Breastfeeding Twins Or More!
Multiple pregnancies make up about 1.5 per cent of births in Australia, with about 4300 sets of twins and just over 80 sets of triplets and higher order multiples born each year.
For many years I facilitated breastfeeding classes for parents expecting more than one baby. A comment I heard repeatedly was they had already been told that breastfeeding might be possible but they should be prepared to formula feed instead. Before their babies were even born, those in their support network of family, friends and health care providers were already attempting to let them down gently.
Yet time after time, I would hear the stories of participants overcoming challenges common to multiple births: childbirth interventions, prematurity and the practicalities of establishing breastfeeding with two or three infants. I even met a couple of families who had multiple multiple births - coming back to share their experience of breastfeeding thir second set or twins while the first set were toddlers!
So here I have gathered some of the resources those families found useful and others I have found since then. Also, links to articles on this site relevant to every breastfed baby, even if they have a sibling at the breast as well.
Breastfeeding Twins And Triplets
This unique video shares the stories of six families and their experiences having twins or triplets. You can watch the documetary in full online here at no cost.
The biggest barrier to establishing breastfeeding multiples is their likely prematurity. It cannot be stressed enough: don’t presume you have forty weeks to learn about breastfeeding - book into breastfeeding classes as soon as you get the happy news! The more babies in your womb, the earlier they will be born. I had parents-to-be book class dates seemingly well-before their due dates, only to find themselves coming along during a brief respite from being with their babies in NICU! So if you are currently pregnant with twins or more, even if you haven’t yet made the announcement, head over to the Australian Breastfeeding Association and book one of their online Multiples Breastfeeding Preparation Session. Depending on your location, you might be able to access a face-to-face breastfeeding education classes for mothers expecting multiples but, if not, do attend the standard face-to-face classes available in your local community. If time permits, I recommend doing both the online class AND a face-to-face class.
Recommended reading from the Australian Breastfeeding Association:
Breastfeeding: twins, triplets and more is based on the latest research and the experiences of mothers who have breastfed more than one baby of the same age. It covers many of the breastfeeding challenges that mothers of twins and multiples may face.
Breastfeeding: your premature baby outlines the unique challenges of having a premature baby and how to manage breastfeeding in the early weeks.
Breastfeeding: caesarean births and epidurals covers events that may happen during labour and birth and how they can affect breastfeeding.
Twins are now predominantly delivered by planned caesarean section and you will need to be very proactive if you hope to have a vaginal delivery. I is best to be mentally and practically prepared for the eventuality in any case.
Caesarean Birth
The rate of twins born by caesarean delivery in Victoria, Australia almost tripled in three decades, from less than a quarter of all twin births in 1983 to 71 per cent in 2015.
There have been calls to reduce the number of caesarean deliveries in countries with high rates, including Australia, where more than one third of women now give birth via C-section — a rate double what the World Health Organisation estimates is medically necessary.
Over half of mothers had no labour, and this proportion has increased over time (49% in 2010 compared with 59% in 2020). Mothers of multiples therefore had a high rate of caesarean sections (75%).
If you are having a planned caesarean birth, speak to your care team about skin-to-skin options for your babies these might be:
skin-to-skin with the birth mother immediately after delivery for one or all babies
skin-to-to-skin with the the non-birthing parent/support person immediately after delivery for one or all babies
skin-to-skin with the birth mother as soon as they and/or their babies are stable
At this hospital, it was the first time skin to skin had been done by dad in the Operating Room with twins. Photo by Jennifer Mason Photography.
Breastfeeding Premature Babies and Babies Needing Special or Intensive Care
Worldwide, an estimated 15 million babies are born preterm each year. In 2015, preterm birth was responsible for nearly 1 million deaths – World Health Organization.
More than 26,000 Australian babies are born preterm each year.
Preterm birth is defined as birth before 37 completed weeks of pregnancy (and after 20 weeks)
Overall, twin pregnancies are much more likely to be complicated by preterm birth (>50%) than single ones and for the babies to be of low birth weight. This risk is increased even more in higher order multiple pregnancies, such that virtually all triplet pregnancies are born preterm (average 32-34 weeks gestation).
