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Tandem nursing: a review and guidelines.

Breastfeeding is presently receiving increasingly substantial interest and is highly recommended for both mother and infant due to its well-documented benefits to maternal health by widening birth intervals (Mazumder & Hossain, 2012) and providing optimal infant nutrition and growth, particularly if the infant is exclusively breastfed with appropriate techniques (Engstrom, 2007; Marques, Lopez, & Braga, 2004). Nevertheless, tandem nursing is not well understood and health care providers can benefit from having more precise guidelines on the practice of breastfeeding during a subsequent pregnancy. The author addresses these subjects with personal experience and knowledge derived from numerous years of dedicated tandem nursing.

Tandem nursing is the practice of simultaneously nursing two children that are not twins or multiples (van den Berg & Ball, 2008). Whilst some practitioners are proponents of nursing twins and higher-order multiples that are often born at risk (Gromada & Spangler, 1998), they may be unaware of the advantages of an older child nursing alongside a younger sibling. Understanding the advantages of nursing the children concurrently, healthcare providers will be better prepared to support women who choose to tandem nurse.

My first child, 10 month-old Devon, resumed nursing about two weeks after the birth of my second child Rae. I had originally not planned to tandem nurse, and commenced the practice at the ingenuous request of my older daughter as an attempt to ameliorate her anxiety towards the presence of a younger sibling and perceived divided attention. It is commonplace for the firstborn of an expectant mother to experience apprehensiveness (Anderson, 2006). I reluctantly ablactated her at 12 months as a consequence of predisposed conventional beliefs. I would likely have been discouraged from continued breastfeeding by family members and healthcare practitioners contrarily. Olang, Heidarzadeh, Strandvik, and Yngve (2012) studied the questionnaire responses and interviews of 63,071 mothers of infants up to 2 years of age in a retrospective study, and revealed that 54% of the mothers discontinued breastfeeding in abidance to physician recommendations and insufficient breast-milk production. However, the study demonstrated that only 28% have self-perceived or actual inadequacy. This represents that 26% of mothers have been advised against continued breastfeeding despite the non-evidence of contraindications.

The concerns include i) pregnancy is a physiological state involving a rapid depletion of maternal reserve of nutrients, and breastfeeding during pregnancy increases nutrition risks for the mothers, firstborns, and newborns, and (ii) the older child may compete for nursing privileges and promote sibling rivalry (Arizona Department of Health Services, 2011). These concerns are not unfounded. Exclusively breastfed infants have increased likelihood of becoming deficient in vitamin D, as reported by Greer and Marshall (1989), and Basile, Taylor, Wagner, Horst, and Hollis (2006), in their comprehensive studies of the relationship between exclusively breastfed infants, serum vitamin D levels, and the significance of infant and/or maternal supplementation. It is imperative for tandem nursing women to correspondingly increase nutrient intake to accommodate the elevated nutritional requirements to ensure adequate milk production, including additional fluids and calories from whole grains, fresh fruit and vegetables, as well as foods rich in protein, calcium, and iron.

Nonetheless, the preponderance of appropriately nourished women may breastfeed during pregnancy with minimal risk, on the condition that they do not present preterm labor symptoms, such as prolonged uterine contractions or bleeding (Lynn, 2004). The benefits of nursing extend beyond the first months of infant development, and the World Health Organization (WHO), the leading international agency for human health, recommends continued breastfeeding to two years of age or beyond (Wen, Baur, Rissel, Alperstein, & Simpson, 2009). The expectant mothers that recognize the recommendation is 5.5 times more likely to exclusively breastfeed for 6 months and continue breastfeeding for a substantial duration in contrast to those that are unfamiliar with these guidelines, in assent with their findings.

