Skin to Skin Contact

Jack is Born at Heath Hospital

Skin-to-skin contact, when possible, is important for getting breastfeeding off to a good start.

Skin-to-skin contact (SSC) following birth is incredibly important for all babies, including preterm babies.  It is easy to do – a mother simply holds her baby with his stomach down (prone position) against the front-side of her chest between her breasts, neither with clothes between them.  A blanket can be placed on the outside of the baby while he is wearing a diaper and/or a hat.  Ideally, SSC should begin immediately following birth and last through the first breastfeed – or for the first 1 ½ – 2 hours following birth. The results are amazing!

A new baby has just come from the safest place he’s known – inside his mother’s womb.  There, he has been cared for completely having every need met immediately.  He was protected, hearing gentle noises buffered by the womb; his heart rate and oxygen saturation levels were optimal; he was held, warm, fed, and loved on demand.  After birth, this same baby has entered a whole new world and the safety of being skin-to-skin against his mother’s body helps him in this transition.

Today the over-medicalization of the birthing process many times leads to the separation of mother and baby following birth.  Lights are bright, sounds are loud and unfamiliar, scales are cold, and the person he knows best, his mother, is not always nearby.  Research shows this separation of mother and baby is highly stressful and can lead to what is known as “protest despair” in baby.  When babies are separated following birth, babies exhibit a ten-fold increase in stress hormone levels.1  This stress should not be underestimated either!  The baby will protest by crying. His heart rate, blood pressure, and breathing will increase.  After protesting, he will despair, moving to a state of dissociation.  Left in this state of distress, away from his mother, can have lasting emotional effects. And maternal levels of oxytocin (which is often referred to as the love hormone and significantly impacts bonding) peak following birth. When mom and baby can’t be together, precious bonding time is lost in their relationship.

SSC is a safe and simple alternative to separation following birth.  In fact, babies’ body temperatures are better regulated in SSC than in an incubator; heart rates are more stabilized; cortisol and blood glucose levels are more normalized; and there are greater chances for breastfeeding success . . . not to mention the precious time of cuddling and bonding together.   For mothers, SSC not only helps to regulate her body temperature, but heightens oxytocin levels and milk volume, promotes bonding , and increases confidence in her mothering ability.2 Babies who are placed in SSC following birth are much more likely to spontaneously breastfeed than those who are not.

SSC was first used in Colombia, South America in the 1980s for babies in the NICU when there wasn’t space available in conventional incubators.  Compared to babies cared for in environments with greater technology, the babies receiving skin-to-skin contact each day fared much better.3  Research on SSC and twins has found that each breast uniquely regulates its temperature depending on what each baby needs.  If one baby was too cool, the breast temperature on that side would increase; if the other baby was too hot, that breast would decrease in temperature.4  SSC after birth has also been shown to significantly increase the survival rate of babies who are born with very low birth weights.5

In addition to its many positive benefits immediately following birth, SSC continues to have a positive impact on breastfeeding in the early weeks and months with your new baby.  SSC continues to promote bonding between mother and baby, helps baby to latch, increases a mother’s milk supply, and can even help a baby who is refusing the breast to begin to nurse.  The benefits of SSC are increased, the longer and/or more frequently a baby is held this way.

The first hours after birth are critical to bonding with your new baby and can never be returned.  All necessary interventions in a healthy newborn can be done while baby is skin-to-skin with his mother.  Bathing, weighing, etc. can all wait until later.  Postpone all non-essential things and relax and enjoy this precious time with your new little blessing.

Adoption and Breast Milk

mom baby on beachCasey Brown is a wife, Paramedic-turned-stay-at-home mom, and adoptive mom of one princess. She is passionate about adoption and breast milk and her journey to make sure her baby could have breastmilk in the NICU hit the national stage in social media.  She encourages other adoptive mamas to fight for the liquid gold, to not back down, and stand up for what they believe in. Ending discrimination against adoptive mamas has become a passion of Casey’s.  She is co-founder of the company Quiver Full Adoptions, an adoption consultation service based out of Greenville, SC.  You can also follow her on Twitter and Facebook.

When I was little, I had one million baby dolls. Almost. I played “house” every single day and ever since I can remember, I have wanted to be a mama. Not a teacher, not a doctor, but a mom. Maybe that desire came from seeing my mom making it look like the best “job” in the world. I won’t bore you with the details or make you feel inferior by telling you about how awesome my mother is, instead, I’ll tell you about the day I found out I was going to be a mom. Let’s rewind. My husband and I had been married four years and had been trying to conceive since the day we were married. Hey! I told you I wanted to be a mom! The stars weren’t aligning and the doctors were saying I would need science to help our dreams come true. Science. That’s something I was familiar with, being a Paramedic for three years and being in the health field for seven. After much prayer, Josh and I decided to forgo the science and medicine and pursue adoption. Adoption had always been in our hearts and on our minds, but something that we imagined doing when our biological children were older.

Three weeks after announcing that we were adopting, we were matched with our birth mom. Now if that wasn’t a sign from the good Lord, I don’t know what is. Crystal, our birth mom, asked me to attend her doctor’s appointments with her, and of course I said, “Yes!” I was going to be a mom and she was allowing me to experience as much of the process as I could. During the second or third doctor appointment, I was sitting in the room with Crystal, and she sat up on the exam table and said, “Have you thought about breastfeeding your baby?” Wait. What? Our birthmom has to be the coolest birthmom on earth to be asking me this question. I replied, “No,” although I had actually been thinking about it. I had been in contact with Krista Gray from Nursing Nurture and had already started the Newman-Goldfarb protocol – that’s how much I had thought about adoption and breast milk. I’m not sure why my immediate response was “No,” it wasn’t meant to deceive her, it was just a knee jerk reaction. I later told her the truth and she was very supportive. Crystal was already sixteen weeks pregnant when I began the protocol. Ila Mae, my princess, was born six weeks early and had a two week stay in the NICU. I had no time to stop the birth control and begin pumping, as the protocol needs eight weeks of pumping to start producing milk. Ila Mae was on a ventilator, had a chest tube due to a collapsed lung, and was on TPN. Seeing her fragile, tiny four pound, thirteen ounce body lying in the isolette, I knew I had to do something to get her that liquid gold. I did what any mama would do. I fought. Then I took on the hospital.  Below, you will find my Facebook post that went viral just a few days after Ila Mae was born.

