Triple feeding is a term often used to describe a specific feed plan that may be recommended to you by your healthcare team. This is usually suggested if there are any concerns about your baby’s weight gain.

So, what exactly is ‘triple feeding’?

The term triple feeding is often used to describe a feeding plan where you are recommended to do the following 3 things every time you feed your baby (at least 8-10 times per 24 hours)

Direct breastfeeding;

Expressing your breasts to stimulate further milk production;

Supplementing feeds (topping up) with expressed breastmilk, donor milk or formula milk.

Typically, this is a feeding plan that is introduced in the early days if there are concerns that your baby has either lost too much weight, or is not gaining weight as well as would be expected. It is described as triple feeding because for every feed, you are doing these 3 components. This is an intense approach and is never meant to be a long-term solution. However, all too often families are started on this type of feeding plan with no discussion or guidance for how or when to stop.

This article aims to inform you of the following – what the purpose of triple feeding is; what to review with your healthcare team prior to starting this feeding plan; how to help baby drink more at each breastfeed; some alternative options; how to progress away from triple feeding. As with many situations with breastfeeding/caring for new babies, there are many individual circumstances that can affect your own situation. For this reason, it is always good to seek support and guidance from a skilled professional who can help explore your own unique circumstances. A home visit from an IBCLC can really help you to navigate this challenging time and get you back on track with your breastfeeding journey Book Breastfeeding Support

What is the purpose of triple feeding?

The main goals of triple feeding are to increase the amount of food baby is getting as well as increasing your milk production. If your baby has lost too much weight or is not gaining as expected, then this is often the go-to feeding plan that is recommend to help improve weight gain and improve milk production. The main purpose of triple feeding is to remain supportive of your breastfeeding relationship and protect you milk supply, only using formula as a short-term addition if necessary. Triple feeding is always meant to be a temporary approach because it is so labour intensive for you at each feed. The plan should be reviewed and adjusted as needed at each weight check.

What to review with your healthcare team before commencing a triple feeding schedule

Prior to commencing a triple feeding schedule, it can be hugely beneficial to have skilled support with recognising why your baby may not be gaining weight. This could be because of their ability to feed at the breast effectively and efficiently, or it could be that your milk production is not as high as baby’s current needs. Sometimes it can be a combination of these things –

Some common causes that can make feeding more challenging for baby

Poor positioning and attachment
Sleepiness following birth, making it hard to keep baby actively drinking
Jaundice (can lead to increased sleepiness)
Tongue tie – making it hard for your baby to feed effectively
Baby is unwell (can lead to increased sleepiness)
Baby was premature (can lead to increased sleepiness or difficulty with attaching)

Some common causes that can affect your milk production

Poor positioning and attachment – leading to poor milk removal which then affects ongoing milk production.
Not feeding responsively – trying to feed to a schedule instead of offering feeds in response to hunger cues
Infrequent feeding/ milk removal – if baby is sleepy and not feeding well or not waking for feeds often enough, then they will not be removing milk well, which leads to less milk being made.
Prolonged or difficult labour/birth – can delay onset of full milk production (usually day 2-3 after birth)
Increased blood loss at birth – can delay onset of full milk production
Tongue tie/jaundice/prematurity (can all lead to poor positioning and attachment which means poor milk removal so less milk being made to replace the milk removed)
There are also some rarer causes that your healthcare team could help you to recognise – certain medications such as oral contraceptives/ decongestants or retained placenta.

Signs that positioning and attachment need adjusting/improving

You have sore or damaged nipples
Baby is slipping off lots
Baby is not actively drinking during feeds
Baby has poor/slow weight gain
Baby is not doing at least 7 heavy wet nappies per 24 hours (once over 7days old)
Baby is not doing at least 2-3 yellow/orange/mustardy poos per 24 hours, at least the size of a 50p coin (once over 7days old)

Effective positioning and attachment matter

If it has been suggested that you commence a triple feeding plan, you should first receive support with positioning and attaching your baby to the breast. Often, the main reason a baby is struggling to gain weight is because they are not attaching well to the breast, which means they cannot access the available milk as easily as they need to. This can then lead to a cycle of events where baby is not removing much milk from the breast which in turn means the breasts aren’t stimulated to make enough milk. This support should involve a skilled professional observing an entire feed, helping you to fine tune your positioning and helping you to recognise when your baby is drinking well. Book Breastfeeding Support

Good drinking at the breast matters

It is helpful for you to have support with recognising when your baby is drinking well at the breast compared to when they are only gently suckling at the breast but not drinking. Some babies can spend a long time at the breast but not really be drinking, this can be both tiring and unproductive for you and your baby. If your baby is actively drinking at the breast, then 2 things will be happening – they will be getting milk, and they will be draining the breast more effectively, which will help to increase your milk production. Remember, the more milk that is removed, the more that is then made to replace it.