One in five (20.0%) babies required some form of resuscitation at birth. Almost half (43%) of those requiring resuscitation received suction or oxygen therapy, and almost 2 in 5 (38%) received ventilatory assistance by intermittent positive pressure ventilation (IPPV) through a bag and mask or via endotracheal intubation.
If you give birth prematurely, your milk will be slightly different from milk at term. This is because your baby’s needs are different from those of a baby born at term. Because premature babies need more proteins for growth than term babies, your colostrum will have more protein than the colostrum of term birthing mothers. Your breastmilk will also have more of an enzyme called lysozyme. Lysozyme attacks certain bacteria and helps protect your baby from infections. And your breastmilk will have more fat and less lactose, because premature babies find lactose hard to digest.
Kangaroo Care and Skin-to-Skin Contact
Research has shown that Kangaroo Mother Care (KMC) of pre-term babies increases he rate of exclusive breastfeeding. The optimal model of Continuous KMC is not practiced in Australia however in many lower-income countries premature babies are cared for this way routinely. However, higher-income countries like Sweden have recognised the approach has benefits beyond cost-savings. Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care (2010) stated:
KMC enhances bonding and attachment; reduces maternal postpartum depression symptoms; enhances infant physiologic stability and reduces pain, increases parental sensitivity to infant cues; contributes to the establishment and longer duration of breastfeeding and has positive effects on infant development and infant/parent interaction. Therefore, intrapartum and postnatal care in all types of settings should adhere to a paradigm of nonseparation of infants and their mothers/families. Preterm/low-birth-weight infants should be regarded as extero-gestational foetuses needing skin-to-skin contact to promote maturation.
Conclusion: Kangaroo Mother Care should begin as soon as possible after birth, be applied as continuous skin-to-skin contact to the extent that this is possible and appropriate and continue for as long as appropriate.
Nyqvist KH, Anderson GC, Bergman N, Cattaneo A, Charpak N, Davanzo R, Ewald U, Ibe O, Ludington-Hoe S, Mendoza S, Pallás-Allonso C, Ruiz Peláez JG, Sizun J, Widström AM. Towards universal Kangaroo Mother Care: recommendations and report from the First European conference and Seventh International Workshop on Kangaroo Mother Care. Acta Paediatr. 2010 Jun;99(6):820-6. doi: 10.1111/j.1651-2227.2010.01787.x. Epub 2010 Mar 6. PMID: 20219044.
Even though Neonatal Intensive Care Units in Australia are not set up to facilitate Continuous Kangaroo Mother Care, you can be proactive about maximising your opportunities to support your babies with KMC during their NICU stay. Birth mothers and their partners, grandparents and other caregivers can discuss the concept prior to the arrival of babies expected to need longer-term intensive care. These Skin-to-skin Care (STSC) guidelines from The Royal Children’s Hospital in Melbourne can help you prepare for the experience.
Babies who have shared a womb are reunited as they share skin-to-skin with their mother
Expressing Breastmilk and Maximising Milk Production
The sucking reflex begins to develop around 32 weeks gestation and only really matures around 3 weeks. Even then, the foetus needs to practice using it in the remaining weeks before full term. A “late pre-term” infant born between 34-36.6 weeks gestation might be fed by various methods while also experiencing time in Kangaroo Mother Care to become familiar with the breast. They may attempt feeds or even latch, however effective transfer of milk may not yet be possible. As the baby matures, breastfeeding will progressively be initiated alongside other feeding methods. Babies born prematurely may not reliably wake for feeds, so a 3 hourly feeding schedule is usually in place. Once these babies reach term and are in the home environment, responsive feeding can usually replace these scheduled feeds.
If you have spend several weeks or even longer pumping, storing and feeding your baby your expressed breastmilk, transitioning to direct feeding at the breast can bring anxiety around the babies’ intake. Your experience in hospital has been one of recording every wet nappy, poo and volume of milk taken. No longer needing to do so for your healthy babies after discharge can be very hard to accept.
Going home pumping and bottle feeding expressed milk, potentially supplemented with infant formula and attempting feeds at breast is a very demanding expectation for parents of singletons and for those juggling the care and feeding or two or more babies, it can be easy to let the time at breast slide, use more infant formula to reduce the time spent pumping and even decide to exclusively feed your babies expressed breastmilk or fully wean onto infant formula.
