When babies are born a bit early, or a bit sleepy or a bit inefficient on the breast, they have higher risk of jaundice, low blood sugar and weight loss. They also may struggle to put on enough weight and regain their birthweight.
Often these issues can be overcome by concentrating on achieving a deeper latch, more frequent feeding, and by using breast compressions to increase the flow of milk. Compressions maintain active feeding for longer and increase the length of the sucking bursts. We should encourage baby to have a second go on the breast by waking with a nappy change and offering the other side.
However, it is sometimes clinically indicated that baby needs a little extra milk. Many of these parents start their breastfeeding journey topping up their babies with formula to make sure they are getting enough milk. But if their long term goal is to exclusively breastfeed, or even majority breastfeed, using formula will be detrimental to their future milk making potential. To protect their breastfeeding goals, it is important to encourage parents to pump whenever babies are getting milk from elsewhere. This expressed breastmilk can then be used for all or some of the top-up feeds, meaning less formula is necessary and milk supply is closer to the baby’s intake. The volume and frequency of top ups should be the minimum necessary to maintain an appropriate rate of growth.
The act of breastfeeding, top-ups and pumping is often called “Triple Feeding” because there are three parts. Doing all three parts, every feed can be very overwhelming and time consuming, so it is important to stress to parents that this is a temporary intervention. As soon as babies are breastfeeding more effectively they should be able to reduce and eventually remove the extra milk, or move to a more manageable combination feeding pattern. Triple feeding is not a long term solution.
Triple feeding is much less overwhelming if there is a helper to do the supplemental feeds. If no helper is available, do the best you can.
Triple Feeding Plan
*Wake baby, or pick up baby if they are showing early cues and waking
*Bring baby to the breast with a deep latch
*Watch for deep suck and swallows
*Use breast compressions to maintain active feeding and extend sucking bursts
*Once compressions are no longer stimulating deep sucks and swallows take them off and offer a cuddle. If baby wakes, offer the other side. If baby does not wake, wake them and offer the other side.
*Breastfeed baby on second breast with a deep latch and compressions if necessary.
*Once compressions are no longer stimulating deep sucks and swallows, pass baby to a helper if you have one, to top-up with expressed milk or formula, pacing the bottle feed.
*Pump for 15-20 mins with an efficient double pump, this milk can be used for future top-ups
NB If no helper is available then the baby will need to be breastfed and topped up and then pump as soon after the feed as possible.
Moving away from triple feeding and topping up
Before moving away from triple feeding regime, certain criteria must be met:
*Baby should be gaining weight appropriately with the top ups in place before thinking about reducing, and also be having appropriate wet and dirty nappies
*Baby should be able to latch well with deep sucks and swallows, developing longer bursts of sucking, especially towards the beginning of the feed. They should be maintaining active feeding for more than a few minutes
*Baby should be feeding at least 8 times in 24 hours and mainly waking themselves for feeds, more frequently is to be expected.
Once the baby is beginning to be more alert and breastfeeding is improving we can begin to gradually reduce the extra milk. Regular weight checks are necessary.
Frequency of feeding
Exclusively breastfed babies will often want to feed more frequently than every three hours. If babies are waking “early”, they can be brought to the breast. But we should not need to top up more frequently if weight gain is appropriate.
Reduce the volume of the top ups
Baby can be offered a third or fourth go on the breast before a top up is offered, called switch nursing. Each time a baby latches triggers another let down of milk and they will take more milk. This should mean a smaller top-up, or perhaps no top up.
Babies can be encouraged to settle on the breast. Both breasts are offered first, a smaller top up given in the middle, and then baby can be brought back to the breast to settle, taking some more milk directly.
Removing top ups
A baby will often be more settled in certain parts of the day. Mornings especially are a time when they tend to feed well and the parent may naturally have more milk.
Take a 4 or 5 hour period in the morning and just breastfeed, putting baby back on the breast as many times as it takes to settle. Top ups continue the rest of the day. Then extend or add another stretch of exclusive breastfeeding.
During night feeds, baby should begin to settle more easily without the need for extra milk.
Pumping
As the need for top-ups decreases, pumping can be reduced. Either pump whenever babies get extra milk, or pump the total 24hr top-up volume baby is taking over however many pumping sessions it takes to express that volume.
Kathryn Stagg IBCLC, June 2024
