Worried for DSIL - tiny twins and feeding

[designerbaby]

Hi all,
My DSIL gave birth to beautiful twin daughters a fortnight ago by CS. They are tiny wee things weighing just 2.1 and 2.2kgs and spent their first week in the NICU on oxygen and tube fed.

DSIL is in the US and we skype 3-4 times a week. She seems increasingly down. I know it's been a tough and worrying fortnight, so to a degree thus is to be expected. Plus she is in recovery from a CS which can't be much fun.

One thing that concerns me though, and I feel like Can't be helping, is feeding. She is currently pumping and the babies are bottle fed a mix of EBM and formula. This is apparently because the DTs are too small to suck, and the paed wants an exact record of how much milk they are having - to the ml - and when. The babies aren't put to the breast at all at the moment. DSIL says she doesn't have much milk yet (?).

Everything I know about BF (which admittedly is only from EBFing two huge, strong sucking singletons) says to me that these little ones should be on the boob as much as humanly possible both to help DSIL establish supply, and to help their sucking, not to mention the bonding and psychological benefits.

I asked DSILs wife one time about the supply - as I didn't want to worry DSIL and she said "we're pumping every 2-3 hours so her supply should be fine". I really wanted to say that in my experience pumping is nothing like BFing which is as much an emotional and psychological thing as it is a physical one and that nursing might be helpful in a variety of ways... I know that I found pumping both difficult and depressing, with disappointing results, but found BFing totally different. But I kept schtum as I didn't feel I know enough about their specific situation.

Please can someone give me some insight as to the challenges of looking after tiny prem twins, and whether my instinct about the BFing is at all relevant?

She looks very blue, we rarely see her holding the babies (but that may only be when skyping) and she's very quiet... Probably knackered but still, this is very unlike her. I experienced PND with DD1 and I know how big a part of my psychological state was linked with my experience of BFing, I can't help but wonder if the relentless pumping, lack of supply and not BFing at all is contributing.

But I'd like your opinions and experiences before I venture anything. Aware if the need to be well informed and tread carefully.

Sorry, mammoth post. Especially grateful to any who have made it this far through my ramblings and iPhone typos.

db
xx

Tiny babies = tiny tummies

I would imagine she is being overwhelmed with info at the moment. If it were me I would hold back on saying anything, just try to be supportive.

The first weeks with twins is just a blur and a haze. I ended up Bfing one and pumping for the other as she refused to latch on.

Hope the little ones get bigger and start to suck soon.

You don't say how early they were but am guessing 30+ weeks by those weights. I had my twins v early (27 weeks) and they were tube fed to start with. It may be that its done slightly differently in the US, so I guess for the time being you just need to be supportive but if she or her husband ask for extra info, then perhaps pass on what you know or suggest a couple of tweeks. If the babies are not strong enough to breastfeed (it might be that the Dr thinks they need to conserve their energy), then she has no alternative but to keep pumping, and every 2-3 hours is fab (as long as she's doing it throughout the night too). I imagine that if she's recovering from a section too, it just might take a little bit longer for her milk to come in.

I was told that the sucking reflex starts to develop at about 34 weeks - when mine got to that age, I'd put them on the breast whilst they were being tube fed (so they associated the feeling of having a full tummy with being on the breast) and gradually (it took 4 weeks) we reduced the amount of EBM they were having via the tube as I felt them sucking / feeding better. As we got better, they'd have a b/f, I'd then tell the nurse how long they'd fed for / how many sucks they'd had and she'd decide whether they needed a tube top up or not. There may be reasons why the Dr wants to know exactly how much they've had (perhaps they're not growing very quickly or have other complications?) but after my babies had breastfed, they used to pull a tiny amount back through their tube to see what was in their tummy - obviously if it was milk they knew they'd properly fed.

In the early days (so I had at least 4 or 5 weeks before they were put to the breast) the focus on bonding was on kangaroo care, doing the cares for the baies etc rather than just the b/f. As long as she's getting lots of skin to skin then she should still be bonding with them - b/f isn't the only way to bond.

