Triple Feeding - 10 Hacks to Help You Survive

Breastfeeding moms often feel confused and overwhelmed when receiving the news that Triple Feeding is necessary. This demanding routine requires three tasks at every feeding, eight feedings a day, which equals 24 things in 24 hours. It takes at least an hour to accomplish a single feeding, and then you can expect only an hour or two of a break until the next feeding. It may sound like a sadistic program to sleep-deprived new parents...because it’s not like you have an army of volunteers, including a full-time dishwasher, to help you take care of this baby! However, as fully consuming as it is, the triple feeding program will get breastfeeding established, and then it can be phased out. But in the meantime, you'll need all the time-saving hacks to cope.

Baby's weight is one piece of the puzzle

It's never a quick and easy fix when we realize that baby isn't getting enough at breast. Sometimes the situation develops over the course of the first days or weeks, and parents may have a suspicion that is confirmed by a lactation consultant or pediatrician. Other times, the program is initiated at birth, such as, when baby is born a few weeks early. It's common to feel some disappointment at the news that your baby needs a supplement, especially if it caught you off guard. You may have imagined that breastfeeding your baby would be simple and natural, and when reinforcements are necessary, it may affect your confidence. When I counsel parents in this situation, I try to reassure them that this is a common situation, and every day on our postpartum floor, several families are assigned the program, for various reasons. After we establish that baby needs larger volumes, I detail all the steps necessary to get baby fed and protect mom’s supply. This is the point at which parents’ eyes start to glaze over, because they’re still processing the fact that baby isn’t getting everything he needs at the Breastaurant, and they were trying hard to trust the process, which has now let them down. Once they understand that baby just needs a little help, they’re on board. “What was that middle part again? You need us to do what? At every feeding?” Commonly, I start writing down an outline of the program. This brings relief, because it's a lot to remember! I close with a pep talk, because everyone needs encouragement that they're doing a great job, and that this new schedule will get things on track. Now we know this new routine isn't sustainable in the long term, but it’s meant to be temporary. We will reassess baby’s progress every day in the hospital, and there are resources for after discharge, too. As soon as baby’s efficiency picks up, and mom’s volume increases, the family can graduate from the Triple Feeding Program. There’s no medal at the end, but they will have definitely earned their stripes. This baby would thank his parents for their patience and dedication, if he could. 

Let’s break down the program into four parts: why, how, when, and what. Why is Triple Feeding necessary, how can it be accomplished, when can we stop, and what are 10 hacks to make it easier? The hacks are crucial because without them, even the most committed family is ready, after a week or so, to take baby back to the hospital and drop him off. “Hey sorry it didn’t work out, the dog really likes him but we overestimated our ability to manage a million tasks on no sleep. We love him to pieces but could you please keep him until his first birthday, after this breast and bottle feeding nightmare is over?”  Let’s not get to that point! Here we go:

1. “Why is this happening to us??!!”  There are two main reasons, and you probably fall into one camp or the other. A) The first possibility is a problem with milk removal. When baby is born a few weeks early or prematurely, it takes time for him to adjust to the fact that his umbilical cord is no longer feeding him. He may be strong enough to go to breast and remove a little milk, but his stamina isn’t quite there yet, to fully get the job done. Sometimes babies who are “small for gestational age,” or babies with health challenges, also lack the strength to get a full meal from the breast. In these cases, baby needs to gain weight and get older, or more mature, for their skills to improve. In the meantime, they need the boost that Triple Feeding provides. Even a full-term baby sometimes has difficulty removing milk, possibly because he is unable to latch, or sleepy.

   B) The next common reason that Triple Feeding becomes necessary is because of an issue with supply. Sometimes mom’s mature milk arrival is a little delayed, and baby isn’t able to wait. This is common in moms who had a lot of IV fluids during labor, and is especially prevalent amongst first time moms who had a C-section. We know baby can’t wait for that volume increase that mature milk brings, if they’re Hangry, frantic at breast, and losing too much weight. They can also go in the other direction, barely waking for feedings, and sleeping on the breast instead of working. Inadequate volume at the breast increases a baby’s risk of becoming jaundiced. So in all these cases, Triple Feeding may be indicated. 

