they are not distracted by them doing something else Some mothers prefer separate feeding because It allows you to give one to one attention to each baby something mothers of twins often feel they have very little time for It 1s generally easier since you have both hands free to attach and position the baby and once attached you have a spare hand to rock the other baby cuddle another child hold a drink or phone etc e Some women feel more comfortable and less conspicuous feeding one baby rather than two especially in public places Every baby feeds differently and you will learn the best position for each of your babies What you do may change over time You might start off one way and then change to the other as the babies get bigger or you have more or less help Or you may feed them together in particular circumstances such as when two babies are crying at the same time or you want to feed th
36. ss The Milk Bank Queen Charlotte s amp Chelsea Hospital Du Cane Road London W12 OHS Phone 020 8383 3559 Email info ukamb org Website www ukamb org Contact details Address 9 Holyrood Street London Bridge London SE 2EL Phone 020 7 378 1122 Phone Helpline 0500 618 140 Helpline hours are 9am 9pm Email enquiries a bliss org uk Website www bliss org uk Address 2 Salisbury Road Leicester LE 7OR Phone 0800 068 6368 Email info home start org uk Website www home start org uk Feeding Twins Triplets and More A booklet for parents with advice and information THE MULTIPLE BIRTHS FOUNDATION MBI X www multiplebrrths org uk Registered Charity no 1094546
37. taneously while out and about because it is more discreet And it might be difficult to attach and position the babies for simultaneous feeding in a public place without your usual chair cushion helpers etc Breastfeeding friendly places Make a list of all the local places where breastfeeding 1s easy e g a particular caf or infant toddler group or a friend s house There are breastfeeding rooms in some supermarkets department stores etc Iry to plan trips out so that you are within easy reach of such places Going alone Try to have someone with you until are confident about breastfeeding in a public place When and how should I stop The ideal is to breastfeed for at least six months But if you want to stop earlier for instance because you are going back to work or you have simply had enough talk it over with a professional such as your health visitor or breastfeeding counsellor Don t worry she won t make you feel guilty Remember any breastfeeding is better than none But she will be able to help you avoid problems such as a blocked duct or mastitis that might arise if you stop too suddenly In general once you have established a good milk supply you need to reduce breastfeeding gradually When the babies are less than six months old the usual practice is to change one breastfeed for a formula feed per day and to allow the breasts to fully adjust before dropping another breastfeed Expressing breastmilk
38. times a mother s milk supply is temporarily reduced This may be because of a complication at delivery or more often because of exhaustion stress or anxiety If that happens don t hesitate to ask other people for help so that you can concentrate on feeding and resting it might just be for a couple of days until your milk supply is established again One way a partner or friend can help is to cook and do housework for you it s important to have a good diet of regular meals and to drink plenty of fluids This will help you feel less tired and enable you to cope better with any stress or worries A reduction in milk supply may also occur if you are not breastfeeding or expressing frequently enough If your breasts still feel full after feeding your babies then express any excess milk and ask for professional help to check the baby s position at the breast when feeding Should feed them together or separately Mothers of twins have the option of feeding their babies simultaneously with one baby attached to each breast at the same time or separately Some mothers prefer feeding them together while others prefer to feed one after the other Some mothers start off one way and change to the other For the first few days 1t 1s usually advisable to feed one baby at a time at the breast until you are confident about your feeding technique This is especially true if they are your first babies After that opinions va
39. ts properties more effectively than freezing Frozen breastmilk should be thawed in a fridge or using lukewarm water Once thawed use within 24 hours and never re freeze Store expressed breastmilk in labelled bottles Care should be taken to sterilise all feeding and expressing equipment see Chapter 7 Feeding sick or premature babies 4 FEEDING SICK OR PREMATURE BABIES Introduction About half of all twins and most sets of triplets and quads are born prematurely Some are born just a few weeks early but others may be born very prematurely It is not uncommon for babies from multiple pregnancies to be admitted to a neonatal unit This can be a particularly stressful time for parents Some babies will be too premature or sick to breastfeed directly but it is still possible to give them expressed breast milk It is particularly important that these premature or sick babies receive breast milk rather than formula as it 1s more easily digested by their immature gut and can help to protect them from infections and other illnesses If you are unable to express enough breast milk then your babies may be offered donor breast milk This is breast milk which has been donated by a healthy mother who has been screened for various infections and her milk pasteurised Premature babies who are fed donor breast milk are less likely to get NEC necrotising enterocolitis a serious disease of the immature bowel than those babies who ar
40. y are unlikely to have similar breastfeeding patterns and techniques You and your babies will find the feeding pattern that works for you It would only be necessary to change this if you have a problem or any of your babies are not growing well Double underarm hold Double cradle or criss cross hold Cradle hold V shaped hold Baby led demand feeding and other feeding patterns To establish a good milk supply breast stimulation needs to be frequent Therefore breastfeeding needs to be unrestricted and or expression needs to be frequent This is particularly important in the early days You should generally feed a baby when he or she shows readiness for a feed This is called baby led feeding although many mothers still refer to it as feeding on demand Typical feeding cues are a baby beginning to stir or making mouthing and licking movements It helps to look out for these feeding cues and start feeding before your baby gets upset However if your baby has slept for a very long time in the early days or if your breasts are engorged it is a good idea to wake your baby and encourage feeding In the first days after birth you may find it easier to feed your babies separately according to each baby s feeding cues in other words for feeding to be completely baby led But many mothers of multiples find it easier to use a modified baby led approach Here whichever baby wakens
41. y progress towards direct breastfeeding There are several techniques for doing this depending on the needs of your babies and the methods that are preferred in the hospital For example 1t may include using cups and or bottles for feeding The midwives and nurses will help you with this Your babies may start breastfeeding at different times If only one of your babies can breastfeed then that baby can be fed on one or both sides after which both breasts can be pumped to provide milk for the other baby es Discharge planning The midwives or nurses on the neonatal unit will help you work out a good feeding routine that suits you and your babies before their discharge so you can gradually get your babies into this routine before you go home By the time your babies are ready for discharge you should feel confident with your feeding plan If one baby is ready to go home before the other s then this will be incorporated into your feeding plan 5 FEEDING TRIPLETS AND QUADS Feeding Triplets and Quads Much of what has been written in the previous and coming chapters applies to triplets and quads This chapter summarises some of the key issues in feeding higher order multiples together with some practical advice Breastfeeding You will need help with night feeds and also with housework cooking shopping etc so that you can put all your available time and energy into feeding It is a good idea to draw u
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