Don't know whether you've heard of BLISS - the charity for premature babies but they have lots of useful info on their website which your DSIL and his wife might find useful. (www.bliss.org.uk)

Mine were little I expressed for them. It was knackering and demoralising. But they weren't my first children so that bit wasn't so much of a shock.

I think the best thing they can do is lots of cuddling skin to skin. Don't worry about trying to feed directly - nothing worse than trying that when their mouths aren't big enough. That will stimulate the milk production, stimulate the babies and help bonding. If things work out they will start feeding when they are ready, if not then formula is a good substitute.

One thing I learned the hard way - breast feeding is great - but if it doesn't work out in the great scheme of things it is not the most important thing.

My twins were born at 31 weeks and tube fed. As they were so early and delivered by EMCS my milk took 5 days to come in so they were on formula. We then moved to a mix of breast milk and formula as they needed to go on a special high calorie formula to boost their weights. It is hard hard work. If they are sub 34 weeks they will not have a sufficient sucking reflex to feed and it exhausts them too much. I ended up in a vicious circle of expressing, bottle feeding and tube top ups. I gave up after five weeks as supply was crap and medication didn't help increase it. The paeds needed them to finish a certain amount every feed, on their own without a tube top up before they were allowed home - that could have been of expressed breastmilk but it didn't work for us.

She is probably shattered, missing her babies, stressing about how they are feeding and it is exhausting spending every day in a hospital visiting them but it does come to an end and hopefully she will have them home soon. My biggest piece of advice would be to not get hung up on bf, yes its the ideal but it doesn't always work.

Also, if she is expressing, it needs to be every 2-3 hours including through the night and using a hospital grade pump. I was prescribed domperidone (which I know they prescribe more freely in the US) it didn't work in my case. Kangaroo care and skin to skin may be limited - mine were very tiny and the nurses weren't happy having them out of the incubators for more than 5 mins once a day in the beginning. All of course contibuting to the lack of supply!

Also, if she is expressing, it needs to be every 2-3 hours including through the night and using a hospital grade pump. I was prescribed domperidone (which I know they prescribe more freely in the US) it didn't work in my case. Kangaroo care and skin to skin may be limited - mine were very tiny and the nurses weren't happy having them out of the incubators for more than 5 mins once a day in the beginning. All of course contibuting to the lack of supply!

Thanks so much for all your feedback and for sharing your experiences...

DSILs DTs were born at 35 weeks - so prem but not hugely so and small but not minute. They're now 2 1/2 weeks old and have both regained their birth weight and are otherwise doing fine - no other problems. They've been home for a week (the bigger one fractionally longer).

While they were in hospital her time with them was very limited - 2 x half hour visits per day. I guess because she was recovering from CS? Otherwise they had 'certified huggers' doing kangaroo care type stuff. Very odd IMHO...

TBH I'm not sure why they were delivered so early... She had a CS booked for 37 weeks (again for reasons I can't fathom other than they don't seem to allow mums of twins to deliver vaginally in the US both were in the right position and DSIL was otherwise in good health and 6ft tall to boot). She had one contraction, (which I suspect was a Braxton hicks from her description) went in, had no further contractions but they found her to be 1cm dilated (which is perfectly normal - esp. with twins, no? My friend was 2cm dilated for two months before her DS was born!) and decided to deliver immediately. It seems a bit odd to deliver babies earlier than is absolutely necessary. I find it all very odd, and think that it's probably making these first weeks harder than they needed to be.

I wouldn't expect them to be EBF necessarily, and I understand the need to get calories in being the top priority... I would just have thought that putting them on the breast frequently would be helpful for everyone? They must be getting big enough to suck surely?

It just seems to be the pumping and lack of supply getting to DSIL mostly. I think she is taking medication but it doesn't seem to be helping...

I feel for her... But will keep schtum as I agree she's probably being told what to do all the time and is overwhelmed as well as knackered and fed up.

Maybe I ought to talk to her DW instead? Bless her, she is being brilliant this whole time, very supportive in a way I've not seen many men being... There's something to be said for being married to another woman at times like this...

db
xx

mine were 35 weekers induced because one had stopped growing (they were 3,13 lb and 5,5 lb If I remember rightly).

