Every family has a unique feeding journey. I never get bored of hearing people’s stories. But there are a few scenarios that crop up more often than others. Painful breastfeeding. Non-latching babies. Windy, fussy babies. And triple feeding….
What in the world is triple feeding you ask? Well, you may be doing it without realising it had a name! It’s where you breastfeed your baby, and also express, and top them up with a bottle (of either your breastmilk, donor milk or formula).
How do people end up triple feeding?
Good question! It’s definitely not something you’d choose to do. It’s hard work, and very time consuming, so why would you do it? Well, I’ve run into a number of scenarios, but the most common ones are:
- Sleepy baby who is not feeding effectively
- Babies with excessive weight loss, who have been put on a feeding plan
- Low milk supply
- Late preterm babies, who sometimes need a bit more time to be able to complete an entire feed at the breast
- Babies with some underlying medical issues sometimes need more calories than normal, so although breastfeeding is going well, they need more than the average baby just to get by
I’m going to focus most of this article on the scenario I see playing out every single week, for the last several years. The baby who has been put on a feeding plan.
It all starts in the first few days…
In my experience, triple feeding and eventual feeding plans usually have a back story that goes back to the very first day. The all-too-familiar tale is of a baby who seemed to be feeding, only to be weighed a couple of days later and for a weight loss of more than 10% to be discovered. I cannot stress enough the value of being able to recognise effective feeding – try watching this video if you’re not sure. I also cannot stress enough the importance of responsive feeding – or feeding whenever you or your baby feel the need to feed. This is usually at least 10-12 times in 24 hours, including at night. If your baby is feeding less than 8 times in 24 hours, then it’s time to get suspicious!
A typical triple feeding tale
A parent who we’ll call Jane, her partner Sam, and their baby, who we’ll call Ali are enjoying cuddles and closeness after birth. Ali has a little feed, which Jane thinks has gone well – but after all, with nothing to compare to, it can be hard to figure this out. Overnight, Ali feeds maybe once or twice, and then the next morning seems quite sleepy still. Nobody is overly concerned. Someone has checked the latch and says it ‘looks fine’. Jane, Sam and Ali get ready to go home, and are handed lots of leaflets on their way out.
At home, Ali continues to be a little sleepy, but having not been concerned in the hospital, Jane and Sam are not too worried. That evening, Ali seems to want to feed non-stop, and cries quite a lot. A fairly sleepless night ensues…
The next day, Ali is weighed, and is found to have lost 10% of their birthweight. Jane and Sam are bewildered – after all, they did everything they were supposed to. They are put on a feeding plan, and told to allow Ali to breastfeed every 3 hours (not something that is evidence-based, but commonly recommended), but also to offer 40ml of expressed milk or formula, and pump. Triple feeding has now entered the mix.
Jane tries hard to pump, but with a baby to care for, as well as her healing postnatal body, and a good wallop of the baby blues, not to mention feeling awful that their baby has lost weight, this is a pretty unsuccessful and time consuming feat that they quickly write off as a bad idea.
At this point – how the story plays out depends on a number of factors:
- Do they know what the underlying cause of this problem was?
- Has anyone really assessed the quality of the latch? Or was it a cursory look by an inexperienced eye?
- Is there a fundamental problem with the baby’s suck or health?
- Does Jane know how to get the best out of the pump?
- Do they know how important hand expressing is?
- Have they seen anyone at all with some counselling skills (and the time to use them)?
- Have they been shown how to practice paced bottle feeding?
- Do the family have some goals in mind?
- Is anyone working with them to help them achieve those goals?
The trick with this situation is to have a sustainable plan. It boils down to this:
- Keep the baby fed (preferably in a style supportive of breastfeeding, using mums own milk, donor milk, or formula)
- Protect the milk supply (and possibly increase it if necessary)
- Figure out the underlying cause and make a bespoke plan to help the parents achieve their goals, bearing the cause in mind
- Transition the baby back to direct breastfeeding (if desired by the parents)
If there is no plan, then triple feeding can go on and on, relentlessly. If formula is involved, then unless there is an active management plan to increase the maternal milk supply, then this will almost certainly take a hit. Lactation consultants are NOT anti-formula. Sometimes it is a necessary part of this process. But parental feeding goals are important, and not meeting them can lead to grief and regret and sadness, as Amy Brown‘s work has shown all too well.
