Twinfant Tuesday: The Logistics of Feeding Two Infants

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My fraternal twin girls just turned five on Sunday.  Over the past week, as I do every birthday, I’ve done a lot of reflecting.  In thinking back to their infanthood, the complicated logistics of feeding are still very clear in my mind.  By now they’re fond memories…but at the time, I remember any new stage bringing about great stress.  Here are the highlights from our journey…

My twin girls, born at 34 weeks, came home after 10 days in the NICU.  While we don’t have family nearby, my husband is a teacher and he was able to take an extended leave to be home with me those first few weeks.

During that time, we generally each fed one baby.  (I would breastfeed a baby, then supplement with a bottle, and then pump…rinse and repeat, again and again and again.)  During those first few weeks, we were mostly waking the girls to feed them.  On the rare occasions when I had solo duty, I woke one baby (the faster eater) and fed her, and then fed the other baby immediately thereafter, trying to keep them on the same schedule as much as possible.

As my husband neared the end of his leave, I began to panic.  How would I ever feed both babies by myself?  Keeping the girls on the same schedule was a huge priority for me, and I knew the wake-one-baby-at-a-time method wouldn’t serve us long-term.

I reached out to the only other twin mom I knew at the time for some advice.  (Actually, I didn’t know her…she was the daughter of a former colleague who lived about 150 miles from me…but she was kind enough to take my phone call at random.)  She described how she bottle-fed her infant twins, who were about three months older than my girls.  She somehow held both babies in her lap, facing the same way, her arm wrapped around one of them from behind.

Mar4'09 036
Two Boppy pillows were a lifesaver at our house!

I couldn’t begin to imagine how I’d manage my girls in that fashion, but her advice encouraged me to try propping up the girls in different ways.  I remember the look of astonishment when my husband came home to find me feeding both girls…with a huge smile on my face, to boot!

This set-up worked for us for many months, until I started giving the girls bottles in their highchairs, probably around 7 or 8 months old.

Once I finally had bottle-feeding under my belt, I was feeling pretty good about myself…until the pediatrician told me it was time to start feeding the girls cereal.  WHAT??!!!  I **just** got comfortable with milk!!!  Can a twin mama get a break??!!!

I set the girls up for their first feeding, their highchairs side by side and the husband and the camera at the ready to capture what I knew would be the most adorable faces.  Their faces may have been adorable…but the MESS they made wasn’t.

Getting Ready for the First Feeding! 051709 (2)I quickly decided I would take to spoon-feeding the girls one at a time to curb as much of the MESS as possible.  That approach I never changed, although I did have to devise a system, as one of my babes wasn’t very patient once she learned how yummy those fruits and veggies were.

While I have since read about some twin mamas who adamantly rotated which baby was fed first, I never did.  I put Patient Baby in her swing and fed Anxious Baby first.  When Anxious Baby was finished, I could sometimes put her in the swing to feed Patient Baby.  There were times, though, when I would position Super-Anxious Baby in a bouncy seat at my feet.  I would wedge my foot under her and bounce and jiggle while I fed Patient Baby.  Once the spoon-feeding was complete, I would load both girls into their highchairs for bottles.

It was not until the girls graduated to finger foods, around 14 months, that I let them eat at the same time.  And I was right there in front of them…yes, to make sure they didn’t choke…but also to try to keep the smearing of avocado cubes in the hair at bay.

So…in looking back through the trials and triumphs of feeding two babies during that first year or so…I can’t say I had a consistent, or even judicious approach.  But I did manage to experiment to find a methodology that worked for us through the various stages.  It’s OK by me that the girls don’t read this post in a few years, though.  Unless they have twins themselves, may they never know that one was temporarily labeled Patient Baby, and one, Anxious Baby.

MandyE is mom to five-year old fraternal twin girls.  She blogs about their adventures, and her journey through motherhood, at Twin Trials and Triumphs.

DSC_0761This picture was taken on the girls’ fifth birthday.  Yes, they’re still wearing bibs, as this mama still tries to avoid messes, when possible.  And yes, they’re still a mess…but in their partial defense, they requested homemade blueberry syrup for their French toast…and this mama just let them go to town.

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Foodie Friday: Suck-Swallow-Breathe

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Prematurity Awareness Week 2013: How Do You Do It?

World Prematurity Day November 17In the United States, 1 in 9 babies is born prematurely, 1 in 10 in Canada. Worldwide, over 15 million babies are born too soon each year. While not all multiples are born prematurely, a multiple birth increases the probability of an early delivery. Babies born prematurely, before 37 weeks gestation, are at a higher risk for health complications in infancy, some of which can have long-term effects. Full-term infants are not all free from their own health complications, of course.

