Written by Jody Segrave-Daly, RN, IBCLC and Lynnette Hafken, MA, IBCLC

 What is “triple feeding?” 

Mothers who triple feed will feed their babies at the breast, immediately pump and deliver any expressed milk (and/or formula supplement) through a bottle or sometimes even a syringe to the infant.  

Triple feeding originated in the NICU for premature infants who were learning to breastfeed but were unable to empty the breast completely. In order to preserve or increase the milk supply, the breasts were pumped after nursing and the milk was saved for the next supplemental feeding. In this way, the premature baby was nurtured until he or she was strong enough to only nurse from the breast. This was sustainable because the parent has access to nurses and lactation professionals to assist her during the triple feeding cycle.

For full-term babies with ineffective milk removal or moms with low milk supplies, the triple feeding cycle at home is recommended by some lactation consultants.  

Unfortunately, many mothers who have followed this regimen say that they were given little guidance on how long to triple feed and when to stop.  As a result, these mothers have endured the equivalent of caring for triplets (feeding a baby at the breast, “feeding” the pump, then feeding a bottle). In addition, there are pump parts to wash up to eight times a day, and sometimes other children to care for.   Triple feeding requires a considerable amount of effort and time, and there is little time between feedings for the mother to take care of her own basic needs, such as sleep, eating, and hygiene.

“I didn’t eat or drink for days because of the time constraints of triple feeding. By the time my baby was admitted to the hospital on day 5 of life, I lost consciousness and then broke down in the corner of his room from profound exhaustion. I’m a doctor and had done surgical and anesthesia residency. I’m used to sleep deprivation. Those five days were hell on earth. Not only did it not work, but I also unknowingly starved my baby under the care of lactation professionals.  They knew I had a breast reduction, but I was told to triple feed without a backup plan. That week of my life lives over and over in my head all the time.” —Dr. N. King 

 

Why is the triple feeding strategy recommended by medical and lactation professionals?

The common reasons for prescribing triple feeding are:

• Poor latching, lack of sustained suckling, oral anomalies, and insufficient milk removal.
• Delayed onset of full milk production and excessive infant weight loss or failure to gain weight.
• Chronic low milk supply for poor breastfeeding management, hormonal insufficiency, insufficient mammary physiology, and unknown mammary dysfunction.

The theory behind triple feeding is based on the first two rules of lactation management: feed the baby and maximize the milk supply.  

1. When a baby is not transferring milk effectively, he is not stimulating his mother’s milk-making hormones adequately, and milk remains in the breast. This causes a reduction in her milk supply and does not provide a full feeding for the baby.
2. Giving the baby frequent opportunities to breastfeed despite the low milk transfer is thought to help the baby improve his latching and milk transfer skills, and avoids bottle preference.
3. Pumping after nursing will remove most of the milk from the breasts, thus helping to increase the mother’s milk supply to a sufficient level (a full milk supply is about 25-32 oz/day). When successful, this will allow her to gradually wean the baby from supplementing and return to fully feeding at the breast. 
4. Immediate supplementation is necessary to provide the baby’s full feeding, as babies have caloric, nutritional, and hydration needs that cannot wait until the breast milk supply potentially increases. 

Unfortunately, triple feeding has become the default method that is recommended by medical and lactation professionals for a large number of breastfeeding challenges, with no regard to the maternal complications that will eventually occur, or the likelihood of it solving the problem of low milk supply. It is imperative for all mothers to know that triple feeding is not sustainable for longer than four to seven days, and it cannot be recommended unless the mother has a full-time helper. If triple feeding is working, there will be evidence with increased milk supply/volume. This is how we know it is working. If there is no increase, triple feeding will not work for this mother, and her breastfeeding plan will require changes. Most likely it will be a combo-feeding plan. 

Before triple-feeding is recommended, medical and lactation professionals must make careful considerations because of the daunting amount of time that is necessary for every feeding. The things that need to be considered are:

1. Does the mother have full-time in-house help?
2. Does she have any preexisting history of mental illness?
3. Does she have the best mammary physiology and general health profile to sufficiently increase her milk production?  (The word “sufficient” is subjective and is determined by both the baby’s needs and the mother’s goals.)
4. Does she have a high-quality electric breast pump?
5. Does the proposed triple feeding plan allow for sufficient sleep, nutrition, and self-care to support her basic physiological needs?