“Baby Ila Mae was born July 23. The adoption papers were completed today. Through this group [Breast Friends] and Adoptive Breastfeeding group, I have begun the Newman Goldfarb Protocol. I haven’t started

NICU battle for adoption and breast milk

NICU battle for adoption and breast milk

pumping yet to induce lactation. I have a ton of donor milk that I was planning to use with my Lact-aid. Today, I experienced bullying for the first time that I can remember. It was so real. I said to the nurse, ‘When Ila Mae gets off the ventilator, we have breast milk that we want her to have instead of formula.’ She looked at me like I had three heads, turned around and went and got the lactation consultant. This lady comes over and says, ‘So, I hear you have breast milk. Where did you get it?’ This breast milk comes from my best friend. I told her this and she looked at me like I was disgusting and said, ‘you cannot use that unless you get it from a milk bank.’ I said ok, and asked how to go about doing that and if I could see the protocol they have set in place that says I cannot use donor milk. They could NEVER produce one and then finally admitted that they had never had this happen ‘because adoptive moms just don’t do this kind of thing. Mam, if you want to give this baby donated milk, then you’ll have to do it when she is actually yours in your own home.’ Ummmm, I about lost it at this point. This baby is MINE. Then, I leave and come back three hours later in hopes that she has left, only to get cornered by her and the neonatologist. While I was gone, they decided that I wouldn’t be able to use milk from a milk bank ‘because there isn’t one close enough’ and 4pounds 13 ounces isn’t a low enough birth weight and adoption isn’t a special circumstance that they could write a prescription for.’ They went on to tell me about all of the “risks” of donor milk and I politely informed them of how misinformed they are. My question is, would y’all be willing to write a letter to this hospital informing them of the benefits of breast milk, donated whether through a milk bank or not, and the non benefits of formula? They also told me that in order for me to use the Lact-aid, I’d have to have blood work done!! WTH?! Seriously? Ok, what’s the difference then? Why can’t my milk donor go have blood work done to show she isn’t infectious and then allow me to use her milk? I’m so aggravated that I can’t make an informed decision and I have been bullied into using formula. It will still be a few days before she is off the ventilator and able to nurse, but this is a big deal to me!”

Adopted yet thriving on breast milk!

Adopted yet thriving on breast milk!

Six months later, here I am reading what I posted on Facebook, and all I can see is how stressed I sounded. I could hardly form complete sentences. The group Breast Friends has approximately 5,000 members. About 300 of them wrote the hospital handwritten letters, fighting on behalf of me and my princess. Four of the members called the hospital, and one of the members spoke directly with the President of the hospital. After some threatening of getting the news involved and threatening to picket on the sidewalk while mothers nursed their babies, the hospital finally caved. They finally agreed to get me the donor milk from a milk bank. I compromised since they were getting me breast milk, to agree to not use the Lact-aid and to not use my personal stash of donor milk. Ila Mae is now six months old and has never had a drop of formula. We have had a total of eighteen milk donors (plus how many ever donors from the milk bank), all friends or friends of friends. (And due to Casey’s battle with the hospital, the policy has officially been changed regarding donor milk.  Here is more information on Spartanburg Memorial in SC.)

You have a choice, mamas! You don’t have to settle for fourth best, according to the World Health Organization, you can have that liquid gold. Fight if you have it in you, settle if you don’t. Either way, I won’t judge you, but I will stand behind you if you decide to fight!

You may also be interested in reading more about Adoptive Breastfeeding, Induced Lactation, 5 Challenges of Adoptive Breastfeeding, and Tube Feeding Devices.

Breastfeeding Positions

How should I breastfeed my baby?

There is no right or wrong way to nurse your little one.  Any position that is comfortable for you and your baby is just fine.  And while it is important to ensure your baby is positioned and latched well in the beginning, after a few months your growing baby and then active toddler just might choose some positions you never would have considered!  The following breastfeeding positions will give you ideas of ways many moms have comfortably and effectively nursed their babies.

Positioning Techniques

Many moms find it helpful to have plenty of pillows to prop up around them so they don’t have to support the weight of their baby while nursing.  Other moms find having pillows and feeling like they can only nurse in their “nursing station” to be cumbersome.  These moms prefer to not use pillows or other support.  Either way is perfectly fine!

What is most important is to make sure your baby is supported throughout his head/neck/shoulder region, his head and neck are in alignment, and he has equal muscle movement on both sides of his body.  This means you will want his body gently pressed against yours – his tummy on your body – and your hand securely holding his head between his shoulder blades.  Make sure your hand does not hold his head though as this is very uncomfortable and keeps a baby from latching well.  (Imagine if you had to keep your chin down on your chest while you chewed and swallowed your food!)  His head should be free so that he can bring it back if his nose becomes blocked.  Your baby should have firm contact against his mother (skin-to-skin is ideal!).