2. “How does this work again?” There are three steps with every feeding, and this is repeated at least every three hours. Here’s a brief YouTube video that explains the steps, if you’re a visual learner: https://www.youtube.com/watch?v=sEfrhCuJtiU

   1. The first step is to offer the breast. You can offer on cue, but ensure that feedings are given at least every three hours, which may mean waking your baby. I usually suggest up to 15” per side. This means that if your baby quits and falls asleep at just five minutes in, and nothing you do will rouse him, then you go to the next step. If your baby is participating, you can give him a full 15” on each side, but not longer, because you’ve got more steps ahead, and you want to get this accomplished inside of ONE hour so you don't go insane.

   2. Second step is to double pump both breasts. As soon as baby comes off the breast, you double pump for 15” or so. You do this because your baby didn’t remove very much milk, not as much as he needs to gain weight well. That’s a problem, because mature milk production works on the principle of supply and demand. Your baby is only demanding a little, and you don’t want to end up with a correspondingly "little" supply. So the pump offers insurance that your supply will get the message - make MORE than this baby demanded. Pumping both breasts at the same time provides double nipple stimulation, which is proven to give a higher yield than pumping one breast at a time. Make sure the flanges on your pump are comfortable; you may need to experiment with different sizes to see what feels best, and what gives you the highest yield.

   3. Supplement the baby. A “supplement,” is any bonus milk that baby receives in addition to what he transfers out of the breast; it can be mom’s own expressed milk, donor milk, or formula. When moms are in the colostrum phase, it’s challenging to express enough to fulfill an order for more volume. A vigorous baby at the breast will be able to extract more than a pump. But you might not have the most vigorous baby…that’s one reason to implement this program. Another reason is that baby is ready for more volume and it hasn’t arrived yet, in which case pumping sends an important signal to make more, but may not yield the amount you need. Initially, small amounts of a supplement can be given with a syringe, but by baby’s third day he’s needing at least half an ounce, if not a full ounce (30 mls) PER feeding, and if mom is still in the colostrum phase, most of that volume will come from the supplement, after he breastfeeds. A typical scenario is that after breastfeeding, baby is given mom's expressed colostrum via syringe, and then a larger volume of formula, from a bottle. And not just any bottle will do; a bottle with a true slow-flow nipple is best. If the hospital provides nipples that say “slow-flow” but are made by a formula company, don’t trust that they are truly slow-flow. I like the Dr. Brown’s preemie nipple, even for a full-term newborn. It requires active participation from baby, which is good practice for the breast. (For more on calculating how much of a supplement to offer, see postscipt at the end of this article.)

3. “When can we get off this train? When can we just offer the breast and trust that he’s going to take enough to gain weight?”

   I will admit, it’s tough to know when. A baby who has taken a nice amount from the breast, say, two ounces or more, may still take that bottle of milk afterward if it’s offered. So it’s not like you can wait until he gives you the Heisman with his hand, indicating that he’s full. He may never do that. It’s like if you had Thanksgiving dinner and felt stuffed, is there a chance you’d make some more room if someone offered you a piece of pie? The same is true for baby. It certainly is a good sign if baby seems sleepy and disinterested in the bottle after breastfeeding, but since you can’t quantify his intake at the breast, you really have no idea if he removed a substantial amount or not! Parents have to reclaim that “trust in the process,” but it’s ok if you need to “trust, but verify.” This is why I recommend a weighted feed. (See below in the addendum for full description) 

   The weighted feed provides solid data on baby’s ability to efficiently transfer milk, and based on that, judgments are made on whether he continues to need more volume afterward. Some pediatrician’s offices will provide a weighted feed, as do some support groups, and private lactation visits. What I think is much less helpful in determining if you’re ready to graduate from the hell that is Triple Feeding, is a simple weight check. Many pediatricians, once they ascertain that baby is above birth weight, will inform parents that they can stop supplementing. And then parents cut out the bottles cold turkey, and at baby’s next weight check, there is no weight gain. The supplement was providing crucial volume, and when parents took it away, baby was still only transferring enough milk to maintain his weight, and hadn’t gotten efficient enough yet to climb into that weight-gaining zone. This is a depressing scenario that can be avoided by acquiring regular weighted feeds to check baby’s progress. Many parents hire a professional to do this, and some parents rent a baby scale and track it themselves. Once baby starts taking weight-gaining amounts from the breast, you can start phasing out the bottles, as well as pumping. Some parents will cut the bottles in half, offering them at every other feeding instead of every feeding, or start decreasing the amounts given in each bottle. As this is happening, baby should be monitored carefully, to ensure that his weight keeps going in the right direction. By the time bottles are eliminated, baby will go through a phase where he nurses a lot more than 8 times a day. 10-14 nursing sessions a day is pretty common! You can expect those nursing sessions to become more frequent once the bottles are out of the picture. At this point, it’s helpful to stop watching the clock, and just offer the breast on cue, allowing baby to cluster feed, which helps improve their efficiency. 