In honor of November’s Prematurity Awareness Month, led by the March of Dimes, How Do You Do It? is focusing this week’s posts on The Moms’ experiences with premature deliveries, NICU stays, health complications, special needs, and how we’ve dealt with these complex issues.

Almost all preemies have difficulty with feeding, and my boys were certainly no exception. In order to eat, a baby has to be able to suck (at the breast or bottle), swallow, and breathe. But not at the same time, of course, and trying to coordinate that is very difficult.

Mr. D was born with the ability to do all three. He never required oxygen support, could generally swallow what was in his mouth (although he did need “reminding” from time to time), and could hold onto a pacifier, bottle, or my nipple like a pro. What he couldn’t do was figure out how to do all three in such a manner to ingest enough milk to live…especially when he’d rather be sleeping.

D’s challenges were fairly typical for preemies. Eating is hard work. So hard, in fact, that a twenty-minute rule is placed on both breast- and bottle-feeding in most (all?) NICUs: the baby gets 20 minutes to eat all he can, and then is weighed (if breastfeeding) or the amount remaining in the bottle is examined, and the rest of the required meal is poured down the feeding tube. I wanted to breastfeed, but was told we could only attempt it twice a day, as it’s even more work to extract milk from a breast than it is from a bottle.

The first time I breastfed Mr. D, he took me by surprise. He did really great! The lactation consultant warned me that many babies take one or two good feeds from the breast, and then begin to struggle. That was the case for him: he could extract a few drops of colostrum, especially when I pretty much hand-expressed it into his mouth, but once my milk came in, it was beyond him. He would latch on, and then fall asleep.

Suck-swallow-breatheHe didn’t fare much better with the bottle. I was taught how to hold him, how to stroke his cheek or under his chin to “remind” him to swallow, how to burp him, how to tickle his feet when he was nodding off…and he would still only swallow a few milliliters. He would sometimes become fearful of the liquid in his mouth, and hold his breath until I sat him up and helped him to dribble it all out. But mainly he would just look up at me, with an expression of what felt like disdain on his face, and then close his eyes. He held onto the nipple (mine or the bottle’s), but that was it. That was all he wanted to do.

The nurses told me it often happens like a switch—nothing, nothing, nothing, BOOM: eating! That wasn’t the case for Mr. D. Instead, he’d take a few more milliliters each day, most days. What was exceedingly frustrating to me was that, as his weight (from his oral plus tube-feedings) increased and his IV-nutrition was tapered off (to end abruptly when he yanked out his second scalp IV and they couldn’t find better access), his required intake went up, too. He was supposed to eat 23 mls, and would manage 19, and I’d go home to pump in triumph, only to return to discover they’d raised his goal to 26.

But he did improve. He kept getting so close. I felt like we were nearly there. Feeding was the only thing keeping him in the NICU, and I wanted him home.

He developed reflux. My pediatrician tells me “100% of babies have reflux”, and I don’t doubt her. Mr. D’s was worse than some, which again is common with preemies. That muscle at the top of their stomach (cardiac or esophageal sphincter) is as weak as their other muscles, and is forced into doing its job way too soon. One of his day nurses asked me if there was a history of milk intolerance in my family. Yes, there is: I was allergic to milk protein for my first few years of life. She suggested eliminating dairy from my diet, in case Mr. D had the same problem. I did. We also began fortifying his breast milk with soy formula rather than the special preemie formula. (Breast milk has about 20 calories, and it is very common to add formula to it to boost that to 22, 24, or even 27 calories for premature babies, as their tiny stomachs can’t hold enough volume to give them their necessary caloric intake.) I don’t know that it made much difference, but I was willing to try anything.

On his tenth day of life, he pulled out his NG-tube for his tenth (estimated) and final time. He wasn’t meeting his goals, but they decided not to replace it. He did well, getting closer and closer. On his thirteenth day, we were told we could take him home the following day: Valentine’s Day.

At 6 am on V-Day, I got a call from the neonatologist. She was just coming on shift having been gone a few days, and she didn’t think we should take Mr. D home. “He simply won’t grow on this,” she said, referring to his intake and reflux. I asked her if she was planning on re-inserting his feeding tube. No, she was not. Then why? What could they do for him that we couldn’t do at home? “He simply won’t grow,” she insisted. We reached an agreement: if Mr. D could eat all 55mls of each of his day feedings that day, and I agreed to take him to his pediatrician in two days instead of three, I could take him home. She strongly implied that she disagreed with this, but not enough to rule it out.