The benefits of breastfeeding are broadly recognized, including increased sucking and breathing coordination, positive effects on oxygen saturation, enhanced skin-to-skin contact, optimal nutritional preservation and immunological properties (Buckley & Charles, 2006). The U. S. Department of Health and Human Services (USDHHS) identifies breast milk as liquid gold (USDHHS, 2012). Breastfed infants receive colostrum from the first suckle, which is rich in nutrients that build tissue and antibodies, protecting them from illness and disease. Colostrum is a natural substance that cannot be replicated by technology as it has all the necessary ingredients to promote nutritional health in infants, and it contains immunoglobulins, lactoferrin, and lysozyme responsible for significantly reducing infections and mortality rates (Bandyopadhyay, 2009). Some of the invaluable nutrients found in colostrum are growth proteins, antibodies, and vitamin A. Breastfeeding delivers these nutrients in low volume and high concentration for optimal digestion and absorption, and has measurable health benefits to the infants even for brief durations. The early bonding created by breastfeeding decreases the risk of maternal postpartum depression as the hormone oxytocin released during breastfeeding naturally induces relaxation and tranquility in the mother (Dermer, 2001). Moreover, breastfeeding is economical and the increased calorie expenditure facilitates healthy weight loss in postpartum mothers.

Beyond the initial exclusively breastfed period, the benefits of breastfeeding continue to promote a child's health and wellbeing (Meyers, 2009). Breastfed children are less prone to intestinal upset, Type ii diabetes, asthma and obesity, during breastfeeding and later in life (Stolzer, 2011), and breastfeeding is linked to greater mental development (Wang, McVeagh, Petocz, & Brand-Miller, 2003). Kramer et al. (2008) conducted a large cluster-randomized trial involving 17,046 healthy breastfeeding infants and followed up with i,3889 infants in 6.5 years, and the study revealed that "at the age of six and a half, children who had been exclusively breastfed scored 7.5 points higher in verbal intelligence tests and 5.9 points higher in overall IQ tests" (p. 58i).

Breastfeeding is cost-effective and ecological since the usage of plastic bottles, inserts, and nipples is diminished. In addition, women who breastfeed have fewer incidents of breast cancer and ovarian cancer, (Palda, Guise, & Wathen, 2003), and are reported to miss less work to care for sick children than those who bottle-feed (Rippeyoung & Noonan, 2012). Studies show that breastfeeding has been linked to fewer incidents of infant mortality and lower healthcare costs (Kent, 2006). The American Academy of Pediatrics (AAP) further supports exclusive breastfeeding for the first six months (AAP, 2012), and Vesel, Bahl, Martines, Bhandari, and Kirkwood (2010) substantiated this assertion by stating that breastfeeding for this amount of time significantly decreases the prevalence of malnutrition, which contributes to approximately 3.23 million child deaths worldwide per annum.
   Researchers compared CDC records of 1,204 children who died between
   28 days and one year of causes other than congenital anomalies or
   cancer with those of 7,740 children still alive at one year.
   Children who were breastfed had 20% lower risk of dying between 28
   days and one year than children who weren't breastfed. Longer
   breastfeeding was associated with lower risk (NIH, 2004, para. 2).


Chertok and Zimmerman (2007) suggest continued breastfeeding as long as it is mutually desired by the mother and child, and breast milk continues to add important nutrients to the child as solid foods are introduced (AAP, 2012). Furthermore, suckling enhances comfort for the child, eliminates the need for pacifiers (Page, 2001), and significantly reduces the risk of decayed deciduous teeth, nursing caries, malocclusion, and streptococcus mutans in comparison to children that are not breastfed (Cartwright, 2008). National Resource and Defense Counsel (2012) reported that breastfed children develop fewer psychological, behavioral, and learning problems, and it may contribute to academic performances (Oddy, 2010). These psychological benefits of tandem nursing not only extend to biological children but to adopted children by increasing trust and reducing anxiety and discomfort (Gribble, 2006).

During breastfeeding, the body releases prolactin, a hormone that suppresses ovulation and is regarded as a natural form of birth control (Valeggia & Ellison, 2009). Suppression is optimal up to about 10 months but can be prolonged in some women. The natural spacing of siblings is aided by breastfeeding, and the interbirth intervals improve reproductive success and prevent maternal depletion syndrome. However, women who are intent on not becoming pregnant should discuss contraception with a qualified medical practitioner.

