{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,10,19]],"date-time":"2025-10-19T14:56:12Z","timestamp":1760885772883,"version":"build-2065373602"},"reference-count":47,"publisher":"MDPI AG","issue":"9","license":[{"start":{"date-parts":[[2021,9,3]],"date-time":"2021-09-03T00:00:00Z","timestamp":1630627200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Nutrients"],"abstract":"<jats:p>Background: Over the past year, there has been a rise in twin births. The current scientific consensus recommended breast-feed milk for all newborns for at least 6 months. They stated that it is possible to meet the nutritional needs of two or more newborns with only one mother\u2019s milk. More information would be desirable about the factors that influence or lead to the initiation and interruption of breastfeeding. The quality of the evidence available from multiple studies has been inconclusive and therefore led to controversial interpretations and practices. Aims: The first aim of this study was to analyze the extent of the feeding of multiples with breast milk in the experience of our clinical unit in terms of incidence and duration. The second objective was to evaluate the correlation between maternal, perinatal and neonatal variables with breast milk feeding rates and duration. Methods: The study was conducted between 2015 and 2020, in a NICU in Southern Italy (San Giovanni Rotondo, Foggia). Sixty-one women who have given birth to multiples were enrolled into the study. Newborn data were retrospectively collected by informatic database and breastfeeding information were collected by a questionnaire. Results: In our centre, the percentage of twins out of the total number of births over the years has almost doubled from 1.28% in 2015 to 2.48% in 2020 and the 88% of twins are premature. 18.1% received breast milk for more than 6 months and 6.3% received it for more than 12 months. Infants of lower gestational age and weight, born to multiparous, more mature and medium-high schooling mothers received breast milk for a longer period. 35% of women explained that the interruption of breastfeeding was due to the insufficient milk production and 41% to the stress and difficulties in managing the twins. Qualitative analysis of maternal narrative revealed, for many of them, the awareness of the importance of breastfeeding and the efforts made to try to give breast milk, but also fears about the quantity of milk and satiety of their children. Conclusions: It is important to identify the factors both favoring and obstructing maternal milk feeding of multiples and it would be desirable the activation of a network of training and support for mothers after discharge, with particular regard to the categories found to be less inclined.<\/jats:p>","DOI":"10.3390\/nu13093099","type":"journal-article","created":{"date-parts":[[2021,9,6]],"date-time":"2021-09-06T13:18:26Z","timestamp":1630934306000},"page":"3099","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":19,"title":["Feeding Twins with Human Milk and Factors Associated with Its Duration: A Qualitative and Quantitative Study in Southern Italy"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-3131-8700","authenticated-orcid":false,"given":"Pasqua Anna","family":"Quitadamo","sequence":"first","affiliation":[{"name":"Neonatology\u2013Neonatal Intensive Care Unit, IRCCS Casa Sollievo Della Sofferenza, 71013 San Giovanni Rotondo, Italy"},{"name":"Human Milk Bank, \u201cCasa Sollievo Della Sofferenza\u201d Foundation, 71013 San Giovanni Rotondo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laura","family":"Comegna","sequence":"additional","affiliation":[{"name":"Neonatology\u2013Neonatal Intensive Care Unit, IRCCS Casa Sollievo Della Sofferenza, 71013 San Giovanni Rotondo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Giuseppina","family":"Palumbo","sequence":"additional","affiliation":[{"name":"Human Milk Bank, \u201cCasa Sollievo Della Sofferenza\u201d Foundation, 71013 San Giovanni Rotondo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Massimiliano","family":"Copetti","sequence":"additional","affiliation":[{"name":"Statistical Department, \u201cCasa Sollievo Della Sofferenza\u201d Foundation, 71013 San Giovanni Rotondo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Paola","family":"Lurdo","sequence":"additional","affiliation":[{"name":"Neonatology\u2013Neonatal Intensive Care Unit, IRCCS Casa Sollievo Della Sofferenza, 71013 San Giovanni Rotondo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Federica","family":"Zambianco","sequence":"additional","affiliation":[{"name":"Faculty of Medicine, University of San Raffaele Vita-Salute, 20132 Milano, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria Assunta","family":"Gentile","sequence":"additional","affiliation":[{"name":"Neonatology\u2013Neonatal Intensive Care Unit, IRCCS Casa Sollievo Della Sofferenza, 71013 San Giovanni Rotondo, Italy"},{"name":"Human Milk Bank, \u201cCasa Sollievo Della Sofferenza\u201d Foundation, 71013 San Giovanni Rotondo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Antonio","family":"Villani","sequence":"additional","affiliation":[{"name":"Neonatology\u2013Neonatal Intensive Care Unit, IRCCS Casa Sollievo Della Sofferenza, 71013 San Giovanni Rotondo, Italy"},{"name":"Human Milk Bank, \u201cCasa Sollievo Della Sofferenza\u201d Foundation, 71013 San Giovanni Rotondo, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2021,9,3]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"157","DOI":"10.1177\/0890334403252563","article-title":"Long-term duration of breastfeeding in Swedish low birth weight infants","volume":"19","author":"Flacking","year":"2003","journal-title":"J. Hum. Lact."