Challenge accepted, I thought. For each meal, I stripped an irate baby down to just his diaper. There was no way I was letting him get warm and comfy. I did not alert the nurses to his small spit-ups during burping. I twice emptied the remaining 2-3 mls of milk into the burp cloth at the end of his 20 minutes. And he got to come home with us that evening.

Mr. A could neither suck nor swallow nor breathe at the start. He did take early breaths on his own, but with much effort. The NICU staff quickly determined that he could not maintain his breathing, and gave him surfactant and intubated him. Once extubated, no one was surprised that he could not suck. He actually had the reflex, and would happily gnaw on a Soothie if it was held in his mouth. His cleft soft palate, however, left him with the inability to form negative pressure in his mouth. As such, he could not draw liquid from a nipple, nor could he hold his own pacifier in his mouth by sucking merrily to sleep. In order to assess his ability to swallow, the neonatologists had the nurses perform what I have since learned is a very outdated “test”—they poured sterile water into his mouth. They assured me that, if inhaled, it would not cause any problems, as it was sterile and a very small amount. The first time they “tested” him, the liquid slowly dribbled out of his mouth. He could not swallow. They repeated the “test” two days later, and he “passed”—the water went down somewhere, and they assumed it went down his esophagus. He was cleared to begin oral feeds.

I was introduced to a variety of bottles and nipples, all specially designed for babies with clefts. I was a bit dismayed to realize most of the nurses had no more familiarity with these “feeding systems” than I did. Essentially, they all worked the same way: a nipple was placed into A’s mouth and he chewed on it and the nipple released milk due to compression. Some of the bottles were squeeze bottles, so that I could force extra fluid into his mouth.

It was a disaster. I was too naïve to realize how large of a disaster it truly was. Only once did Mr. A take in over 10 mls (two teaspoons). Feeding him generally went like this: hold him in a specific way (hands angling his jaw upwards, entire body elevated to at least 45 degrees, while trying to support his head and body but not of course cradled in my arms), introduce nipple, watch him struggle, watch him desaturate (often followed by heart rate decelerations), fearfully yank the nipple out of his grey-blue lips, let him recover, repeat. At the end, measure remaining milk and discover only a handful of milliliters to be missing, and then pour the remainder down his feeding tube while snuggling him to sleep.

After a few days, I told the nurses I no longer wished to feed him by mouth. I was terrified. I could feel, somehow, that his desaturation and bradycardia events were different than Mr. D’s episodes of breath-holding. I hated feeding him, he hated eating, I feared I would kill him. The nurses told me I didn’t have to do anything I wasn’t comfortable doing, meaning they would continue to do his feedings for me. That wasn’t entirely what I meant, but I was too insecure to argue. And so he struggled along for a few more days, with me or my husband holding him while the nurses fed him. I came to accept his “behavior”—after all, he was gaining weight and showed no ill signs. So I resumed the feedings.

When he was transferred to the children’s hospital, he was evaluated by their feeding and development expert. I wasn’t there (we were not forewarned of it, or I would have been!), and came to his crib an hour later to be informed by the nurse that he was no longer to eat by mouth. Ever. He would need a surgically placed tube going directly into his stomach. I was irate. He had been, I thought, showing signs of improvement. And here some lady looked at him once, did not even give him a chance to truly try, and ruled out eating for the rest of his life? I made the staff aware of my displeasure, and they promised me she would speak to me. She didn’t, not for some time.

Mr. A was eventually given a swallow study: he sat in a car-seat-like chair, being fed radioactive barium mixed with breast milk to various consistencies: pudding, nectar, thin. X-ray-like machines videotaped the entire event. And there it was in black and white: Atticus was drowning. The milk went up his cleft palate and into his nasal cavity, and from there it entered his trachea and lungs. What remained into his mouth also largely ended up in his lungs. He was unable to cough to protect himself. My baby boy had silent aspiration.

I felt awful. Guilty, guilty, guilty. If I’d held my ground at the first hospital, if I’d truly listened to my instincts, we would have stopped feeding him by mouth weeks ago. He must hate me. He must fear me. My job was to keep him safe, and here I was, endangering him every three hours on the dot. And my pride, my pride at what I thought was improvement and my wrath at the feeding therapist, who had told me what I had been unable to believe, as if my wishing could make those drops of milk enter his stomach safely. “He was took 13 ccs!!” I had argued, over and over, his record amount so strong in my memory. Almost half an ounce, I was forced to admit, almost half an ounce of my milk flooding into his lungs.

