Archives of Perinatal Medicine 16(4), 201-205, 2010 ORIGINAL PAPER

Breastfeeding of twins
BOGUMIŁA KIEŁBRATOWSKA1, DOROTA ĆWIEK2, KRZYSZTOF PREIS1,
WITOLD MALINOWSKI2, AGATA HOFMAN3

Abstract
Natural breastfeeding is beneficial to a mother and to twins. Twins fed with breast milk less frequently suffer from
infections of the respiratory system and septicaemia. Breast milk ingredients have a positive influence on the
digestive system, the immune system, and other systems, especially in case of premature twins. Organisation
of hospital units, professional training for employees supporting mothers of twins, plays a vital role in natural
feeding promotion.
Key words: milk, breastfeeding, breast, mother, twins

Natural feeding is one of bodily functions that deve-
loped during evolution in order to support harmonious
development of men. It sustained human life and exi-
stence for millenniums. It is also fundamental to the
development of a modern man. During evolution the
perfecting human genetic program has guaranteed opti-
mal composition of mother’s milk which is compatible
with the needs of a newborn and an infant. Its ideal, spe-
cific ingredients make it incomparably better than all ar-
tificial mixtures, milk-like products or milk of other
mammals. According to our present knowledge, mo-
ther’s milk is the optimal food for newborns, infants, and
small children. Its influence on immune system is also
widely appreciated. It is especially beneficial in case of
premature children because of its effect on NEC, ROP,
and BPD. Moreover, it facilitates neural development.
Mother’s milk is also applicable to the treatment of so-
me diseases in older children and adults, among them
immunodeficiency, allergies, metabolic disorders. The
composition of mother’s milk changes during the day,
later during subsequent weeks and months of breast-
feeding, depending on the needs of a baby [14].
Mother’s milk is the best food for a baby, which has
been confirmed for years by many Polish, foreign, and
international organisations which deal with the problems
of baby’s nutrition.
In December 1997, the American Academy of Pe-
diatrics (AAP) published the statement entitled Breastfee-
ding and the Use of Human Milk which contains scientific
researches, information, and recommendations for pa-
rents and people supporting women after childbirth. The
statement of The American Academy of Pediatrics indicates
various advantages of natural feeding and emphasises that
“the breastfed infant is the reference or normative model
against which all alternative feeding methods must be mea-
sured with regard to growth, health, development, and all
other short- and long-term outcomes” [18].
Advantages of breastfeeding are well documented
and there is no question about their plausibility. Ingre-
dients supporting the immune system in mother’s milk
protect a baby against bacterial and viral infections [5].
The duration of natural feeding is also crucial to the de-
velopment and health of a baby. A human is a mammal
and mammals are born immature to independent exi-
stence and they need mother’s milk during the time of
growing up to independence. Natural feeding is not only
a natural phenomenon. It is also a relationship that is
born between a mother and her newborn baby [1].
Milk has an ideal composition as far nutritional va-
lues are concerned. It contains all ingredients that are
indispensable to a developing child:
• water (clean, filtered),
• proteins (easy to digest, do not sensitise),
• fats (mainly unsaturated, necessary for the develop-
ment of nervous system and retina),
• sugars (lactose — material necessary for nervous
tissue),
• vitamins, minerals, digestive enzymes,
• growth factors,
• hormones,
• and many other substances that adjust proportional-
ly to the digestive efficiency of a baby [6].
While expecting a baby women most frequently do
not show interest in thorough knowledge of breastfee-

1
Department of Obstetrics, Medical University of Gdańsk, Poland
2
Department of Obstetric and Gynecology Nursing, Pomeranian Medical University of Szczecin, Poland
3
Faculty of Languages, University of Gdańsk, Poland
202 B. Kiełbratowska, D. Ćwiek, K. Preis, W. Malinowski, A. Hofman
ding. When a woman starts to learn how to breast-feed,
it is important for her to know something about physio-
logy of processes stimulating lactation. Mother’s milk
has a perfect composition that acts as a protection in-
comparable to any artificial mixture.