   So how long should you expect to Triple Feed? Sometimes this program can be abandoned after 24 hours, and sometimes it takes a couple of weeks. If baby is premature, it could be necessary until he reaches his due date. I'll share a very encouraging story which belongs to my sister, who had a C/S for her 38 week old twins, who each weighed over seven pounds. They had each lost over 10% of their birth weight by Day 3, so it was recommended that she nurse, pump and supplement. She Triple Fed twice, and then her milk started to come in. We noticed that while breastfeeding, the boys were vigorous and frequently gulping, so she stopped Triple Feeding before she even was discharged from the hospital! At home she tandem nursed them on demand while not offering pacifiers, which resulted in fantastic weight gain. So, you never know when this program is initiated, how soon you may be able to abandon it.

4. “There are hacks? What are the hacks? For the love of all that is holy tell us how to make this easier!” As promised, here are TEN ways to make this less time consuming and more efficient:

• This probably already occurred to you, but divide and conquer. Nursing mom breastfeeds and pumps while partner, support person, or hired help offers the bottle. It’s too many steps for one person, so if nursing mom delegates the bottle feeding task, and the washing of the pump parts, then she is responsible for the breastfeeding and pumping only. I’m all for nursing mom delegating the diaper changes too - if you have willing volunteers, use them! Make sure the bottle-feeding helper is using a paced bottle feeding method with a slow-flow nipple. Baby's breastfeeding skills may suffer if the bottle doesn't require some work.

• Get ready for my best hack, which is to simplify at night. Don’t offer the breast. Skip step one. When it gets dark outside, you're finished with step one. You will pump and bottle feed through the night every 3 hours, and if you have a partner who can bottle feed, then nursing mom spends 15” with her pump every three hours, gets a nice oxytocin surge which makes her sleepy, and then she goes right back to sleep. In the morning, the sun comes up, and you resume offering the breast with each feeding. This helps everyone get more sleep at night, and that is crucial with such a demanding schedule. Eventually, nursing at night is easiest because baby gets very efficient, takes what he needs, and passes out. But when latching is a struggle, or getting him to suck actively is a struggle, and you’re undressing him and stimulating him and watching for his swallows, and spending 30” doing all this, just forget it. He will get enough practice during the day. When he gets really good, you can start nursing him through the night.

• When baby is at the breast it’s helpful if he’s skin to skin and your partner is helping you stimulate him to keep him awake. Get a glass of ice water and touch his feet with it occasionally. Rub his arms and legs and feet, blow on his face, and talk to him. Changing his diaper in between breasts may get him more alert for the second side. I know, I know, you never imagined harassing your baby like this! Once baby gains back his birth weight and passes his due date, (if he was premature) he has achieved two big milestones that really help him have more stamina and energy at the breast. You’ll notice breastfeeding getting easier when you accomplish birth weight, and due date! He won’t need so many reminders to keep going.

• Massage your breast while he is nursing. This is a proven method to help more milk flow into him. The more that he transfers, the better he understands how this system works, so it’s OK to crank up that faucet manually. But wait, if you’re using one hand to steer his head, and supporting your breast with the other hand, exactly how are you supposed to massage your breast? It helps to grow a third arm, or you could recruit someone else to do it. Remember when you learned how to ride a bike, and someone held the seat for you as you pedaled, to help you keep your balance? It’s kind of like that. Also, using a nursing pillow like the My Brest Friend, makes it easier to sneak a hand away from his head, and use it to gently rub your breast, toward his mouth.