Whatever pathway is your reality at home, the value of every drop of breastmilk your baby received during that vulnerable time in NICU should not be denied. Breastmilk feeding of premature infants significantly reduces the risk of Necrotizing Enterocolitis a serious complication more common in babies who are exclusively formula fed. Any human milk - expressed by the mother or donated to a hospital milk bank - is protective. If you have ever felt under pressure to supply breastmilk by the doctors or nurses caring for your babies, this is the most significant reason why. Any breastmilk you continue to express and any time your babies spend at the breast, even if it seems only for comfort, continues to protect your baby. Sometimes this is referred to as “breastfeeding as medicine” where the babies might be getting their nutrition needs from infant formula but are also receiving the unique properties of their mothers own milk.
These two video links are my go-to resources for anyone needing to establish and maintain their milk supply by expressing their milk:
You can also refer to our articles:
Tandem Feeding … or not
Many mothers of twins have expressed feeling overwhelmed by the process of feeding two small newborn babies at the same time. Yet well-meaning midwives, nurses and lactation consultants often strongly encourage the babies to be fed together before the family is discharged together.
Part of the reasoning behind this is time-management. The other is opportunity to learn with support on hand. Both of which are great options but NOT mandatory. You can decline, defer or otherwise indicate your preference to feed your babies individually. This might be a short-term approach while you establish effective milk removal by each baby or it might be a long-term plan to support the different needs of babies born together. Your babies, your family, your choice.
Feeding your babies individually is absolutely going to be more time consuming. However, it will allow you to practice learning techniques such as baby-led attachment without the complications of two babies getting in each other’s way! It also means that a baby still learning to get a good latch can be focused on without also trying not to dislodge another baby. If your babies are also receiving milk from bottles, your support team can give one baby a bottle feed while you give the other time at the breast before swapping babies and reversing the process. If you do decide to progress to tandem feeding (two babies, two breasts) you can arrange for an IBCLC lactation consultant to visit you in the home, where you are able to learn with your own seating and support pillows, cushions etc. This video shows how one mother manages feeding her twins at the same time.
Breastfeeding Pillows
While most babies can be breastfed without the use of pillows designed to support their bodies, when it comes to tandem feeding twins, these pillows can be useful, at least in the early days. However, if you find them adding an extra level of complication and want to throw it out the window, then don’t feel you have to use it or carry it everywhere for months to come. Humans and other primates have breastfed twins perfectly well without such pillows for thousands of years! You can too.
The important thing to keep in mind when using a breastfeeding pillow is its purpose is to support your body to support their’s. Laying a small baby directly on a breastfeeding pillow is unlikely to place it in an optimal position to seek the breast and stay attached.
I am often asked to recommend specific brands of breastfeeding pillows for twins. It is an impossible question as the pillows come in nearly as many designs as human breasts and babies! What I do suggest is buying secondhand if you can and borrowing different types before making a purchasing decision. Multiple birth support groups are the perfect way to connect with parents wishing to get rid of the bulky pillows taking up space in their home!!
Multiples South Australia have a great online review of pillows available in Australia.
Breastfeeding Triplets
The first woman I met who was breastfeeding triplets was transitioning her babies from hospital to home - one at a time. That period was the most intense, as she juggled the needs of a newborn in the household with the needs of parents with babies in NICU. I caughte up with her after the last baby was discharged and asked her how it was going. She replied:
I just sit on the couch all day and people hand me babies to feed!
The biggest barrier to breastfeeding higher order multiples - triplets, quadruplets or more - is time. From a milk production perspective, provided the supply is well-established to the demand of three full-term babies (by effective and frequent pumping in the early weeks) the human breast will maintain production at that level. The challenge is the intensity of breastfeeding any newborn, times three or more, with the added challenges of prematurity. The more foetuses, the shorter the pregnancy and the less developed the infants sucking ability. The demands of all this plus pumping to maximise supply and provide EBM for babies not at the breast is huge. The chances of taking home exclusively breastfed babies after weeks or months in intensive care are reduced. However, it is not impossible and the few women finding the time in ther lives to share their stories are inspirational.
