The top-up concept

If your baby has weight gain challenges, you might be advised to "top up" after each of your baby's breastfeeds with certain volumes of expressed breast milk or formula. The advice to use "top-ups" is often based on the following assumptions or beliefs, each of which became popular after the Second World War, and each of which unfortunately misunderstands normal baby biology.

• Myth #1

Each feed needs to be a whole, satisfying meal, which completely fills your baby up with milk. This is the only way you'll have a happy, manageable baby who sleeps reasonably well.

• Myth #2

Babies either go to sleep after feeds or are happily satiated and willing to be put down after feeds. If baby dials up or is not happy to be put down after a feed, it is because he is hungry and not receiving enough milk.

• Myth #3

If your baby has a good feed, then he will be happy to not to take milk for the next three hours. If he begins to dial up in that time, either he

• Can't be because he's hungry, because he's already fed

• Is hungry, and isn't receiving enough milk with the feed.

Since the top-up concept comes out of these outdated ideas about baby behaviour, which don't reflect biological or evolutionary norms, parents who are advised to use top-ups might find that the top-ups seem to solve the weight gain problem in the short term, but actually make breastfeeding less likely to succeed, and even make poor weight gain more likely, long-term. Of course, no-one intends this, but I explore why this is often the case below.

The triple feeding concept

Triple feeding is an extension of the top-up concept. Triple feeding builds on the three beliefs or myths above which underlie the top-up concept. You're being advised to triple feed if you're asked to

1. Offer the breast first (usually both sides), for a limited period of time

2. Then pump from both breasts

3. Then offer baby your expressed breast milk as a "top-up" in a bottle

4. And sometimes then also to offer your baby more formula "top-up" in a bottle.

Triple feeding takes a long time, usually an hour and often up to 90 minutes. You can see why the feeds are then spaced out to every three hours. Otherwise, a woman who is triple feeding simply goes from feed to feed and never has a break!

Triple feeding often starts in the hospital setting

There are times when triple feeding can be helpful, usually within the hospital setting. Mothers building their milk supply to feed prematurely born babies, for instance, often triple feed, and this is a useful initial strategy which gives everyone on the ward a sense of order and manageability.

One day, Neonantal Intensive Care Units in both high income and low and middle income economies will adopt the new, carefully evidence-based World Health Organisation's recommendations concerning kangaroo care for prematurely born infants, found here. In the meantime, the habit of routinised predictability allows your team of doctors and nurses to best protect your premmie and keep him safe and growing.

Triple feeding can backfire in the community setting

This doesn't mean that a routinised predicability around feeds is in your baby's best interests once you're home - on the contrary, it can back-fire spectacularly and make life much harder than it needs to be. Here's why.

• Pumping and triple feeding regimes quickly result in very high levels of occupational fatigue. You might even feel you just can't keep on going and have to wean altogether, because it is so exhausting.

• Offering the breast every three hours (that is, eight offers each breast in a 24-hour period) is not enough to maintain many babies' weight gain or many mothers' milk supply. Long episodes of milk removal don't remove milk and build supply the way frequent but shorter periods of milk removal does. This is why triple feeding is often a recipe for increasing amounts of formula.

• Staying inside the home typically causes your baby to dial up, because of the low sensory motor interior environment. You can find out about this here. Babies who are triple fed might dial up after feeds, or in between feeds, and this might be misread as due to hunger when in fact it is due to baby's unmet sensory motor needs. Having a dialled up baby often worsens a woman's exhaustion and misery.

• Babies who are triple feeding very commonly don't have an appetite drive to transfer much milk from the breast. It's normal for a baby who is triple fed to be offered the breast before the bottle, but for parents to report that the baby suckles without transferring much milk and quickly drowses into sleep. You can find out more about this here.

I know this sounds quite upsetting, if you've been advised to triple feed. It's no-ones fault, because this is the way health professionals are trained. It's why it's so important for our health systems to address the blind spots we have about breastfeeding support, so that things go better for breastfeeding women and their babies, right from the start!

• You can find out how to transition to direct breastfeeding from triple feeding when you are mostly using formula here.

• You can find out how to transition to direct breastfeeding from triple feeding when you are mostly using expressed breast milk here.