Active drinking is where your baby will be actively swallowing milk every 1-2 sucks that they take at the breast. You should be able to see that your babies jaw drops wide every time that they are filling their mouth with milk, as the jaw comes back up, you should hear an audible swallow, often noted as a ‘kuh’ sound. If you are seeing the wide, slow jaw drop and hearing the ‘kuh’ sound when the jaw closes, then you can be reassured that your baby is drinking. If your baby’s jaw is always moving very rapidly and not opening wide, then they are not actively drinking. They can do this more rapid suckling at the beginning of a feed as they stimulate your milk to flow, but they should move to the more rhythmic and slower jaw movements that indicate active drinking within a few minutes of attaching to the breast.

How to help baby to drink more with each breastfeed

If you have had support with positioning and attachment and recognising when baby is drinking and it has been identified that baby is struggling to continue actively drinking, then the following techniques can really help increase activity at the breast, improving how effective each breastfeed is.

Breast compressions

Breast compressions are where you cup your breast in your hand (being sure to be further back on the breast so that you do not interfere with baby’s attachment) and gently squeeze the breast. Hold this squeeze until baby slows with their drinking again, then release and squeeze again. This can be repeated throughout the feed. Breast compressions make it easier for your baby to keep accessing the milk, if milk is flowing to them then this encourages a sleepier baby to continue more active drinking. When you notice that baby is drinking less actively, you can take baby off this breast and switch them to the next breast.

Switch nursing

This can be used alongside breast compressions to help baby to actively drink for as much as possible each breastfeed. Once you notice baby is drinking less actively with the breast compressions, you can detach them from that breast and switch them to the other side which will have a larger volume of stored milk that is more easily accessible to your baby. Please note! Your breasts are never empty, but they can be drained! Whilst baby is feeding on one breast, the other side is busy making more and building up the stored supply. You can switch back and forward between breasts several times each feed as this will help baby to take a bigger overall volume between the two sides.

Supplementary nursing system use

These clever devices can be used to help you to provide the required supplement (top up) whilst your baby is at the breast, thus negating the need to use a bottle. The supplementary nursing system (SNS) consists of a thin tube that can be attached near your nipple. The other end of the tube sits in the milk that you are using to supplement the feed. You attach baby to the breast as normal and whilst they breastfeed, they will also draw the milk via the thin tube. It is good to block the flow of milk off initially whilst baby takes what they can directly from the breast, then you can release the flow once baby begins to slow with actively drinking from the breast alone. This then gives them the additional milk via the SNS which keeps them at the breast for longer, giving them the supplement that is needed but also giving additional stimulation to your breasts. SNS can be tricky to master initially, but can be such a vital set up for some families and minimise the need for using bottles if this it what you prefer to do.

Pumping to support increasing your milk production

Not all breast pumps are equal, especially when it comes to establishing a milk supply. A double electric, hospital grade pump is the recommended pump for establishing milk production in the early weeks. Read Breast pumps and expressing breastmilk; all you may need to know! to learn more.

The following approaches can make pumping more manageable when you are on a triple feeding plan –

Power pumping

This can be a useful technique if you have found it hard to manage pumping after every feed or can be used as additional breast stimulation at any time. It essentially mimics your baby cluster feeding. This is best to do with a double electric pump, you can use your bra to hold the pump cups in place, or there are special pumping bras available. Consider ways to help keep your oxytocin levels high (the hormone that lets the milk flow) – dim lighting; relaxing music; keep your shoulders covered and warm; watch something you enjoy on tv; some yummy snacks. It can also be good to cover the bottles with socks, so that you are not constantly watching the milk flow if this causes you anxiety.

Pump for 20 mins

Rest for 10 mins

Pump for 10 mins

Rest for 10 mins

Pump for 10 mins

Opportunistic pumping

This is an approach that can really help if you are struggling to find the time to pump after every feed. Set your pump up somewhere that you walk past frequently – the kitchen for example. Every time you pass the pump, use it for a few minutes. The frequent short bursts of stimulation will really help to keep your prolactin levels high; this is one of your key milk making hormones.