Latching Techniques

In addition to ensuring good positioning in the early days, it is equally important to ensure a proper latch.  A mother can support her breast with her hand if necessary.  Make sure to keep your fingers behind the areola and position fingers in a C-hold so that you can easily help your baby latch on and take enough breast into his mouth.  A baby’s nose should be level with the mother’s nipple.  Your baby should have his head tilted back and lead his mouth to the breast with his lower jaw.  His mouth should be opened wide, tongue down and extended over the bottom gum, with nipple pointing up toward roof of baby’s mouth.  His chin should be pressed against breast with bottom of jaw/lip taking in more areola than the top.  Your baby forms a teat with the nipple and breast tissue, which should be tucked well into baby’s mouth.  His mouth should be open very wide with both top and bottom lips relaxed on the breast and flanged outward.  There should not be any pain!  Make sure to allow your baby to nurse as long as he wants – don’t set a time limit.

Cradle Hold

Cradle Hold

Cradle Hold

This is one of the most popular nursing positions.  A baby lies on the forearm of the side she is going to nurse, and her body extends across the front of her mother.  Her head may be cradled in the bend of the elbow or down lower on the mother’s forearm depending on the size of the baby.  The baby’s chest is against her mother’s chest without space in between; baby’s chest should not be facing up toward the ceiling.  Her legs/feet may be tucked in around the mother’s waist to feel more secure.  It is important that baby is held at breast-level rather than the breast being lowered down to reach baby (which can alter the latch, put pressure on the breast, and keep milk from draining adequately in some areas leading to plugged ducts and mastitis).

Cross-Cradle Hold


Cross-Cradle Hold

Similar to the cradle hold, but the baby is supported in the arm opposite of the side she is nursing on.  If nursing on the left side, baby would be held by the right arm.  In this example, a mother could support her breast with her left hand and help ensure an optimal latch.  This position is often used with preterm infants.

Football/Clutch Hold

Football Hold

Football Hold

In this position, a baby lies at breast level on the arm of the side she is going to nurse.  Her head is by her mother’s hand and her body wraps around the side and back of her mother.  This hold is especially helpful for a mother who needs to be able to better see her baby’s latch – with large breasts or with a painful latch – as well as after a c-section so baby doesn’t put weight on the incision.  Many mothers of twins also nurse their babies in this position.

Laid-Back Nursing/Biological Nurturing/Reclining

Laid-Back Nursing

Laid-Back Breastfeeding

It has a variety of names but in this position, rather than sitting straight up, the mother is comfortably reclining.  She could simply slide down in a straight back chair, sit in a reclining chair, or lie on a bed propped up with a couple pillows.  A baby can then be positioned across the mother’s body allowing gravity to securely position baby’s body against hers as well as allowing gravity to help with the latch.  This position allows a baby’s natural breastfeeding instincts to kick in.  It is particularly helpful for a tired mom to get rest while nursing or when your baby struggles to open wide to latch such as in cases of tongue tie.

Nursing Lying Down (Side-lying)

Side-Lying Breastfeeding

Side-Lying Breastfeeding

Nursing lying down is an essential tool for breastfeeding and sleep.  Since babies need to nurse at night but mothers also need sleep it is a wonderful way to meet both needs.  In this position, mother and baby lie next to one another on a safe surface.  Baby is securely pressed against mother’s body, and a mother protects her baby with her legs curled around the bottom of her baby and arm over the top.  It can be challenging to first learn this position, but with practice most mothers find it very relaxing to know they can nurse while also getting rest.

Upright Nursing (Baby Sitting)

Upright Breastfeeding

Upright Breastfeeding

Some babies prefer to be in a seated, upright position when nursing.  This type of position is especially useful when a mother has a forceful milk ejection, baby has breathing or swallowing issues, cleft palate, etc.  This position helps reduce choking from a fast flow of milk.  It is still important to adequately support a baby in this position allowing her body to feel a secure touch across her body as well as ensuring her head is well supported by holding one hand in between the shoulder blades at the base of the neck.

Breastfeeding Twins, Twice

Tara Dew HeadshotTara is a former 2nd grade teacher who now spends her days at home with the “Dew Crew,” the loving term she has given to her two sets of boy/girl twins. She is married to her high school sweetheart and they reside in NC, where she stays busy homeschooling the children and supporting her husband in ministry.

I’m excited and thankful for this opportunity to be a guest blogger today. My name is Tara and I am the proud Mommy of two sets of twins. Our first set, Natalie and Nathan, are now 6 ½ years old and our second set, Samuel and Samantha, are 3 ½ years old. I’m very grateful to be a breastfeeding Mom that was able to nurse all 4 of my children for the first year of their lives.

3But, let’s rewind back to the beginning…When my husband and I found out that we were expecting twins, we were shocked! Never in a million years did we dream that we would have twins. (Turns out that I have fraternal twins three generations up on my father’s side, and the genes were passed down to me :))

As we began preparing for their arrival, one of my biggest fears was if I’d be able to produce enough milk for them. I so desired to nurse my children, not only for the bonding and nutritional factors, but also for the economic reason: We couldn’t afford 2 in diapers AND 2 on formula! My mom had breastfed my siblings and me, so I knew that breastfeeding was what I’d love to be able to do. But, would my small-breasted self really be able to produce enough milk for not one, but two babies?

Natalie and Nathan were born at 34 weeks gestation, and were immediately taken to the NICU. I was not able to nurse them for the first few days of their life (since they hadn’t acquired the suck/swallow/breathe reflex yet). So, my first experience with “nursing” was actually with the hospital breast pump. I can remember pumping that first time and NOT GETTING ANYTHING! I was so discouraged. But the sweet nurse reassured me that this was normal: My milk hadn’t come in yet, and we were just stimulating and “prepping” my breasts for what they were created to do.

Two days later, my milk came in… And then I acquired the nickname of “Dairy Queen.” I often cried tears of joy at how my biggest fears had subsided. My body produced all that my babies needed to eat! And even when I wasn’t in the NICU, the nurses would feed my pumped breastmilk in through a small tube in Nathan and Natalie’s noses and then down to their tummies.