• “What about the baby who’s refusing to latch, like shaking his head back and forth, frantic and screaming at your breast? Or the baby who can latch only for a few seconds and just can’t sustain his grip, or the baby who’s just sleeping on the breast? What do you do then? How do you accomplish step 1?”  Give baby a few sucks from the bottle. It calms a Hangry baby, it awakens a sleepy baby, and it gets baby into a rhythm of active sucking. Then you pull the bottle out and assertively guide baby to the breast. I call it the Bait and Switch. Remember to wedge your breast tissue to help him attach deeply. Once he latches and starts sucking, he may quickly lose interest and fall asleep, so then your partner can turn the bottle upside down, and let it drip onto the corner of his mouth while he’s latched. It’s messy, but if you aim it well, it seeps into his mouth, and then he may be incentivized to suck more actively. It’s all about getting him to suck actively, like a machine, at the breast, because that’s how he triggers spurts of milk. Short, infrequent bursts of sucking don’t get the faucet turned on, and he will not transfer much milk. You need long, sustained bursts of sucking, with swallows noted either visually or audibly. *If none of these tips consistently work to keep your baby latched, you might want to try a nipple shield. (see my blog post about nipple shields)

• Lubricate your nipples after baby nurses, and before you pump. I like organic, purified, coconut oil for this purpose. Nursing plus pumping equals a lot of action for your nipples, and the coconut oil makes them glide better inside the pump flange, which is more comfortable. Coconut oil is also mildly hostile to yeast, and will help prevent a nipple yeast infection. If you had any IV antibiotics with your delivery, such as for a C-section, premature delivery, or Group Beta Strep, you’re at risk for nipple yeast, and baby could then develop oral thrush. It’s also a good idea to take probiotics if you had any oral antibiotics after delivery, such as for a UTI or mastitis.

• Get a hands-free pumping bra to hold your pump flanges in place. This helps you to be able to scratch your nose and operate your phone during your 15" pump session. Now you may have a wearable pump, and certainly it's convenient to multi-task while the entire pump sits in your bra, expressing milk. But be careful - wearable pumps are not recommended to help establish a full milk supply. When baby isn't getting the job done, you really need a good double electric, plug-into-the-wall pump. Once your supply is established and you’re making a total of 24-32 ounces a day, then your wearable pump can take over. (and hopefully also your baby's skills have improved)

• Don’t wash your pump parts every time, unless you have a premature baby. If your baby is full term or near term, you can get away with this hack, which is to place your sticky, wet, pump parts into a ziplock bag, and toss them into the refrigerator or, better yet, a bedside cooler, so you don’t have to get out of bed. You can also put your expressed milk into the cooler. If baby is going to be drinking that expressed milk within 4 hours, you don’t even need to keep it cool. You do not want to be washing things, or traipsing out into the kitchen several times a night. Once per day, you need to sterilize your pump parts by running them through the dishwasher, hand washing them with hot water and soap, or using microwavable bags designed for this purpose. Pump parts do not need to be thoroughly washed every time, if you are keeping them cool. Refrigeration arrests the development of bacterial growth enough that the milk is safe. Gets a little sticky, but you’re washable. Sleep is more important! 

• Start wearing a Haakaa or other passive milk collector while nursing. It should suction onto your breast, not just sit in your bra catching milk that drips out. The Boon Trove is another example, so is the Elvie Curve. If the Haakaa starts collecting as much milk as you need for the supplement, then you don’t have to pump afterward! It works like this: baby cues hunger, or maybe it’s been 3 hours since the last feeding, so you attach the Haakaa to your left breast. Then you pick up your baby and offer the right breast. When baby starts sucking actively, hormones are triggered that “let down” your milk BILATERALLY. That means the milk sacs in both of your breasts are being squeezed, sending milk into the ducts. Your baby suckling, and also the gentle constant suction from the Haakaa, will turn on the faucet, moving milk out of the breast. The Haakaa typically doesn’t empty your breast though, it might just collect your first let down. That means after baby finishes on the right side, you switch the baby and the Haakaa - you offer him the Haakaa breast, and move the Haakkka to the side he just nursed from. If your supply is really low, then you may be worried about the Haakaa stealing milk from baby. On that left breast, if the Haakaa removed a decent amount, baby might notice that it’s missing. If you suspect that is the case, then just wear the Haakaa on the side that baby has finished, and don’t let it take milk out before he has a chance. The bottom line here is that when baby isn’t transferring enough milk to gain weight, you need something else to coax milk out of your breasts, to give a signal to your body to increase production. Even if you started with an ample amount of milk, if baby doesn’t remove it - it will go away! Your body will regulate production to the amount that is being removed.

