Q&A: Bottles, Supplementation and Late Preterm Infants

Tawny asks:

My twin boys were born at 35 weeks and are doing great except for the nursing. In the hospital we finger fed with a syringe and feed them a combo of my expressed milk and donated milk. As the amount they were supposed to eat increased the hospital suggested using a bottle as they said it was important for them to be getting as much food as possible to put on weight. Our routine was to get them to latch, feed them with a bottle or syringe and then pump. Now we are home and I desperately want to breastfeed them exclusively but I am afraid that they have already developed a preference for the bottle. They don’t latch for very long and get frustrated easily, as do I. I know I should be patient and not expect too much but I just don’t know what to do. Any advice? Thanks so much.

Congratulations on your new babies! And how exciting to have them home!

Babies born at 35 weeks are considered “Late Preterm Infants” – they’re not too tiny and often don’t require much (if any) extra hospital or NICU time, but they’re still very sleepy and need a lot of encouragement to eat.  It’s pretty typical hospital protocol for late preterm infants to involve breastfeeding, supplementing (at breast, if possible), and pumping to stimulate milk production, just as you’re doing.  This process, known as “triple feeding” works to stimulate milk production while ensuring that the babies get enough to eat so they can grow!  It’s also exhausting!  If triple feeding needs to continue for more than a week or so, parents are often advised to supplement using bottles rather than using a supplemental nurser at breast (or by finger)  because the tubes and syringes are quite a production and parents often want to get more efficient with their time management so mom (and dad) can get some rest.  Plus, babies can get tired out when breastfeeding and we want to be sure that they don’t burn more calories nursing than they are taking in.

While you’re in this combination feeding phase — and it is just a phase — here are some tips for balancing breastfeeding and supplementing:

  1. When bottle feeding, use a slow flow nipple and practice paced bottle feeding.  It’s easy for a baby to chomp on a bottle and elicit a fast flow of milk, but this flow can overwhelm them.  Build in breaks when you’re feeding by bottle to give the babies a chance to catch their breath, and to keep them in practice for the slightly slower pace of breastfeeding.  To do paced feeding, hold the bottle in a more horizontal position relative to the baby’s mouth, and watch the baby for signs they may need a break. Tip the bottle down slightly to encourage the babies to pause for a moment before resuming their bottle feeding. (More tips for paced bottle feeding [pdf].)
  2. Continue offering the breast!  It may seem like the babies are developing a preference to the faster flow of the bottle, and you may need to work with them to transition to feeding exclusively at the breast once they are stronger and your supply is well established.  Until then, keep breastfeeding as part of the feeding routine.  Many moms begin their feeding sessions at the breast, then follow with a bottle.  You can also reverse this order – offering the bottle first to satiate the babies’ immediate hunger, and following with the breast once they are less frantic. This may help the babies (and you) get more comfortable with the breastfeeding without getting as frustrated.  (This has been dubbed the “finish at the breast” method of supplementation. [pdf])
  3. When the babies are at the breast, consider using breast compressions to increase milk flow to the babies. Breast compressions and breast massage can increase milk flow to the babies, giving them a bit of a boost while they’re getting the hang of sucking.
  4. Tandem nursing is wonderful for breast stimulation (and time management!) but in the early days it may be easier to feed the babies one at a time so you can focus on the basics – establishing a comfortable position, getting a deep latch, and helping the babies transfer milk.
  5. If the babies are still having trouble latching, you may benefit from a visit by a Lactation Consultant who can help assess the babies’ latch, weigh them before and after a feeding to determine how well they’re transferring milk at the breast, and help you develop a plan to meet your breastfeeding goals.

What do you say, moms? How did you help your babies transition to breastfeeding after using bottles? What other tips do you have for establishing breastfeeding in the early days?