Step 1: Keep the baby fed
Sounds simple enough right? This is the part of the plan that is easiest for everyone to make sure of. But the devil is in the detail. It’s not enough to simply give parents a number of millilitres to get their baby to drink every few hours. Parents need to know how to feed this milk to their baby as well. There are a couple of things that can go wrong here:
Firstly, if the baby is being supplemented with a bottle, it is essential that the parents know how to pace the feed, and feed responsively. This slows the feed down, helps the baby to manage the flow rate, and prevents the baby from becoming frustrated with the slower flow from the breast. At the breast, a baby is more in control of the flow of milk, and the flow rate changes throughout the feed, according to fullness, infant suckling, and individual anatomical factors.
Pacing the feed can make a big difference to how successfully the baby will breastfeed later on. Have a read of my earlier blog on bottle feeding here, and try watching this video made by a colleague of mine, Wendy Lever IBCLC.
Remember you don’t have to use a bottle. There are other options – such as supplementer (where you use a feeding tube at your breast so that your baby stays at the breast while they receive their supplement). You could also use a cup, spoon, or finger feed. It’s worth talking to an experienced breastfeeding counsellor or IBCLC if you want to use any of these options.
The second problem I run into is the baby who is fussy at the breast. One scenario I’ve seen play out over and over again is the baby who is not effectively latching, or becomes distressed at the breast. Often, parents give up and the baby has a bottle. The problem is that if we consider this unsuccessful attempt as a breastfeed, and do not protect the milk supply, then the supply will quickly dwindle.
A better way is often to make sure the baby is calm and not super hungry. This way, they’re more likely to have an effective feed. In practice, offering a small amount of their top-up can calm a hungry baby so that they can feed effectively. Christina Smillie MD IBCLC pioneered the term ‘finish at the breast’ – although of course, many parents find themselves instinctively trying this when they realise that breast first doesn’t work so well.
Step 2: Protect the milk supply
This is the part of triple feeding that most often gets missed. There is a narrow window of opportunity to calibrate the milk supply. If we miss that window, then it can be much harder (but not impossible) to increase milk production. Often the focus is on ensuring the baby is fed, which of course is the priority, but we cannot take our eyes off the vulnerable milk supply.
You’ll need to protect your milk supply. Either with your baby, the pump, hand expressing, or possibly all three!
Your baby is the obvious first choice. If your baby is keen and willing to breastfeed, then do this as often as you can. If your baby is not feeding effectively, then you can get help with this. Some quick tips:
- Watch your baby for deep, active suckling with rhythmic jaw movements
- Listen for audible swallows (they don’t always sound like gulps – sometimes they sound like a little ‘hup-ah’ sound)
- Watch your baby’s tone and posture, including their hands. A baby who looks relaxed and is obviously drinking is reassuring. A baby who is wriggly, squirmy, fussy, and pulling off and crying is less so.
- Try some breast compressions to increase the flow and fat content of milk
If you need to use a pump, look at this video of hands on pumping, by Jane Morton. And when you’re convinced (by the end!) that hand expressing really is more effective at removing milk than a pump, then you could have a look at this video by Maya Bolman IBCLC.
Also think about when you pump. Parents are often taught to pump every 3 hours. I tend to recommend a much less rigid plan of pumping. You could pump more frequently at some times during the day, and then less frequently at others (just like a baby does). Some people talk about power pumping, cluster pumping, or switch pumping.
You’ll need to find what works for you. I often suggest leaving your pump out, and simply pumping for 3-5 minutes every time you remember, or every hour. Removing fixed ‘rules’ sometimes is the best way to get over a psychological block with pumping. If you’re struggling, try watching this video I made a while ago.
Finally, you may want to try a ‘galactogogue’. These are foods, herbs or medicines that may increase your milk supply. It’s unlikely any of them will work as a ‘magic bullet’, and it’s also really important that your chosen product is tailored to your underlying need. Diana West IBCLC and Lisa Marasco IBCLC have a great book that I highly recommend.