2When they were several days old, I was able to nurse them for the first time and though it was an unusual feeling, it was not painful for me. I praise the Lord that I never dealt with cracked or bleeding nipples, and that my body was able to produce enough milk for both babies! The only “hurt” that I had with nursing came when the kids were 2 weeks old. I developed mastitis in both breasts and felt like I had the flu with a fever! It was terrible, but cleared up quickly with medicine.

During the first few weeks of their lives, I nursed them separately in the cross-body position. They were learning how to latch correctly and stay awake for a full feeding. But after the first month, they became excellent nursers and I began feeding them at the same time. I used a double-boppy pillow, which I fondly call “my boppy on steriods” because it is so much bigger than a normal boppy. I fed the children in a “football-hold” position. One child would nurse on one side, but then at the next feeding, they would get the other side.

I fed the twins’ simultaneously until they were about 9-10 months old. By this time, they were getting more and more interested in the world around them and would “lose interest” in nursing. I found it easier to nurse one at a time at this point. They were such efficient nurses though, so feeding one and then the other didn’t cause any issues. When they were 13 ½ months old, they weaned themselves and gave up the last early morning feeding/snuggle session.

1Samuel and Samantha have a very similar nursing story, except they were born at 37 weeks and didn’t spend a day in the NICU! They were “full-term babies,” who latched correctly the very afternoon they were born and were excellent nurses the entire time! I was so blessed to be able to nurse them until almost 14 months old as well. Though nursing required a lot of dedication for that first year, I am so thankful that I was able to produce enough for them and that I was able to share that special bonding time with my children.

Large Nipples, Small Baby

Large Nipples, Small Baby

Nipples and breasts, just like babies, come in all sorts of shapes and sizes; rarely does nature mix up babies and breasts. However, when a mother has exceptionally long nipples and a baby is very small, it may take time for a baby to grow into her mother’s nipples. Statistically speaking, long nipples are less of a breastfeeding concern than inverted nipples.1 Nonetheless, large nipples can be a cause excessive weight loss and/or slow weight gain in the first week following birth. 2

What breastfeeding challenges can large nipples present?
Extra long nipples with an accompanying small baby can cause an infant to gag and then slide off the nipple to cope with its length. This poor latch can cause milk supply issues and breastfeeding pain for a mother as well as allow her baby to learn a lazy attachment at the breast. A newborn may learn to have a shallow latch while nursing which could then continue even when he grows bigger and the size of his mother’s nipples would not prevent him from actually latching much deeper. This shallow latch could impact a mother and baby negatively in a variety of ways:

  • Poor latch can decrease a mother’s milk supply. This is especially of concern in the beginning days/weeks of lactation when a mother’s milk supply is being established.
  • Poor latch can cause pain. Sore and cracked nipples can make a mother more likely to supplement or wean her baby altogether.
  • A shallow latch can cause slow weight gain or even failure to thrive in baby.
  • A shallow latch in a baby can mimic bottle feeding and limit breastfeeding’s effects of proper oral-facial development.
  • A shallow latch can be harder to correct later when a baby does grow into her mother’s nipples.

What can I do if large nipples are a concern?

First, it is important to have your baby’s oral anatomy checked. There could be a tongue tie, lip tie, hypertonia, cleft, or other developmental variation that is affecting how deep of a latch your baby has on your breast. Sometimes these can be easily corrected and allow your newborn to quickly breastfeed better.

If your baby’s oral anatomy is normal then it may be a matter of protecting your milk supply until your baby grows and is able to latch properly. There are several steps to take to protect/build your supply:

  1. If your baby’s weight gain is not adequate and/or she does not have enough wet and dirty diapers/nappies then you will need to pump your breasts following each feed. If your baby struggles to latch and suckle, you can then top off your baby with this expressed milk (or, alternatively, give it as the “appetizer”). This should help your baby gain strength and energy and give her time to grow into your nipples.
  2. Make sure to take necessary steps to protect yourself from developing sore or cracked nipples.
  3. Some mothers may need to exclusively pump in the beginning to build their supply, protect their nipples from pain and cracking, and give their babies time to grow.
  4. Make sure to spend as much time as you can skin-to-skin with your baby. You may want to carry your baby in a wrap or sling, take a bath together, or hold her this way even when giving a bottle. Skin-to-skin promotes bonding, growth in baby, and a mother’s milk supply. If she spontaneously tries to suckle at times, let her! In fact, continue to offer to breastfeed at your breasts as much as possible so that the transition to exclusive breastfeeding can be smooth.

The important thing to remember about large nipples and a small baby is that this is temporary. Babies grow very quickly and your baby will grow into your breasts. Large nipples do not make breastfeeding impossible but having lactation support in the beginning is essential.

Exclusive Pumping

When a baby isn’t breastfeeding, effective milk removal from the breasts becomes critical in order to build or maintain a milk supply.   Exclusive pumping can be necessary in a variety of settings: when a baby is born prematurely or cannot breastfeed due to illness; when a baby refuses to latch at the breast; in cases of adoptive breastfeeding, induced lactation, and relactation, or when mom needs to be away for a period of time.  Some moms begin pumping and, though the reason they initially began to express is resolved, find that their baby prefers receiving expressed breast milk. If you are in a situation of exclusively pumping, here are 5 tips for your situation.

