Breastfeeding, Twins, and the NICU - Advice?

[Mama2RMM]

I am currently pregnant with twins that will be delivered prematurely due to a medical condition. We can't predict when they will be delivered, but it will be no later than 34W.

After reading so many stories of NICU babies refusing the breast after being bottlefed EBM, I am really concerned about our options while in the NICU. I didn't have a supply issue or problems pumping with my first daughter, and I have a Medela PIS for home use, and will have a hospital grade pump rental for use at the NICU. I really believe I will produce enough EBM for them, and I do understand that it may need to have fortifier added. I am okay with that.

I know that some NICUs and Neonatoligists require that babies "nipple" all feedings before being released. It seems not to matter, to them, whether this is a bottle or a breast. I certainly prefer it be my breast, but I will not be able to physically be at every feeding. I also have a very young toddler that will need me at home.

How much ruckus am I going to cause if I refuse bottle feedings all together, and request gavage feedings when I am not present? If both twins show the ability to feed at the breast during the majority of the daytime feedings is there really a leg for them to stand on about bottle feeding in the evening?

Any input appreciated... also posting in Breastfeeding, so I apologize if you read twice. :)

[redwolf2]

I had my twins at 34 weeks and they were in the NICU for 2 weeks. They had a family room for us to stay in but with a toddler at home I was unable to be the 24/7. They stayed in there at first because they did't have the coordination with breathing and feedings. They were given bottles because they had trouble latching and they would tire quickly while getting frustrated at the breast. They were given a bottle for 30 minutes and whatever they didn't take they got through the NG tube. They were to go home a few days after I was released but they got infections that kept them there for 2 weeks.
I pumped every 2-3 hours. It is extremely important to establish your milk supply. I would set the alarm at night and force myself to get up and pump. When staying at the hospital over night, I would get up at there feeding time put them to the breast (if just for skin to skin because they really weren't nursing) I would feed them their bottles and then go and pump. I didn't want them to recieve bottles at all but it came down to their health and the fact they needed the nutrition in any way they could get it.

I would think only gavage feeding wouldn't allow them to learn the suck swallow breath coordination but I am not an expert.

When we got home I was absolutely determined to get them BF totally. There were times I never thought it would happen. You just have to stick with it. It will happen, don't give up. They just need to wake up and be alert abit. Preemies tend to be very sleepy and when mine started to be more alert they were better at nursing. And little by little remove a bottle feeding. They are 8 weeks now and have been totally bf for 4 weeks now. It was hard but worth it. Just be persistent.

Blessings on the birth and BF'ing. It is a wonderful thing to nurse 2 and watch them grow.

namaste

[DeeEast]

Not much time to type now but my DS was in NICU for 12 days and received bottles along with gavage feedings. The hospital was 1.5 hours away and I had a toddler and his twin to deal with at home, along with recovering from a vaginal and an emergency c-section delivery so I didn't get to the hospital as much as I would have liked. He latched on like a pro towards the end of his hospital stay and ever since he's BFd better than my DD who was BFd from day one. Bottle feeding is not necessarily equal to breast rejection.

[Satori]

We have an MDC mama who's 32 weekers are still in the NICU and are coming up on being 1 mo old. She has been told she can't bring them home until they are 100% oral either breast or bottle but there policys are dumb because they only allow every 4 hour feeding, if you BF your infant every 4 hours you'd have CPS knocking on your door for starving your child! Anyway, she's being forced to allow bottle feedings as she can not be there for every feeding and they have long shift changes (like 2 hours long) in which the parents are not allowed in the NICU which means yet another missed feeding time. I would check to see how BF friendly your hospital really is by talking to other NICU moms there.

[whimsy]

Gosh i can't believe it's been almost 13 years ago already, but when my twins were born @ 34 weeks only 1 went to NICU (100 miles from the other twin - but i digress)

They were all about me breastfeeding. The just weighed the dipes to determine how much she got. i think sometimes they would weigh her before she nursed and after also.