Breastfeeding is especially important for twins who
are frequently born prematurely and thus are excep-
tionally susceptible to many infections. A multiple child-
birth is an exceptional situation for a mother and for
hospital’s health service. Nevertheless, nature enabled
a woman to breastfeed more than one child. Yet, it is
commonly believed that breastfeeding of twins is diffi-
cult, troublesome, and even impossible. For years hospi-
tal practice and convictions have favoured supplemen-
ting natural feeding with a bottle since the birth of twins
which has no scientific background and proves negli-
gence of perinatal services in hospitals. However, there
are instances of twins, or even triplets, fed solely on mo-
ther’s milk who often do not know any other kind of food
for the first 12 months of their lives [1, 4]. Anxiety about
the deficiency in mother’s milk for both newborns is
groundless. The scientific researches demonstrate that
the production of milk in case of mothers of twins is
doubled. Six months after childbirth a body of a mother of
twins can produce from 1.0 to 2.0 kg of milk per day,
while a body of a mother of triplets, more than 3.0 kg
[9, 17].
Most often mothers of children from multiple preg-
nancies want to breastfeed their babies or feed them
with their milk from the bottle. Giving birth to twins is
neither a contraindication to breastfeeding, nor an indi-
cation to bottle-feeding. Nonetheless, giving newborns
bottles can cause disorders in mechanics of sucking and
consequently make normal breastfeeding impossible.
Breastfeeding of twins is much easier than breast-
feeding of triplets and is possible but requires help from
health service and family. Encouragement to mothers to
breastfeeding should not be limited solely to presenting
its advantages. Mothers should be informed also about
obstacles which are to be avoided so that lactation pro-
ceeds without difficulties, especially in the event of pre-
term birth.
Natural breastfeeding of premature twins requires
preparing a mother by informing her how she should
stimulate lactation and how she should maintain lacta-
tion on the level indispensable to baby’s nutrition.
A mother should be encouraged to:
• an early and frequent contact with a newborn baby,
• begin regular expressing of breast milk as quickly as
possible, at least 8 times per day, also at night,
• expressing breast milk before planned breastfeeding,
• get a baby to latch on whenever the baby’s condition
is favourable.
A mother of premature twins should be taught how
to hand-express breast milk and how to use a breast
pump. A mother of twins is under stress which makes
her feel lost in new reality so she requires special care.
After childbirth it is crucial for a mother of premature
twins to begin breast stimulation by expressing milk as
quickly as possible. Premature infants are not breastfed
at the beginning. Most frequently they are nourished pa-
renterally. Nevertheless, since the first hours and days
after giving birth to a premature infant it is recommen-
dable to give him or her drops of mother’s milk. This
will facilitate the development of the digestive tract and
prepare mucous membrane for digestion of other food.
Mother’s milk contains immune bodies which protect
a baby against bacteria and infections.
When a baby’s condition stabilises, it is best to pro-
vide him or her with regular, direct contact with a mo-
ther. If a mother decides on stimulating lactation and if
newborns seem ready to coordinate sucking and brea-
thing, a mother should try to lay a baby on her body and
to begin latching a baby on, which is called kangaroo
care. When a mother of a premature infant is taught how
to look after her baby, she is encouraged to establish her
relationship with it by touching, stroking, and hugging.
Initial breast milk expression often limits itself to
single drops of milk which discourages a mother who is
not aware of the development of lactation physiology. In
this case, health service taking care of a baby should sup-
port a mother by informing and motivating her during
breast milk expression training.
First days after childbirth is a special time during
which every woman, especially a mother of twins, requi-
res help and support in initiation of lactation.
Difficulties which might hinder breastfeeding:
• more common complications of pregnancy, child-
birth, and the puerperium,
• tiredness,
• stress,
• emotional problems,
• doubts about feeding potential.
Difficulties resulting from giving birth to twins:
• there are two of them – coordination in feeding
two children,
• condition of children preventing breastfeeding diffi-
culties in initiation and sustenance of lactation,
• prematurity,
 Breastfeeding of twins
• absence of sucking reflex or poor sucking reflex 6
poor food consumption,
• absence of coordination of sucking – swallowing –
breathing 6 poor food consumption ŕ slow weight
gain,
• CNS injuries or immaturity,
• necessity for the separation of children because of
treatment in Neuro-Intensive Care Unit.