They were too small to physically fit their mouths over the nipple for weeks. By the time they were I had given up trying in favour of expressing which at least gave them breast milk. Others have managed it though (I had a toddler as well and made a considered decision not to push it any more). I didn't have the time to express, try to get them feeding, and do everything else (and squeeze some sleep in).

It is demoralising though to express - so if she can get them to feed directly it is much easier. The worst thing about expressing is obsessing about volumes. The more you worry the less you get. I found it best if I could distract myself - read a book, surf the net, watch something - anything to take your mind off it. And don't express for more than 20 mins, every 3 hours. Skin time, and gentle latching if they will take it will help no end - the key is not to get stressed by it, and not push it if it isn't working at any given time. Maybe best to try skin time, then express (and hope the stimulation help let down) while the other parent bottle feeds either ebm or formula depending on what you have available.

If they have regained their birth weight and are growing I wouldn't bother too much on exact volumes (easier to say with hindsight rather than being in the middle of it). It is scary to be responsible for two tiny beings. If you can calm the mental bit down then the physical falls into place.

Hi there - not read through all the replies - so might be repeating what some people have already said above! My ID girls were born at 34 weeks (not that early) but had low birth weight - both 1.6 kg at birth but then DT1 dropped to 1.3 kg over the first week.

My situation was very similar to your DSILs. I began pumping after my CS and found like her that my milk supply was low (it's beacause no skin to skin contact with baby) DT1 was not allowed out of the incubator for a few days, we held her when born on the Tuesday and i didn't hold her for a few days after and then only for a little while at a time. She only came to the breast after a week. DT2 came the next day. As with your DSIL we were told the same thing - that the babies could only bf for a short time and not every feed. They were also to be topped up with my milk by bottle afterwards.

In short - once the babies were home and with much perseverance on my part ( i expressed every 3/4 hours for 3 months and fed them at every feed when they had the energy to suck)i created a big supply and i am still breast feeding my twins at 21 weeks. It seemed as they got stronger each week they were able to feed better and better. I packed away the pump after 13weeks and was afraid my supply would diminish but the babies were then stronger suckers and could draw the milk down.... so it can also work for her in time and perseverance, that's all it takes!

Things will get much easier for them all in a few weeks, it's very hard going at the start.She probably just needs some time to get her head around everything that has happened. It's quite emotionally draining and worrying having babies in ICU. She should kangaroo care her babies , her DH can also do that too - will help them bond with the babies.

:)

Thanks twinnies and throck... I think the thing that's concerning me and I feel may not be helping with supply/bonding and feelings associated with that is that at the moment the babies aren't being put to the breast at all, which I find odd and counter-intuitive.

DSILs DW says this is because the paeds require an exact record of how much they're having...

Seems rather pedantic to prioritise recording of amounts over establishing a good supply and Mum's mental well being... Especially as they're gaining well.

I think they're having plenty of skin to skin now they're home - I guess that will have to suffice until the paeds back off about quantities to the ml.

I find the US approach to ob gyn baffling generally, I have to say...

db
Xx

Hey there, I can't contribute much in terms of experience as my twins haven't been born yet (due any minute!), but I am living in North America so just wanted to say - lots of your instincts are probably right about the care your DS's are getting. America has one of the highest incidences of c-sections and maternal mortality in a developed country. They do not like risk because of litigation so will attempt to deliver babies before they're ready to be born just to avoid this. They're also very pedantic about weights and measurements, which is hard as it is a fact that you do not express milk as efficiently as a baby sucks it. I'm in Canada where they're a lot more liberal, but I've still had to put up quite a fight to get a 'normal' birth agreed.

Anyway, just wanted to say that you're not mad to be a bit baffled by it all, but hopefully now they are home they can get some good nesting in time. Your DSIL's DW sounds great and I would continue talking to her rather than bombarding your DSIL. Also maybe just give them the UK perspective - i.e. some of the stories above - just so they get an idea that neonatal care isn't the same everywhere!