• My last suggestion is not really a hack, but rather, the subtraction of a hack. Here goes: it’s not recommended that you offer a pacifier until breastfeeding is well established, at the earliest 3 weeks. Anyone who is Triple Feeding, is not well established yet, so hold off on the pacifier. I know that pacifier is the ultimate fix for a fussy baby. But, pacifier use is not going to make this easier in the long run. It will prevent baby from cluster feeding, which helps him develop efficiency. He will also struggle more with developing a consistent latch, if he takes a pacifier in between feedings. This is a topic for another blog post, but trust me, it will take longer and be infinitely more frustrating for you and baby to master breastfeeding, if he is taking a pacifier at the same time that he’s learning. Ideally, he doesn’t get a bottle either, but in the case of Triple Feeding, a bottle is necessary and unavoidable. The pacifier, by contrast, has nothing to offer him but sucking practice on yet another nipple that is nothing like the breast.
  

So, there it is, as promised - 10 Hacks! During this program, pamper yourself as much as possible. Don’t try to accomplish anything else, like cleaning, organizing, laundry, meal prep, showering daily, rotating your tires, answering email, correspondence with friends, or anything work related. The program is all-consuming, so cut yourself some slack, and take a nap EVERY DAY. You can do it! 

Addendums:

~Let’s talk newborn math. At 3-4 days old, baby needs to stop losing weight. After that, they might spend day a day or two maintaining their current weight, but then they need to start gaining. An ounce a day is a great weight gain in the first 3 months or so. Sometimes just half an ounce per day is acceptable if baby was small for gestational age or late pre-term. A seven pound baby who is struggling to return to birth weight, or having slow weight gain, likely needs at least 17.5 ounces per day, every 24 hours, to be in a weight-gaining zone. How did I come up with 17.5 ounces? I multiplied baby’s weight in pounds, by 2 ½. This is a general rule to follow when trying to establish weight gain in the early weeks. You can actually multiply weight by 2 ½ - 3 to come up with a range for volumes, but let's just keep it simple with 2 ½. Now if that seven pound baby has 8 feedings a day during Triple Feeding, then at each feeding, he needs (17.5 total ounces a day, divided by 8) = 2.2 ounces per feeding. So if baby took one ounce from the breast, he needs another 1.2 ounces as a supplement to equal a 2.2 ounce feeding. Has your brain exploded yet? I know it’s confusing, and this is why it’s super helpful to meet with a lactation consultant, or have an appointment at a feeding clinic. And by the way, this newborn math is less applicable for older, heavier babies. Your giant, chubby 4 month old who weighs 16 pounds, will not need necessarily need 40 ounces a day to keep gaining weight, thanks to the changing composition of breast milk. At about one month of age, whatever volume in 24 hours a baby is consuming and thriving on, is likely about the same number of ounces they will continue to need as long as they exclusively breastfeed. As an older baby, those ounces will be distributed differently, but the 24 hr total will remain fairly constant. Good news, huh? You don't have to keep increasing your milk supply as baby doubles their weight!

~For weighted feeds, baby is initially weighed in a clean diaper. Let’s say he weighs 7 pounds even, or 3175 grams. I highly recommend doing this calculation in grams, because the math is a lot easier. (If you measure his weight in pounds and ounces, you have to have a scale that is sensitive enough to capture the tenths of an ounce.) Baby then nurses, hopefully having a typical feeding so you get a snapshot of his usual intake. During the feeding, he is likely to fill that diaper, and you DO NOT change it. Everything in that diaper was inside his bladder and intestines when you weighed him before the feeding, so it gets included in his weight after the feeding. If you change that diaper, it will look like he gained nothing! So, he gets weighed with his full diaper and now weighs 3205 grams, so that is a gain of 30 grams. You can assume he took approximately 30 mls, or an ounce. He probably needs another 1.2-1.5 ounces of expressed milk/donor milk/formula as a supplement, depending on how many days old he is.