  1. Establish your milk supply.
    The most important thing you need to do when exclusively pumping is establish a full milk supply. Your body needs to get the message to make enough milk for your baby. Perhaps your baby was born prematurely and isn’t taking much milk in a 24 hour period. This will change in a few weeks and your body needs to make sure it has the supply ready for your baby. In the beginning, a mother should pump a minimum of eight times in a 24 hour period for at least 20 minutes on each breast.  It will help to record what time you pump and how much milk you get. A double electric pump is the most efficient way to do this.  Though hand expression, single pumps, and manual pumps are all other options, a double electric pump of good quality has been found to stimulate greater milk production. 1
  2. An empty breast makes more milk.
    It’s the law of supply and demand. Therefore the more completely the breast is drained and the more frequently this occurs, the more milk a mother’s body will make. 2 It is completely possible for you to make enough milk to exclusively nurse twins or even triplets!
  3. Shorten pumping duration AFTER supply is established.
    After a full supply is established (25-35 ounces per baby every 24 hours) 3 then you can shorten the duration of pumping at each session to the amount of time necessary to gather the required milk. Many times this is as short as 5 minutes!  In general, once a strong milk supply is established, one nighttime pumping session can be dropped but it is important to ensure you are still pumping at least once during the night and never going more than 4-6 hours between pumping during the longest interval between sessions. Every mother is different and every breast has a different storage capacity. While a few mothers may be able to go 10-12 hours between their longest stretch, other mothers can only go 3-4 hours. Full breasts make milk more slowly so the longer a mother waits between pumping sessions, the slower the milk production becomes. Every mother will have to work out what her “magic number” is for how many times to pump and how long in order to maintain supply.
  4. If you begin to notice a drop in supply, increase pumping sessions and/or duration.
    A general guide, once milk supply is established, is to pump 6-7 times in a 24 hour period, at least once during the night, and only for the time it takes to get the required amount of milk. Should you notice your milk supply beginning to decrease from the shortened pumping duration and/or number of sessions you should return to pumping more often and for a longer duration.
  5. Your “magic number” will be different than another person’s.
    Don’t worry if you have to pump more often than another mother to get enough milk. Don’t worry if you don’t have to pump nearly as often. Every mother is different. Not only is every mother’s breast storage capacity different, but each breast on the same mother can vary! It only matters what your magic number is. Therefore, once you have worked out how frequently you need to pump and it works for you, don’t worry if someone else does it differently.

Expressing breast milk is hard and can be very emotional. You may need to grieve not being able to nurse your baby at the breast. While expressing milk can help you connect with your baby, it also is a symbol of the disconnection. 4 Realizing that grieving is not only important but normal is critical to dealing with one’s feelings and healing. Also realize that no matter how long a mother has been exclusively pumping, transitioning back to breastfeeding is an option.

When the time comes to wean from expressing there are ways to do this both safely and comfortably.

Emergency C-Section in Egypt

Premature twin in incubator

The twins spent their first few days in an incubator in the NICU in Egypt.

To say I was excited when I found out I was pregnant would be an understatement.  I had dreamed of being a twin when I grew up and always thought I would love to raise twins. Still, I’m not sure anyone can be totally prepared to hear they are having twins! This excitement quickly turned to fear though when I realized I would have to birth twins.

I really wanted to avoid a C-section and I planned and prepared all throughout my pregnancy.  We were living in Egypt and my doctor strongly encouraged me to have a planned C-Section.  When my boys were breech and not changing positions we made plans to return to the states where my doctor was still keen to let me try to birth them vaginally.

breastfeeding premature baby

First time to attempt breastfeeding my twins – 26 hours after birth.

Fast forward to January 24th. . . I was 32 weeks, 3 days pregnant without problem. I felt great, well, except for feeling like a blue whale, but don’t all pregnant women feel large at the end?!  I was packing and preparing for our return to the states just four days later.  That morning I woke up around 8:00 a.m. and felt mildly uncomfortable in my still half-asleep state. I tossed and turned a little and remember saying, “I think I’m having a contraction.” My lower abdomen was tightening, but I figured it was just Braxton-Hicks . . .

After getting up and taking a shower, these mild contractions suddenly turned into intense labor with contractions coming almost on top of each other.   We called my doctor (who had been quite relieved when he learned we were going back to the states) and we headed to the hospital in Egypt instead.

syringe feeding colostrum

Since they were losing weight at the breast I syringe-fed my colostrum to the boys.

We arrived at 9:45 a.m. and I was already dilated to 8 cm. Since they were breech the hospital doctor wanted to prep me for a c/s but I refused. I was taken upstairs to labor and delivery and I could feel the contractions change and I had the urge to push – I knew I was now fully dilated. But, I didn’t feel a peace to work with the contractions and push those babies out without my doctor there. (I look back now and have to laugh at this scene because here I am on a bed in the hallway because the medical staff at the hospital didn’t know what to do with this foreigner who was refusing a c/s – and they didn’t know how to help me birth breech twins! We were all just waiting for my doctor to arrive.)

My doctor did arrive and said on the way he’d been thinking about it and he had decided he would give me the opportunity to birth them naturally. I was so thankful. He went and washed up and I went to the delivery room. However, when my doctor checked me his entire demeanor changed and I could sense the intense worry in his eyes. He said he had talked with the neonatologist and both really recommended a c/s.  I just didn’t have a peace to do this naturally without his support – especially since just a few minutes earlier he was okay with me trying for a natural delivery.

Syringe feeding colostrum when my newborn preemie was unable to latch on.

Syringe feeding colostrum when my newborn preemie was unable to latch on.

At this point I didn’t even have an IV so they put me under with general anesthesia.  They put the mask on my face and I was out.  They were born within a couple minutes – which makes me thankful that James and Luke still didn’t get exposed to much anesthesia.

James was born first (3 lb, 15 oz.), and then Luke (3 lb, 13 oz). They received a surfactant lung treatment since there had not been time to give steroids to me to boost their lungs before their birth. They also had extra oxygen to breath for the first 24 hours (their heads were under an oxygen bubble) and the next day they were breathing fine on their own.