Storing your pump parts in between pumping sessions

Popping your pump parts in a sealed sandwich bag in the fridge in between pumping sessions can reduce washing/sterilising time. It’s a good idea to still wash these parts in hot soapy water and sterilise them once per 24 hours, but the other times, you can store the pump shield and component parts in a clean, sealed sandwich bag in your fridge in between your pumping sessions. The bottles that the milk sits in and any teats that you are feeding the milk through will need washing and sterilising each time though.

Other frequently asked questions when you are being asked to follow a triple feeding plan

Is it better to keep the baby on one breast for longer to help them to get to the fattier milk?

This is something that is still often recommended by healthcare professionals because of the notion of foremilk/ hindmilk from many years ago. This concept suggested that the beginning of a breast feed is all watery milk and the very end of a breastfeed is when the baby gets all their fat content. We now have a better understanding of this and know that fat content is present all the way through a feed, so if your baby is actively drinking at the breast then they are accessing milk that has all the wonderful properties they need, fat content included. If they have done some good drinking then have slowed and are rarely swallowing or not swallowing at all, then it is much better to swap them to the next breast to help them to get a volume of milk again. The more milk they take each feed, the more fat content they will be getting!

What volume of supplementation/top up should we be offering each feed?

This will very much depend on several factors – the age of your baby; what their weight loss has been and how well they are feeding at the breast/ what your milk supply is. For this reason, it is always best to take individual guidance on this from your healthcare team or work with an IBCLC to support you with this. In general, the aim is always to keep top up volumes as low as possible and focus on optimising breastfeeding/breastmilk production. It is good to be aware that from 2 weeks of age onwards, the average volume for a full feed may be between 60-90mls, therefore if you are being recommended to supplement with 90mls or more, this is more like a full feed than a supplement. Ideally any suggested supplement volumes should be calculated in relation to your baby’s weight along with consideration that they will be taking some when breastfeeding too. Sometimes it can help to trial a slightly lower top up volume but check weight sooner, so that you can adjust the plan and volumes responsively.

Are there any alternative options/ What if I just can’t manage to do all 3 components every single feed?

It is so important for your healthcare team to work in partnership with you and consider all contributing factors for whether this approach is manageable for you. This is an intense approach so it can take a toll on you physically, mentally and emotionally. Be honest with yourself and your healthcare team about what you feel is manageable. Sometimes it may be necessary to find a better balance that still helps you to head towards your feeding goal. For example, it may be that you can manage to breastfeed, express and supplement during all of the day feeds but to manage some rest at night, you choose to just breastfeed and supplement, or just pump and supplement for each of the night feeds.

It is also an option to approach a feed in a different order if this seems to suit you/your baby best. For example, if your baby is very sleepy and difficult to wake enough to breastfeed, you may find it works better to offer some milk by bottle first, then bring them to the breast afterwards. Similarly, if they get very agitated when very hungry, this can make it hard for them to attach to the breast. Offering some milk by bottle first can take the edge off this hunger which helps your baby to calm and be better able to concentrate on attaching to the breast.

How/when to move away from triple feeding?

If you have had good support with improving how your baby attaches and feeds at the breast and have been pumping and supplementing with additional milk, then we should see improvement in weight gain and milk production by the next planned weight review. It should then be possible to start reducing the amount you have been supplementing your baby with, whilst increasing time effectively breastfeeding. Your healthcare team should advise you on this as it will depend on many individual factors such as how well the weight has increased and how much you were supplementing with at each feed. A gradual approach to reducing the supplement volumes is important to help both baby and your breasts adjust.

In summary, triple feeding is an intense approach involving 3 components every feed to help to improve your baby’s weight gain and your milk production. It should only ever be something that you are asked to work on as a short term measure to help improve effectiveness of breastfeeding and breastmilk intake/production. The most important first steps if there are concerns about your baby’s weight gain or your milk production are to have support with your positioning and attachment to help baby to feed at the breast as effectively as possible. It is also important to find an approach that is manageable for you, so don’t be afraid to discuss with your healthcare team. When you begin to move away from triple feeding, it is important to have support with how to reduce the supplement volumes in a gradual way so that baby and your breasts adjust gently.

Triple feeding – all you need to know!