Most often problems with the beginning and conti-
nuation of natural feeding appear already in a delivery
room or later in maternity unit where a mother stays
with her child. They depend mainly on the knowledge
and involvement of health services.
Among hospital practices influencing the pro-
cess of lactation are:
• absence of latching on in a delivery room or post-
operative room,
• separating a mother from a child 6 difficulties in the
beginning of lactation,
• rare breastfeeding,
• supplementary feeding,
• giving a pacifier,
• absence of support from health service.
On the other hand, there are perinatal practices
which can facilitate natural feeding:
Introduction of friendly hospital practices
• Latching on half an hour after childbirth, if possible.
• Prevention of separation of a mother and a child, if
possible.
• In case of prematurity, encouraging and permitting
a mother to be with her children as often as possible
and to introduce kangaroo care and touch stimula-
tion.
• Avoiding supplementary feeding, unless it is neces-
sary.
• Avoiding pacifiers in silencing a child.
• Health service support for a mother.
• Establishing a constant, regular support for a mo-
ther by fixed service which does not change during
duty hours.
• Continuous, professional service providing informa-
tion on lactation.
• Easy access to pillows and other accessories nece-
ssary for a proper position of a child.
• Access to breast pump or to breast pump rental.
Treatment of a mother
• Allowing her to rest and motivating her to breast-
feed.
• Mother’s education.
203
• Improving her self-esteem.
• Encouraging a family to join in housework in order
to help a mother.
• Treatment of concomitant diseases without distur-
bing lactation.
• Health service willingness to support and to help
a mother.
• In case of children who cannot be breastfed, helping
a mother to express milk and providing her with
necessary accessories, including freezing sets (ra-
tions should be small, initially 1-5 ml).
Treatment of children
• Individual and/or simultaneous feeding of babies
depending on their needs. Each twin is an individual
with different needs and different sucking rhythm.
• Feeding a baby according to its condition, favourably
on mother’s milk.
When babies cannot be fed:
• expressing food by mechanical breast pump after
birth, as quickly as possible (during first 6-12 hours).
• expressing food 8 times per day or every 100
minutes per day.
In hospitals a majority of mothers starts to breast-
feed babies but many mothers decide to give their ba-
bies artificial formulas and drinks too early. Some of
them rashly resign from breastfeeding. Such situation
demands continuous promotion of the recent knowledge
on feeding and bringing into effect recent findings so
that children are nourished properly. Breastfeeding pro-
motion in hospitals should make women realise the role
of breastfeeding as an exclusive form of nourishment.
The more so because mothers who are to become
adept at breastfeeding initially feed their babies separate-
ly. One child should be breastfed and suck from a breast
at least 8 times per day. In case of twins this number dou-
bles approximately to 16-20 feedings per day while one
feeding of a baby lasts more or less 30-40 minutes. During
first days after birth twins should be fed in turns so that
each twin learns how to suck a breast properly. Con-
sequently, feeding of twins in turns lasts approximately 12
hours per day and may be exhausting for a mother.
A mother, who becomes an adept at feeding babies,
should be encouraged to simultaneous twins feeding.
Methods of breastfeeding of twins should be used con-
currently.
Positions which might facilitate twin feeding:
• initially when a mother is still tired she should sit in
a reclining position with a baby on a pillow tuck un-
der her arm,
204 B. Kiełbratowska, D. Ćwiek, K. Preis, W. Malinowski, A. Hofman
• both children crosswise in classic position,
• latch on one twin from under an arm and the other
in classic position,
• both children latched on from under an arm
secured with pillows, blankets.
During breastfeeding of twins it is possible to use:
• Breastfeeding rotation (depending on a mother’s
decision):
– change of breast every feeding,
– change of breast every day,
– each child has its own breast.
• If one twin has bigger problems with sucking (is
weaker) it is recommended to devote him or her
more attention, latching him or her first or more
frequently.
• If one of twins or both of them have to stay in an in-
cubator or need individual specialist care and cannot
be breastfed, a mother should express food as often
as in case of breastfeeding.