Additional Resources:

8 Responses to Q&A: Bottles, Supplementation and Late Preterm Infants
  1. Tawny
    May 5, 2011 | 11:44 am

    Hi-I am so happy to report that through lots of love, patience and practice I am now tandem nursing both twins at EVERY feeding! They really seemed to hit their stride at their 40 week mark and have taken to full time nursing beautifully. Thank you for the advice and encouragement. It can be done! Tawny

    • jona
      May 7, 2011 | 1:07 pm

      I’m so glad to hear this! Thanks for keeping us posted!!

    • Danielle
      December 13, 2012 | 2:07 pm

      I’m struggling with this exact thing right now and feel so lost. I’m exclusively pumping and trying to put the babies to the breast as much as possible, but I feel like we’re not making much progress and the time it’s taking to latch them both for a period of time then pump makes me feel like I have no quality time outside of the small amount I’m with them to practice latching. They were born at 35 weeks also and are about 10 days old now, we spent 5 days in NICU. It’s nice to know the transition may be slow. If you have any tips or advice please contact me, I’d love to have some advice from someone who has been there.

      • jona
        December 14, 2012 | 1:35 am

        Danielle – Hang in there! Many moms find that things really turn around by the time the babies are “term” (~40 weeks). In addition to the tips above, I always suggest meeting with a local lactation consultant if at all possible to assess each baby and help you come up with a plan that is workable for you. Pumping is important to maintain your milk supply as the babies get better able to latch and feed directly at the breast. Some moms find they want to put babies to breast just 1-2 times per day (not at every feeding) until the babies get the hang of latching. Other moms choose to supplement at the breast most of the time. You will find what works for you, and then make changes as needed to keep up with your growing babies and their new abilities. You can do it, mama!

  2. Angie
    May 16, 2011 | 9:19 pm

    I need help! I have twins born at 38 weeks. One was 6 lb 12 oz and the other was 5lb 12 oz.
    They are almost four weeks out and both are weight 6 lbs 8 oz. Therefore, the first is not back to his birth weight. I REALLY want to solely nurse them.

    The Dr. today said I need to feed each for 20 min and then give them each 2+ oz additional and then pump.
    My stored supply of milk has diminished in couple days and I am not pumping enough to stay ahead. Tomorrow I will need formula to complete this pattern.

    I just want to nurse at the breast. They latch on and feed well. I have even been tandem feeding. And now this triple feeding is so confusing. I feel as though I will be underfeeding my twins if I don’t follow the doctors instruction. And if I do, I will be supplementing with formula and will lose my milk supply.

    Please advise. How do I get over this hurdle?

    Thank you!


    • jona
      May 18, 2011 | 2:46 pm

      Oh, Angie, it sounds like it’s been a rough couple of days. Hang in there!

      We like to see a weight gain of approximately one ounce per day, with a return to birthweight by about two weeks, so I understand why the pediatrician is concerned. Supplementing after feeding can help increase the babies’ intake and encourage weight gain. A few days of formula supplementation is not going to damage your longterm breastfeeding success, though I can understand your hesitancy to introduce formula after you’ve been working so hard on the breastfeeding. Is donor milk an option for you at all?

      You’ve said that the babies appear to be latching and feeding well – are you hearing lots of swallows? Do babies maintain a steady sucking pattern for a length of time? How long? Without observing the babies feeding, it’s hard to know what’s going on with the feeding session. Are you able to contact a lactation consultant in your area, or reach out to La Leche League? Having an extra set of eyes on the feeding might help figure out what’s going on (and a lactation consultant should be able to weigh the babies before and after feeding to see what they’re transferring at the breast).

      Hang in there, and keep us posted! You can do this!!

  3. [...] milk supply is one of the biggest issues I see with multiples. Read JonaRose Feinberg’s excellent advice on nursing late-preterm babies. It is easy to get discouraged when your days are consumed with [...]

  4. Susan
    January 28, 2013 | 1:46 pm

    Is there any evidence that supports how many calories a baby burns while breastfeeding for a certain number of minutes. I’ve looked every where and can’t find anything. Thanks.

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