In an article in Mothering, a mother recounts her experience of unweaning her three year old to help resolve a sibling rivalry and reassure an unsettled child (Hull, 2009). This mother found that her cranky, jealous three-year old became a joyful and nurturing person overnight. She found the experience of nursing two children challenging, but the peace and calm in the house benefitted all. "Mothers need energy, patience, and emotional fortitude to nurse siblings" (Flower, 2003, p. 222*). As strange as tandem nursing may seem to some, it is not as uncommon as one would suspect. Flower (2003) devotes an entire book to recounting the often humorous stories of tandem nursing teams, and provides much needed support to mothers who embark on this significant journey. This is an excellent resource for women who are nursing while pregnant and for women who tandem nurse as it contains relevant information and provides immense support.

Women who breastfeed during pregnancy may experience some discomfort from sore nipples, additional tenderness in the breasts, and psychological discomfort. Many women are reticent to breastfeed a toddler, notwithstanding their comfortableness with nursing an infant in public. While nursing an infant has known benefits, many women are unaware that continuing into the second year is recommended. Sue Jameson, a lactation consultant, reminds the reader that the "average duration across the world is 4.2 years" (Wayman, 2012). Women who wish to tandem nurse need a strong support system from family and healthcare practitioners to continue in that oftentimes the social norms discourage this practice. The value in protein that comes from breast milk can be a strong encouragement of continued breastfeeding. Self-weaning will usually happen between 3 and 4 years old, although others may experience this in an earlier time frame (Wayman, 2012). The choice of continuing nursing the first child while nursing the second is a personal commitment to provide the older child with advantages afforded from long-term nursing. Supporting women who choose to tandem nurse is as important as encouraging the new mother who chooses breastfeeding for the first time, on the condition that there is an absence of reason that renders it inadvisable.

Childbirth educators who encounter mothers who wish to continue breastfeeding through pregnancy or tandem nurse are obligated to emphasize the importance of proper nutrition and sufficient rest. When a woman chooses to breastfeed while pregnant she should be prepared for changes in the milk that her child might notice. Although breast milk continues to be nutritionally sound throughout pregnancy, the content and taste of the breast milk may change. "In addition, milk production is quite likely to decrease as the pregnancy progresses" (Harms, 2012, para. 2). Women who nurse during pregnancy should be encouraged to seek medical attention if she experiences preterm labor symptoms or if bleeding occurs, discuss a possible need for additional vitamin and mineral supplement with healthcare providers, and meet with a certified lactation consultant to ensure proper techniques and support. These practices can reduce the physical and mental strain on the mothers.

It may be helpful for the mother to initially nurse one child at a time until the new baby becomes adept at nursing, and prepare an activity for the older sibling to engage in while the baby nurses. This facilitates the adjustments of the older child. Eventually, it is possible for mothers to comfortably accommodate for the nursing trio. This shortens the nursing time and soothes the baby or toddler by eliminating wait time and anxiety during the wait. Switching sides, positions, and order allow each child to benefit from foremilk and hindmilk, which is rich in necessary fat and calories (Walshaw, 2010).

It is prudent for practitioners to inform the general public about tandem nursing and encourage it whenever it may benefit them biologically, psychologically, and socially without ill consequences. Particularly, we can encourage families to support these mothers and have qualified dietetic professionals to provide them with appropriate nutritional advice, suggest relevant reading materials and mother-to-mother support groups, and reassure the benefits of long-term nursing. Furthermore, we can act as reminders that tandem nursing can both be one of the most challenging tasks and rewarding experiences in life. Most importantly, we need to respect their choices, help them practice healthy behaviors, and ensure their well-being while tandem nursing. Further research is necessary to provide more complete insights, and additional adequate and empirically supported evidence on the benefits of tandem nursing in different populations of women.

[ILLUSTRATION OMITTED]

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Tammy Bryant is a Walden University graduate with a Master degree in Public Administration. She is currently a PhD student seeking a doctoral degree in Psychology. She has 13 years experience in early childhood education, teaching young children using the Montessori Method, and is the mother of 4 daughters.

Tammy Bryant, MPA
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Publication:International Journal of Childbirth Education
Date:Oct 1, 2012
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