Of course, every mother and baby have unique needs and require individualized breastfeeding management and support. The plan must also be flexible enough to meet unexpected needs. It is very important for the health care professional involved to inform parents that they may find themselves unable to follow the triple feeding plan perfectly. A backup plan should be provided until changes can be made that the parents are confident they can follow. Mothers need to know they can stop at any given time, and that there is no guarantee triple feeding will provide the results they are looking for. This is part of informed consent. 

Complications of triple-feeding: mental health, bonding and preventing accidents

Jessica Montgomery talks about how triple feeding stole her ability to enjoy her baby and did not increase her milk supply.

Literally everything I read about breastfeeding said that undersupply was rare. After she was born, my milk didn’t come in right away. When it did, it was not enough, and she lost weight and had to be re-hospitalized for jaundice, dehydration, and hypoglycemia. 

I was willing to do anything to increase my supply and hoped to eventually be able to exclusively breastfeed. I saw two lactation consultants (IBCLCs) and both gave me different versions of the “triple feeding protocol” to try. I was supposed to complete the following three steps every 2-3 hours around the clock:

1. Breastfeed baby for at least 10-15 minutes per breast, using breast compressions.
2. Supplement baby pumped breast milk, and then formula if pumped milk is not enough. If the baby is able to latch, use a supplemental nursing system, to supplement at the breast, with a tube placed and taped next to my nipple. If she wouldn’t latch, I was supposed to finger feed, cup feed, or use a slow flow bottle.
3. Pump for 15-20 minutes with a double pump or for 15-20 minutes on each side if using a single pump or hand expressing. If the baby didn’t empty my breasts I was supposed to do this right away, and if not, I was supposed to wait an hour after nursing to pump. 

Triple feeding was my life for months, and my mental health seriously suffered. I couldn’t keep up and that made me feel so guilty, and honestly, it didn’t really do much for my supply. I lost so much time being with and bonding with my baby.

After my second baby was born, I met with a breastfeeding medicine physician who told me that triple feeding was too exhausting for most moms, and it wouldn’t fix my low supply issues because I was diagnosed with insufficient glandular tissue (IGT). I stopped pumping, ditched my SNS, and started combo-feeding my baby. It was amazing for my mental health and literally changed my life. 

Bethanne talks about having a psychotic break from severe sleep deprivation while triple feeding her daughter.

I was a first-time mother and was 100% committed to exclusively breastfeeding.  She was born at 36 weeks and was very sleepy. She latched poorly, so the LC prescribed triple feeding. I had plenty of help at home and thought everything was going well. I was profoundly exhausted because I didn’t sleep in the hospital at all. I didn’t recognize my mind was shutting down. I became confused and wasn’t eating or drinking much. I began hallucinating. My husband called my OB who told him to bring me to the hospital. I was admitted for observation, and the psychiatrist diagnosed me with severe sleep deprivation and anxiety. I had IV fluids and sleep medication and slept for 8 hours straight. When I woke up, my milk was in, but I was very frail and kept crying. I decided I would become a pumping and formula feeding mother so I could get some sleep. I tell every mother I know not to triple feed because of the hell I lived through. My OB filed a formal complaint about the LC who prescribed triple feeding to me.

According to Dr. Marianne Neifert, “the rigors of a triple feeding schedule aren’t for every woman: some are too exhausted or have too many other responsibilities to devote the necessary time and energy to this demanding regimen. Dr. Neifert states, “if a mom’s emotional well-being is at risk because she keeps trying and trying and it’s still not a rewarding experience, we have to assess whether it’s realistic for her to exclusively breastfeed. Many moms who are having a great deal of trouble and are ready to quit will breastfeed longer if they see it as doable for them” — doable, in other words, by combining breast- and bottle feeding.

Sleep deprivation has very serious consequences. As health professionals, we need to protect maternal mental health when developing complicated breastfeeding plans. Very serious sleep deprivation conditions while triple feeding has resulted in postpartum depression, anxiety, psychosis, deteriorating physical health, and serious accidents.

In Part 2 of this blog, we will share stories from mothers describing how a modified triple feeding plan worked for them. It’s important to recognize that every infant feeding situation requires individualized care for the best outcomes.

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Additional education resources:

The Newborn Stomach Size Myth: It is NOT 5-7 mL – Fed Is Best

 

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7. Write a letter to your health providers and hospitals about the Fed is Best Foundation. Write to them about feeding complications your child may have experienced.
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