Step 3: Figure out the underlying cause
It sounds pretty obvious, but different people have a different problem. If we adopt a cookie cutter strategy with triple feeding, it’s unlikely to be successful with lots of people. Understanding the root cause is much more likely to work well. When I’m working with a family, I spend quite a lot of time listening to their story, hearing about the first few days, as well as asking some specific questions. I’m trying to work out whether the low weight gain is due to:
- Primary maternal factors
- Combination of infant and maternal factors
- Infant issues only
I usually start by trying to rule out primary lactation problems. These include chest/breast surgery, trauma, scars and anatomical problems. It also includes assessing for signs of breast hypoplasia/insufficient glandular tissue. I also ask about endocrine problems such as fertility, hormonal, thyroid problems and diabetes. Finally, I want to know about breast disease, and any red flags.
The next part of the detective work for me is to rule out infant issues. The best way to do this is by watching the baby feed. I cannot tell you how many times I have been to family who have been told by numerous health professionals that the latch looks ‘fine’. The difference between a baby with breast tissue in their mouth and an optimal latch can look subtle to a less experienced eye.
Almost 100% of the time, there are improvements that can be made to optimise the effectiveness of the feeding. I will also look at the baby’s tongue, palate, tone and overall wellbeing and either refer on or keep an eye on things, as the situation dictates. Just occasionally, a baby is actually unwell – see my earlier post on how to survive a hospital admission with a breastfed baby.
I leave the most likely scenario last. Usually this situation arises because although there is the potential for a full milk supply, something has happened in the early days that has got things off on the wrong foot. The less effectively the baby feeds, the less milk they remove. I sometimes call this behaviour ‘let-down surfing‘. Often the baby loses weight, and simultaneously the milk supply can either dwindle, or the mother can become uncomfortable with engorgement or sore nipples from a shallow latch.
When we know what the underlying problem is, we can target the treatment. It might be to improve the latch. It might be to increase supply. It might be to get the baby healthy again. Whatever it is, the goal is to figure it out and make a plan.
Step 4: Transition the baby back to the breast
Because triple feeding is not sustainable, we’ll want to move off it as soon as possible. There may be many ways to do this, but this is often what I suggest:
- First, let’s get the baby gaining weight consistently. 20-30g per day and 2-3 yellow stools. The basics are important.
- Then, if milk supply is responding and baby is gaining, we can move on…
- Consider reducing the formula component by 30-40ml in total (not per feed!). We don’t want to put the baby at risk. Reducing the formula a little bit will challenge the milk supply but not risk the baby’s health.
- In practice, this could be one entire top up feed that you abandon, or you might want to reduce the amount of 3-4 feeds by 10ml.
- You could also consider reducing the amount you pump, so more milk is in your breast, rather than the bottle! In practice this could be abandoning one pumping session, or you could consider doing away with all but 2-3 tactical pumping sessions.
- While all this is going on, you’ll need to keep a careful eye on baby’s behaviour, nappy output and weight gain. The baby’s health and well-being are the top priority.
- I normally suggest reducing the formula every 3-4 days. You’ll find this less stressful, as it will take your body a few days to catch up with the increased demand.
An end to triple feeding
I always suggest to people that they set time limits. Triple feeding is very tiring, and emotionally draining. If there is an end or a review point in sight, then psychologically it’s easier to keep going! I will often work with my clients for a few days intensively, then we review and find out if the plan is working or not. It is either;
- Working a little bit, and we carry on a bit longer to improve the situation even more
- Working so well that we can start reducing the top ups faster
- Not making much difference – in which case we decide whether to persevere a bit longer, or make a sustainable plan to move forward with.
If we end up with that last option, then most parents are hugely comforted by the knowledge that they tried everything. There is peace when we know that. You might decide to keep hold of the most meaningful breastfeeds, and bottle feed in between. The parent might decide that breastfeeding with a supplementer is the way forward. You might decide that you’ll keep going with expressing and stop breastfeeding. Or you may feel that you’ll just keep up what you’re doing until it comes to a natural end.
Everyone finds what works for them. It’s not up to me – it’s your baby, your breasts, your family. I’m just the facilitator.
Lyndsey Hookway is a paediatric nurse, health visitor, IBCLC, holistic sleep coach, PhD researcher, international speaker and author of 3 books. Lyndsey is also the Co-founder and Clinical Director of the Holistic Sleep Coaching Program, co-founder of the Thought Rebellion, and founder of the Breastfeeding the Brave project. Check Lyndsey’s speaker bio and talk brochure, as well as book her to speak at your event by visiting this page. All Lyndsey’s books, digital guides, courses and webinars can be purchased here, and you can also sign up for her free monthly newsletter here.
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