We were in the hospital for six days before bringing our twins home.  (I realize that they would have probably stayed much longer had we been in the states as they were just 3 ½ pounds when we brought them home!)  You can read about my journey breastfeeding these little guys here.

Premature baby's hand

My boys were both under 4 pounds (1.8 kg) at birth.

Though this birth was nothing like I’d planned or hoped, I am very thankful they were born healthy and safe.  It is okay, and important, to grieve a birth that doesn’t go as planned.  I took comfort in knowing that I had done everything I could to prepare for a natural delivery – even to the point of buying plane tickets to another country!  I wonder sometimes what would’ve happened if I’d just pushed them out.  I do wish it hadn’t ended in a C-section but, more importantly, I am thankful they are safe and healthy.  And even though there were many “strikes” against us making breastfeeding difficult (preemies, twins, emergency C-section, not breastfeeding for the first time until 26 hours after delivery, no skin-to-skin after birth, and more) we made it.  Determination can overcome these barriers and more!

Getting Started Breastfeeding Twins

Breastfeeding-TwinsCan I make enough milk for twins?

You have two breasts and two babies – you should be able to make plenty of milk!  First, carrying twins you will have more placental tissue than with one baby.  Thus, your body is already preparing to make more milk to feed your babies.  Then, as your body makes milk according to how much is needed.  With two babies nursing, your body gets the message

to make more milk, and will do so.  If you will give attention in the early days to establishing a strong milk supply, and don’t supplement your babies, you will have plenty of milk to nurse twins.  In fact, mothers who later have a singleton, after previously nursing twins will not produce double the milk for their singleton.  Milk production strictly depends on milk removal.  One baby removes the milk he needs, and the body will replenish that supply.  Twins remove twice the milk, and the body replenishes that amount, and so on.

Though, in general, a woman’s body is fully able to make milk to support twins (or even triplets or more!) there are circumstances where there could be a low milk supply.

Can I produce enough milk for triplets or more?

iStock_000020866394XSmallMany mothers have successfully, exclusively nursed triplets and even quadruplets!  Of course finding the time to do this can be challenging.  With higher order multiples, it is such a unique situation and what works for one mother and her circumstances may not work for another.  However you feed your babies, it is going to be important to have help from family and friends, especially during the first year of life.

How can I get breastfeeding twins off to a good start? 

The best way to bond with your baby and get breastfeeding off to a good start is to have plenty of skin-to-skin time immediately following birth (or as close as possible thereafter).  You cannot spend too long cuddling with your babies in skin-to-skin time.  Not only does it have many health advantages to both mother and baby (including regulating body temperature and love hormones) but it helps to increase a mother’s milk supply and impact breastfeeding positively.  If this is not possible, or if your babies are not nursing well, you will need to be expressing your milk routinely to build your supply.  See milk expression for further information.  Your goal will be for your body to produce 750 ml of milk for each baby by Day 10.  Once you are expressing this quantity you can tailor how often and for how long you’re express to your individual body.  Make sure to consult a lactation consultant.

What if my twins are born early?

Most twins are born preterm today.  Though some may only be slightly early – between 36-38 weeks – others can be much earlier.  If your babies are born early and are in the NICU, you will need to follow strict measures pumping or expressing often to ensure your body makes enough milk to feed your babies once they are out of the NICU and eating more.  Read here for information on feeding your preterm baby.  Also, talk with your NICU about Kangaroo Mother Care for caring for and nursing your preterm babies.

What if my babies are sleepy and don’t wake to nurse?

Even if your babies are only slightly early, it is still important to watch them closely to ensure they are latching well and nursing effectively.  It is common for babies born close to term to sleep more often.  In order to protect your milk supply, as well as to ensure adequate growth, you will most likely need to wake your babies up to feed them.  They need to eat a minimum of 8-10 times every 24 hours.  While a clock is the not the most effective judge of eating a good meal at the breast, it is also important to note that a new baby needs time to eat well and if he is nursing for just a couple minutes and falling back asleep he is probably not eating as much as he needs – both for his growth and your milk supply.  In this case, diligently work to wake him and feed him.  If he is not nursing well, make sure you hand express or pump your milk to build your supply.  You can offer this milk to him in a cup or syringe as an “appetizer” to help him have the energy to nurse more effectively and take his “meal” at the breast.

What if one baby nurses well and the other doesn’t?

This is one of the challenges of nursing twins.  It is usually not feasible to nurse one while pumping for the other.  Therefore, you may need to alternate feedings whereby you nurse both at the breast for one feeding and then the next feeding you express and give this milk to your babies in a cup, syringe, or bottle.  Alternatively, if you have a lot of extra milk expressed you could nurse one baby while feeding this already-expressed milk to the other.  After nursing you will need to pump so that your body will continue to make an adequate milk supply for two babies.

Part of feeding twins is making sure you don’t get so tired and run down you don’t want to continue breastfeeding.  Therefore, if it means you express and give milk to both babies (even though one could’ve nursed) that is okay!  Perhaps you work diligently to get both latched at the breast during the day and then bottle-feed your expressed milk at night.  Though you will need to make sure to pump, you may be able to get more rest if you have help giving the bottles at night – especially if they are small and feeds take awhile.  You will need to evaluate your situation but make sure to take care of yourself too.  Accept all offers of help – this is not the time to make sure your house is perfectly clean and gourmet meals are on the table!

How do I know if my babies are getting enough milk?

What goes in must come out – so it is important to watch for adequate wet and dirty diapers.  When you are tired and taking care of multiple babies, it is easy to lose track of which baby did what so make sure to write down on separate charts for both babies what their diaper output has been.

Should I nurse them at the same time?