A woman who breastfeeds twins should take care of
herself, rest anytime she can, eat right, drink more etc.
In order to control twins sucking and activeness a mo-
ther can “allocate” each twin to one breast for a day.
Feeding of twins and triplets based solely on breastfee-
ding for the first 6 months is absolutely normal but re-
quires discipline from a mother and help in organisation
from a family [14].
Sometimes a breastfeeding mother may face some
difficulties:
• A child who has problems with sucking should be
latched on after the first one because the reflex go-
verning the outflow of milk is already working.
• In case of slow weight gain a mother should express
milk and use alternative methods of feeding.
• If a mother has big bust and children have problem
with holding a nipple it is advisable to apply sand-
wich nipple technique.
Mothers can benefit from twins breastfeeding. When
they do not have to waste time on additional time-consu-
ming activities connected with preparing artificial food,
washing and sterilising bottles they can devote more
time to direct contact with children which has an unque-
stionable influence on their emotional relationship. Bre-
astfeeding helps a mother to avoid superfluous equip-
ment when she takes a walk, travels with her babies, or
does anything else that demands going out. Material
gains are significant as well. Even if costs of additional
nutritional needs of a mother are taken into account, the
costs bore still will not exceed 1/3 of costs of artificial
food, which is a matter of great importance for a dep-
leted family budget. A mother of twins is capable of fee-
ding her children but she often doubts about her feeding
potential. Nonetheless, breastfeeding is of utmost impor-
tance for twins who are frequently born prematurely and
are therefore more susceptible to different infections [7].
First weeks after giving birth to children are a true
challenge not only for a mother, but also for her family.
When a woman is learning how to breastfeed it is nece-
ssary for her to gain knowledge on the physiology of pro-
cesses stimulating lactation. In first two days mammary
glands produce a thick substance called colostrum. It
may be yellow, clear, or olive green. It appears in nipples
during the last months of pregnancy. Simultaneously it
constitutes a perfect food for twins, especially those born
prematurely. After giving birth to a child the whole fe-
male organism prepares itself for fulfilling the needs of
newborns.
The balance between “supply and demand” is essen-
tial for breastfeeding. The manner and frequency of
child’s sucking from the breast influences the production
of milk. If a baby sucks more often and longer, it can in-
crease the food production. During the period of breast-
feeding there are days where feeding seems to have no
end [20].
Women frequently complain that they do not have
food or that they do not have enough milk and then they
resort to supplementary feeding. It is a mistake. Stimu-
lating nipples (sucking) is a factor that influences milk
production. If women do not latch their babies on, the
reflex stimulating milk production will not appear. Sup-
plementary feeding of newborns is the main reason for
loss of milk and consequently for cessation of breast-
feeding. That is why introducing bottle-feeding frequent-
ly marks the beginning of an end of breastfeeding. Con-
stant contact between mother and children enables fee-
ding of twins according to their individual needs. This
method of feeding is called feeding on demand, which de-
pends on the needs of a mother and children, and is be-
neficial to a mother and to her children. Initial latching
on should occur already in a delivery room or in a post-
operative room. Later frequent unlimited feeding stimu-
lates lactation and enables its long sustenance.
Direct meetings of pregnant women and mothers
who efficiently breastfed their twins are the best method
of natural feeding promotion. Prearranged meetings with
mothers of twins who breastfeed at present should be
the perfect way of encouragement [4].
As far as breastfeeding promotion is concerned, it is
necessary for a midwife, a nurse, a doctor, and a lacta-
 Breastfeeding of twins
tion consultant to cooperate closely without competition.
A nurse and a midwife have a genuine medical knowle-
dge and offer their guidance within the scope of feeding
during prenatal and postnatal period as well as during
the whole period of breastfeeding. In the event of proble-
matic cases concerning all aspects of breastfeeding, con-
sultants from the International Board of Lactation Con-
sultants Examiners (IBLCE) running lactation groups
offer their professional help [3].
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J B. Kiełbratowska
Department of Obstetrics
Medical University of Gdańsk
80-402 Gdańsk, ul. Kliniczna 1a