I couldn't be there everyday so she did take some bottle feedings. They were great and did everything they could to make breastfeeding work.

[cdahlgrd]

Babies can learn to nurse after taking a bottle. Yes, babies that young are going to need some practice with a bottle before they go to the breast (there are exceptions, of course).

What you are going to need to remember. . . you are one mamma to THREE children. You will need to do what you can, and LET THE REST GO!! This is the hardest part to having twins, but the most vital. You can't take care of three kids if you haven't slept or eaten in days or weeks, so think now about how you can prioritize, get help, etc.

My twins were healthy 37 1/2 weeker's and needed to bottle feed because of MY problems. I was too tired to finger feed, cup feed, etc. so they got bottles (Advent with #1 nipples). I kept trying to get them to latch on, but tried less and less. I used shields and tubes, etc. But had a hard time handling all that equipment and a baby. Finally at 7 weeks, and not trying to latch them for at least a week, my husband encouranged me to try one more time. I sighed, rolled my eyes, and then put the first one in place. . . and HE NURSED!! Then I NURSED HIS BROTHER!! After a week of transitioning, we were good to go!!

So try not to worry. However, also keep in mind that this isn't all about you. . . their are 3 (or perhaps 5 if you count dad and sibling) people who have to work together to accomplish a breastfeeding relationship.

[tikva18]

We have an MDC mama who's 32 weekers are still in the NICU and are coming up on being 1 mo old. She has been told she can't bring them home until they are 100% oral either breast or bottle but there policys are dumb because they only allow every 4 hour feeding, if you BF your infant every 4 hours you'd have CPS knocking on your door for starving your child! Anyway, she's being forced to allow bottle feedings as she can not be there for every feeding and they have long shift changes (like 2 hours long) in which the parents are not allowed in the NICU which means yet another missed feeding time. I would check to see how BF friendly your hospital really is by talking to other NICU moms there.
That sounds so familiar! The hospital had them going every 4 hrs, the rounds in the ISCU took forever and they were not very breast feeding friendly. Thank heavens I got to bring my babies home after 4 days.

[Mama2RMM]

Thanks for all the replies! Turns out, due to a response over in BFing that mentioned our hospital was totally awesome about breastfeeding, that I called and talked to one of the NICU nurses. They seem willing to do everything in their power to avoid nipple confusion. She mentioned syringe feeding when I could not be present, and anytime I am there they encourage actual attempts at breastfeeding or syringe or finger feeding while the baby is at the breast.

They require that I stay with the babies 24 hours before they are released and that I administer all their feedings during that time. They may be by syringe, cup, breast, whatever... just so long as they take in what they need to gain weight.

I have the most supportive husband at home, and we are hiring help when the babies come home from the hospital. My Mom will also be here on a LOA from work for a month or more. I know that there's no reason I *can't* do this, and now that I know our NICU is behind me it makes everything so much easier to think about! :)

[sarahloughmiller]

That is so great the hospital is so supportive and you will have so much help at home when they do come home. I hope everything goes well and they don't have to stay too long.

[Karen Gromada]

Thanks for all the replies! Turns out, due to a response over in BFing that mentioned our hospital was totally awesome about breastfeeding, that I called and talked to one of the NICU nurses. They seem willing to do everything in their power to avoid nipple confusion. She mentioned syringe feeding when I could not be present, and anytime I am there they encourage actual attempts at breastfeeding or syringe or finger feeding while the baby is at the breast.

They require that I stay with the babies 24 hours before they are released and that I administer all their feedings during that time. They may be by syringe, cup, breast, whatever... just so long as they take in what they need to gain weight.