Many twin moms find that nursing their babies together saves time.  However, there can be a big learning curve in the beginning.  It is helpful to work one-on-one with each baby in the beginning to make sure he is able to latch and suckle effectively, then tackle nursing both babies at the same time.  Nursing them together has the added benefit of increasing your milk supply as well as the babies suckling and producing milk let-downs for one another.  It is still important to remember that each baby is an individual with unique needs and may need to nurse at different times than the other, too.

How do I know which baby to feed on which side?

You can either assign a breast to each baby or switch which side the babies nurse from.  Keeping the babies on their own side has the advantage of making milk specific to that baby (though the babies will probably be sharing the same germs anyway as they will be in close contact) and containing something like a thrush infection should that ever occur.  Switching sides has the advantages of eye stimulation and development and making sure each baby is adequately fed as it is very common for one breast to produce more milk than the other.  Or, if one baby eats more than the other, it keeps you from looking lop-sided in size!

If you choose to switch breasts, you can either switch at each feed, or switch each day keeping one baby on each side for 24 hours before switching.  There is no one right way so just find what works best for you and go with it!

What positions work for feeding twins?

The short answer is, “any that are comfortable for you and your babies!”  There is no right or wrong position to nurse your twins.  That said, you want to make sure you are comfortable and propping many pillows around you to help support your babies can make nursing easier.  See this page for pictures and ideas for positions.

Breastfeeding twins is so much work!

Yes, nursing twins is a lot of work.  You will probably look back on their first year of life and think all you ever did was nurse babies.  But, feeding twins, no matter how you choose to do it, is work.  Imagine if you bottle-fed your babies – mixing the formula, cleaning and sterilizing bottles, as well as trying to hold them both while taking their bottles. . . not to mention the cost of buying the formula.  From this perspective, breastfeeding twins seems quite easy compared to the alternative!

Preemies – Transitioning to the Breast

Baby breastfeedingSo you have your milk supply established through either hand expression or pumping and now it’s time to transition away from exclusive pumping because your baby is transitioning to the breast.  How can you know if your baby is ready and how can you best go about this?

First, if you have any colostrum or milk from the very first week, these are both incredibly beneficial for your preterm baby and you should give this milk first.  Then your freshly expressed milk, or milk at your breast, should be given next.  Any other milk you have expressed can be safely frozen for use later.  Or, if your milk supply is established and you have an abundance of pumped milk, you may want to consider donating to a human milk bank.

In order to effectively nurse at the breast, a baby must be able to suck, swallow, and breathe at the same time.  This is actually an advanced skill and requires the development of 31 muscles, 6 cranial nerves, and at least 3 cervical nerves to function properly! 1  Typically, this skill is developed between 32-35 weeks gestation.  However, current research shows that preterm babies held in Kangaroo Mother Care develop this skill earlier than their counterparts in incubators. 2  Babies held in KMC may root for the nipple or lick drops of milk from a mother’s breast; these are positive things and should always be encouraged.

Once a baby is ready to begin to transition to the breast there are a variety of ways to do this.  One of the most common ways in the past (and continues in many NICUs today) is simply to choose a feeding to replace at the breast.  Feedings are usually scheduled every three hours in the NICU and one or two of these are replaced with breastfeeding.  While this method can be effective and has helped many babies transition from bottle (or gavage feeding) to the breast, it may not be the best method.  With current knowledge of Kangaroo Mother Care and all its many health benefits to preterm babies, it has also been shown these babies breastfeed earlier and for a longer duration. Babies in KMC have access to their mother’s breast all throughout the day and tasting of drops of milk on the breast or even attempts at suckling are always encouraged, no matter how young the preterm baby.  Rather than prescribing one or two feeds to be at the breast and the rest from a bottle, babies in KMC are able to “practice” breastfeeding from a much earlier age.  They are able to suckle when they are awake, alert, and/or hungry…whenever they are ready and as often as they wish. Preterm babies cared for in KMC typically breastfeed earlier than those transitioned to the breast using other methods. 3

If your preterm baby is ready for oral feeds but, for whatever reason, is unable to nurse at the breast, feeding via cup, syringe, or bottle are all options.  Worldwide, cup feeding is the most common.  It is easy to clean, affordable, and doesn’t teach a different method of sucking than what a baby would use at the breast.  Though sometimes spillage can be high, studies show babies are able to transition from cup to breast easier than bottle to breast.  In fact, when comparing infant responses to cup or bottle, babies have a significant fall in skin temperature and more difficulty breathing while bottle feeding than cup feeding. 4  Syringe feeding is a similar option to cup feeding, although it tends to be easier to control spillage.  Ultimately, though, even if you giving oral feedings via one of these routes, make sure to continue lots of skin-to-skin time and offer your breast, even for non-nutritive sucking, whenever your baby is willing.

Breastfeeding Premature Twins – My Story

During the first three days I gave colostrum to the twin through a syringe.

During the first four days I gave colostrum to the twins through a syringe.

I was as prepared as possible to nurse my twins, until I spontaneously went into labor at 32 weeks, 3 days gestation.  Though we had planned to return to the states for their birth just four days later, we were currently living in Egypt so they were born there.  The doctors were very uncomfortable with me birthing breech, premature twins vaginally and they did a last-minute emergency C-section which included me being put under general anesthesia.  Neither a C-section, nor premature twins had ever been in my plans for their birth and all of this had an impact on breastfeeding.

Those first few days were a blur.  When I woke up from anesthesia I asked for my breast pump and began to express every 3 hours.  The boys were given IV fluids, but no formula, that first day.  They were in the NICU.  On Day 2 they came off the supplemental oxygen and I met their pediatrician – who was cautiously supportive of me breastfeeding premature twins.  He agreed it was good but never thought I would carry through with so many strikes against me:  C-section, preemies, twins.  He didn’t know my resolve nor my passion for breastfeeding.  He told me once we knew they could suck, swallow, and breath at the same time (a skill developed between 28-37 weeks gestation) and were nursing efficiently I could take my boys home.  I was ready to get started.