It did not occur to me until almost a year later that who I should have been mad at, instead of myself, were the doctors and nurses at his birth hospital. I was in over my head, but so ignorant I had no idea. They should have known. They should have recognized what I felt in my heart and what led me to ask to stop: this was not normal preemie behavior. None of this was typical. And they didn’t. True, the most challenging preemies are probably passed off to the children’s hospital sooner than my Mr. A was, but watching for signs of aspiration is not a difficult art, and it’s one that should be taught to and remembered by everyone working with sick babies.

Mr. A got his G-tube placed when he was negative-one-week, adjusted. His feeding plan was changed to reflect that, while he was not to eat by mouth, certain exercises could be done to help stimulate his oral-motor skills. Feeding has continued to be one of his biggest challenges, but I am happy to end this by saying that we are now very close to replacing one of his 5 daily tube-feedings with an entire meal eaten by mouth. And as for Mr. D, he is an avid eater, and above the 90th percentile in both height and weight. The suck-swallow-breathe struggles are behind us all.

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The 4am Feed

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I confess. I am lazy.

That’s the secret to my efficiency. For example, I’ve got the 4am feed down to a 20-minute science. It took some tweaking for the babies to cooperate, but now most days they do. Actually a lot of what I’m doing now is what I did with Toddler, only I had forgotten until I had to rediscover it all over again. So, if you must do a middle-of-the-night feed, here are some tricks I’ve found that work great for me.

First, not part of the efficiency thing, but greatly helpful to set your babies up for sleep, dim the lights down to one very low wattage bulb. I think mine is 10 watts. It sits in the corner of the room farthest away from the babies. The babies get a clean diaper, swaddled, then placed in their spots in the cosleeper. I sometimes play soft music from my iPhone for them (Pandora’s Lullabye station). Then…

1. Feed babies as much as possible before going to bed. In our case, babies load up before sleeping for good, often 6 ounces over a couple of feedings starting at around 9:30pm. They’re usually out by 11pm.

2. Before going to bed, get all bottles and pump accessories for the night/early morning ready. For me, this means putting nipples on and labeling all bottles. I usually have two bottles of formula made also, as backup. All pump flanges and bottles are clean and screwed together, ready to use.

3. Pump one last time and go to sleep at the same time as the babies. It’s tempting to watch a little TV or get things done while they’re asleep, but I’ve noticed they sleep better with me nearby and I really value my own sleep. I’m sometimes already drifting off while they’re still rustling to settle in.

4. Do not get up before they’re supposed to. If they loaded up on milk before going down, they don’t need to be fed until 4am. Usually all I have to do is replace the paci for the rustling baby and they’re back out before they can really wake up. Toddler never took a paci, so I would just jiggle her bassinet a little and she’d go back to sleep.

5. When the time does come to feed, pop a bottle in the mouth of the hungry one and prop it with whatever you have (I use their blankets). Then do the same with the other one, even if he/she is still fast asleep. They’re still swaddled, so no chance of waving arms knocking the bottles out. My babies will eat while asleep and keep sleeping afterwards without even waking up. I also no longer burp or change them (unless there’s poop) in the middle of the night.

6. While they are eating, pump. There’s a way to secure the flanges with the insides of your elbows by resting the bottles on your thighs, so that you can read your iPhone or reprop a bottle  when necessary. When I’m done, babies have finished eating and have probably also fallen asleep. All I have to do is retrieve their bottles. I leave the flanges on the bottles I just pumped, and everything is left on the nightstand until morning.

7. I can usually do this while still half-asleep myself. Sometimes I will get up to drink some water, pee, and read my phone for a bit in bed before sleeping again, but I can just as easily go right back to sleep. My babies will sleep until 9am, if I replace the paci for them a couple of times starting around 7am. I am usually up by 8ish to watch Toddler after Husband leaves for work, so I can get in a pump and have breakfast with her before they wake up.

Another plus to this is, they usually wake at the same time! That means the day starts off with them on the same schedule. It usually doesn’t stay that way, and I’ve given up imposing a strict togetherness, but sometimes they can stay within a half hour of each other all day.

I’m looking forward to them sleeping all the way till morning and taking regular solid naps (Toddler did it before she was their age), but I think this is as good as it gets for a middle-of-the-night feeding (for twins). But I’ll gladly take any other suggestions to streamline things even further!

lunchldyd is mom to an almost 3 yr old daughter and 4 month old b/g twins, taking whatever sleep she can get!

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