Davina Wright is what could be considered an actual wonder woman. She not only breastfed her triplets but did so well-beyond the World Health Organizations minimum two year recommendation. By several years! She shared her story when they were five, with IBCLC The Milk Meg. You can read it in full here:
Davina’s story was also featured in La Leche League newsletters “Three Babies, Two Breasts” tells her story of breastfeeding triplets.
And - just because you are probably wondering by now ….
Breastfeeding Quadruplets
Four babies, two breasts. Straight away you can see the problem here! However, recorded cases of mothers breastfeeding quadruplets show it can be done. One family were studied in the early 1990s:
The quadruplets were born by cesarean delivery at 34 weeks' gestation and weighed from 1,820 g to 2,240 g. In-hospital breastfeeding experiences were managed by the authors, according to research-based guidelines for breastfeeding preterm neonates and infants. During the first month after discharge of the four newborns, the mother breastfed 12-34 times daily. Mean daily weight gains for the quadruplets during this time varied from 30 g to 54 g, indicative of adequate maternal milk supply.
Mead LJ, Chuffo R, Lawlor-Klean P, Meier PP. Breastfeeding success with preterm quadruplets. J Obstet Gynecol Neonatal Nurs. 1992 May-Jun;21(3):221-7. doi: 10.1111/j.1552-6909.1992.tb02259.x. PMID: 1322454.
Breastfeeding Quintuplets
Five healthy babies to bring home from hospital is amazing. Case study is just such a happy ending:
The first published case of quintuplets who breastfeed and receive expressed mother's own milk and supplemental pasteurized donor human milk. In this case, all 5 babies receive exclusively human milk at 7 months. This result is achieved because of the mother's strong advocacy for human milk feedings and a remarkable support system of 200 individuals drawn from family, friends, and congregation.
1.Szucs KA, Axline SE, Rosenman MB. Quintuplets and a Mother’s Determination to Provide Human Milk: It Takes a Village to Raise a Baby—How About Five? Journal of Human Lactation. 2009;25(1):79-84. doi:10.1177/0890334408328385
A mother in Western Australia naturally conceived quintuplets in 2015 and breastfed all five babies for the first six weeks before experiencing low supply and switching to formula.
Breastfeeding Sextuplets
In 2014, this mother wrote about her experience providing human milk for her six babies in NICU:
Now let’s not get any crazy ideas here. Yes, I had a litter {they don’t call me Mama Cat for nothing!}, but I still only have two boobs. And those boobs only produce so much milk. As much as I would love to sit here and say that the lactation consultant’s plan of increasing my milk supply and doing 3 rounds of breastfeeding with the twin hold back to back was a success, I cannot. I heard that plan and thought I. don’t. think. so. Now I did humor her and attempt to breastfeed, and even do the twin hold a few times in the NICU, but that’s as far as that went.
Breastfeeding Septuplets
In 1997, one couple got a little more than anticipated after accessing fertility treatment to have a second baby - they got seven more!
Bobbi really had a physically draining experience with the septuplets. She needed to personally pump the breast milk for all of the babies, meaning that she would have to provide 4-5 gallons of milk a week, and this lasted until the babies were 3 months old.
Breastfeeding Octuplets
The 2009 birth of eight living babies to a Californian woman is infamous, however the babies were fed expressed breastmilk and donor milk during their hospital stay after being born at 31 weeks gestation. It was reported that:
At present, five of the octuplets are being fed donated breast milk while their mother is pumping to save milk for all of her babies. The medical staff will help the mother learn how to express her milk so that they can store and give it to the infants. Each baby now weighs in at under 3 lbs each, so it is essential that they receive their mother’s breast milk to help their tiny bodies grow in strength, and to build up their digestive and immune systems. Mom and babies will gradually get used to breastfeeding, but will always be allowed to have skin to skin contact while the babies gain their strength. Such contact is another important necessity for their sustained health. (This is the typical recovery breastfeeding system for premature born infants).
Breastfeeding Nonuplets
In 2021, a family in Mali, West Africa, grew by nine babies - two were a surprise as doctors thought the mother was carrying seven! Their mother has been quoted as saying:
‘My children do not sleep at the same time. Some sleep a bit later when others wake up. Breastfeeding was not easy - when we were at the hospital I was using a breast pump.’