I breastfed the twins before topping them off with bottles of expressed milk.

I breastfed the twins before topping them off with bottles of expressed milk.

Nursing my daughter had been a breeze compared to what I was now undertaking.  She was a healthy, full-term baby, who I birthed naturally and was immediately placed on my tummy for skin-to-skin time and to nurse.  In contrast, the first time I tried nursing my boys was nearly 26 hours after their birth and, though they were healthy, they were small and it took great energy to nurse at the breast.  It was difficult with the doctors and nurses “micro-managing” each feed by being concerned about the amount of milk taken in, weighing the babies before and after nursing, and then topping them off with my expressed milk in a syringe and later a bottle.  By day 5, the doctors were satisfied that they were eating enough for us to take them home – though they had already lost a significant amount of birth weight.  (They were 3 lbs 15 oz and 3 lbs 13 oz at birth and were now down to 3 ½ pounds each.)  I was just excited to be able to have my whole family at home. . . and, looking back, glad no one told me what the next couple months would hold!

I loved nursing my twins lying down because we would fall asleep together.

I loved nursing my twins lying down because we would fall asleep together.

The days, weeks, and months that followed were a blur of sleepless nights trying to breastfeed premature twins and take care of their 2 ½ year old sister whose world had just changed dramatically.  Being preemies, they didn’t wake up on their own so I would wake them and nurse them.  Then I would top them off with my expressed milk in bottles.  Then pump, clean and sterilize bottles.  I did this routine every 3 hours, day and night, and it would typically take 1 ½ to 2 hours per feed (it took them a long time to drink milk when they were so small).  With the remaining hour I would eat, or sleep, or play with our daughter, or try to talk with family back in the states to update them, or try to grab a shower for the day, or consult with our doctor in the states, or try to sling skin-to-skin against me. . . but I became utterly exhausted.  I wanted to be diligent about pumping because I wanted to ensure I had a good milk supply for twins when they began to eat more.  I wanted to nurse them each feeding because I didn’t want them to begin to prefer a bottle over my breast.  And obviously I was the only one who could pump and nurse. . . and it was exhausting.  Looking back, I would definitely counsel a mom in my position to not worry so much about nipple confusion/preference before 40 weeks gestation and let others help more with bottle feedings, especially at night, so she could get more sleep.  It got to the point where the alarm right by my bed would not wake me, though it would wake my husband across the house who would have to come and get me up!

This was another common position that I used for nursing the boys.

This was another common position that I used for nursing the boys.

I was extremely diligent in the first few weeks to pump every three hours 24/7.  Though my boys were tiny and couldn’t drink much milk yet, I wanted to make sure to build my supply so I could exclusively nurse them once they were bigger.  I pumped with a double electric pump for 20 minutes on both sides, while doing breast compressions, and made sure to write down how much I got at each session.  Once my supply was strong, I began to drop down the time I pumped, first to 15 minutes and then to 10 minutes.  Eventually I dropped one of the nighttime pumping sessions.  Still, months later I counted how much frozen milk I had stored in my freezer and there was 13 gallons!!

I often enjoyed relaxing outside while nursing my twins.

I often enjoyed relaxing outside while nursing my twins.

I never anticipated the incredible pressure I would be put under from doctors to “fortify” my milk.  I had loved breastfeeding my daughter and I knew breast milk was best for my boys but it is very, very difficult when the medical establishment pushes you to supplement or “fortify” – there were many times I felt like if they didn’t grow it would be all my fault since I had gone against all medical advice.  I was so thankful to be able to consult with a lactation consultant who was a great encouragement to me.  One thing in particular she kept reminding me was to wait until they were 40 weeks gestation and then notice the difference in their ability to nurse.  And I’m thankful I never gave in and “fortified” my milk.

Because one of my boys continued to lose weight and /or stop gaining whenever I went exclusively to the breast (without topping him off with the bottle) I had to continue this nursing routine until they were around 40 weeks gestation.  And then, suddenly, it really was true!  They began nursing more like newborns rather than preemies!  I began to get more sleep – in fact I remember the night when I got 7 hours of sleep – it was all broken up, but still, it was sleep.  I felt like a new woman! They were nearly 3 months old at this time, but, before then, a good night was 4 hours of broken sleep.

I truly believe the biggest challenges I faced in the beginning were on account of the boys being preemies rather than twins.  The day I packed up my pump was a day of celebration and from that time on I just enjoyed nursing my boys.  I used many nursing positions, but typically nursed them together for efficiency sake.  However, if one was asleep and the other wanted to nurse I always just nursed the one.  I loved being able to lie down and nurse them together and go right back to sleep – something I continued to do until they were at least a year old and just became too big.  Having already nursed a child, I knew how wonderful and easy a good nursing relationship could be and that definitely gave me a goal for the hardships I faced in the early days. I would almost always nurse them together and I had a large pillow that I put underneath them so we could all relax.  My most common nursing location was the couch with my feet propped up.  Not only was it comfortable but it also allowed me to interact with my daughter as I nursed her brothers.  My very favorite way to nurse them, though, was lying down.  The three of us would almost always fall asleep this way! I also found an added benefit nursing twins: when you breastfeed your body produces oxytocin for the Milk Ejection Reflex.  One of oxytocin’s many wonderful benefits is relaxation.  I could become so relaxed nursing twins I could fall asleep almost anywhere!  It was a great way to wind down throughout the day and I loved the opportunities I had to nurse them lying down.

I nursed my boys until they self-weaned at 2 1/2.  It had been a wonderful nursing relationship and I’m so thankful I was able to nurse them the way I did!