I have the most supportive husband at home, and we are hiring help when the babies come home from the hospital. My Mom will also be here on a LOA from work for a month or more. I know that there's no reason I *can't* do this, and now that I know our NICU is behind me it makes everything so much easier to think about! :)


Anna, lots of MOT have helped twins transition to breast after all kinds of alternative feedings -- including bottle feedings. Does this hospital have LCs in the NICU? I'd call and talk to one of them. Keep in mind that you will have a toddler in addition to twice the usual number of newborns coming home -- plus you WILL need to keep pumping until both babies obviously are breastfeeding effectively. So alternative feeding methods that may be realistic for a mom of a single aren't always realistic for a mom with twins. Not trying to discourage, especially since your mother will be available to support you, but realistic optimism is useful!

Work first on kangaroo care -- that often "accidentally" leads to a first BF -- and getting an early start on moving milk/pumping. (Don't worry about how much you obtain the first days; just pump 8 or more x/ 24 hours.) When either starts nuzzling, ask if you may offer the "empty" breast by pumping immediately belfore. As each shows she can handle the "empty" breast, ask if you may try BF before pumping. Move forward based on each baby's cues -- expect each to have a somewhat different pace in the transition. The most important thing is commitment to transitioning with continued practice, persistence and patience. (May take a bit beyond full term due date for the transition, as preterms may need time to make up for other issues that affected them.)

I no longer believe it is the bottle-feeding, per se, that interferes with BF and there's no real research to support the notion of "nipple confusion." I think what we call nipple confusion is actually related to bottle teat flow rate and the adaptations a baby must make to control flow with coordination of breathing. A LC colleague and I tested bottle nipples and found several that "rewarded" babies without being too fast. BTW, the brand starting with an A was faster than we think within compatibility. We checked the bottle teats provided in-hospital too and one was better than others, although all were faster than desired. (I'm willing to share more specifics, but ask via personal email.) Some NICU let parents bring their own bottle-feeding systems in -- at least before discharge for a few feeds.

In addition to flow through the bottle teat, holding a baby in a seated position (flexed at hips -- not waist) can help. (Don't we feel more in control when eating in a seated vs. when lying down?!?!) Then take the tip of the bottle teat and gently tap baby's nose to elicit rooting and a wide mouth gape so baby can latch onto the bottle as you want her to latch onto you. Bottle-feedings shouldn't be rushed. Very young infants pause more during feedings and those pauses should be respected vs constant jiggling to get baby to suck. Preterms may need some stim to "remind" them to keep going, but pausing for a bit won't hurt and may help.

Rule #1 always is "feed the baby" and with preterms that sometimes includes less than ideal feeding practices. But as baby does better, one moves to the better feeding practices.

Good luck. Get in touch if there's other info that may be useful. No matter what the initial circumstances, most preterm babies will move to breast in time...

Karen

[GatorNNP]

balawre,

Hi there, just wanted to give some input from a Neonatal nurse practitioner point of view. I personally feel that the first by mouth attempts should be made at the breast. at 34 weeks some preemies will be "pirhannas" or "pokey". the pokey ones wont eat by mouth, the pirhannas act like a term infant with eating--you never know how they will act depending on their maturity. If the babies won't eat then they should be tube fed. Do not allow your infants to be given bottles until they are successful breastfeeding. Once they are breastfeeding 2 times a day at least that is when I would feel okay about introducing bottle feedings. Getting them to latch on is important, however getting them to eat all by mouth gets them out the door.

Tips to help preemies latch on: pump to at least one let-down prior to nursing them, latch on sometimes takes a little bit for them to be ready and you don't want to be really full or bursting just thinking about feeding them, a softer breast is easier for them to manage, and you will still have milk, the flow will be a little slower and easier to manage. I usually have moms start breastfeeding attemtps with pumped breasts for a few days (and I tell the nurse not to expect them to do anything) so there is less expectation and no feelings of failure.

You may want to try and find someone to help with your toddler so you are able to try and get some rest each day to help your milk supply come in. Also you want to make sure you have a hand pump with you at all times in case you are delayed in getting to a pump room or your house, pump in the car--whatever it takes to pump enough times per day, frequency is important initially.

Hope that helps you.