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"2405","DOI":"10.1016\/j.socscimed.2007.03.008","article-title":"\u201cI wanted to do a good job\u201d: Experiences of becoming a mother and breastfeeding in mothers of very preterm infants after discharge from a neonatal unit","volume":"64","author":"Flacking","year":"2007","journal-title":"Soc. Sci. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1666","DOI":"10.1093\/humrep\/deab029","article-title":"Twin Peaks: More twinning in humans than ever before","volume":"36","author":"Monden","year":"2021","journal-title":"Hum. Reprod."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1323","DOI":"10.2105\/AJPH.92.8.1323","article-title":"The impact of the increasing number of multiple births on the rates of preterm birth and low birthweight: An international study","volume":"92","author":"Blondel","year":"2002","journal-title":"Am. J. Public Health"},{"key":"ref_5","unstructured":"World Health Organization (WHO) (2003). Global Strategy for Infant and Young Child Feeding, WHO."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"389","DOI":"10.1080\/14767058.2017.1379073","article-title":"Morbidity and mortality of very low birth weight multiples compared with singletons","volume":"32","author":"Porta","year":"2019","journal-title":"J. Matern. Fetal Neonatal Med."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1016\/j.clp.2016.11.008","article-title":"The importance of human milk for immunity in preterm infants","volume":"44","author":"Lewis","year":"2017","journal-title":"Clin. Perina-Tol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"964","DOI":"10.3389\/fpubh.2020.589736","article-title":"Anti-Infective, Anti-Inflammatory, and Immunomodulatory Properties of Breast Milk Factors for the Protection of Infants in the Pandemic From COVID-19","volume":"8","author":"Quitadamo","year":"2021","journal-title":"Front. Public Health"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"20","DOI":"10.3389\/fnut.2017.00020","article-title":"Optimizing nutrition in preterm low birth weight in-fants-Consensus Summary","volume":"4","author":"Kumar","year":"2017","journal-title":"Front. Nutr."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"683","DOI":"10.1016\/j.clp.2017.05.004","article-title":"Reducing Incidence of Necrotizing Enterocolitis","volume":"44","author":"Patel","year":"2017","journal-title":"Clin. Perinatol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"71","DOI":"10.1038\/jp.2017.149","article-title":"Maternal milk feedings reduce sepsis, necrotizing enterocolitis and improve outcomes of premature infants","volume":"38","author":"Cortez","year":"2017","journal-title":"J. Perinatol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"69","DOI":"10.1016\/j.clp.2016.11.004","article-title":"Neurodevelopmental outcomes of preterm infants fed human milk: A Systematic Review","volume":"44","author":"Lechner","year":"2017","journal-title":"Clin. Perinatol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"102","DOI":"10.1038\/pr.2017.227","article-title":"Effects of early nutrition and growth on brain volumes, white matter microstruc-ture, and neurodevelopmental outcome in preterm newborns","volume":"83","author":"Coviello","year":"2018","journal-title":"Pediatric Res."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"77","DOI":"10.1016\/j.neuroimage.2013.05.090","article-title":"Breastfeeding and early white matter development: A cross-sectional study","volume":"82","author":"Deoni","year":"2013","journal-title":"Neuroimage"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1016\/j.jpeds.2016.06.045","article-title":"Breast milk feeding, brain development, and neurocognitive outcomes: A 7 year longitudinal study in infants born at less than 30 weeks\u2019 gestation","volume":"177","author":"Belfort","year":"2016","journal-title":"J. Pediatrics"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1016\/j.neuroimage.2018.09.045","article-title":"Early breast milk exposure modifies brain connectivity in preterm infants","volume":"184","author":"Blesa","year":"2019","journal-title":"Neuroimage"},{"key":"ref_17","unstructured":"Royal College of Paediatrics and Child Health (2011). Guidance for Health Professionals on Feeding Twins, Triplets and Higher Order Multiples, RCPCH."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1371\/journal.pone.0025239","article-title":"Twinning across the developing world","volume":"6","author":"Smits","year":"2011","journal-title":"PLoS ONE"},{"key":"ref_19","first-page":"129","article-title":"The changing epidemiology of multiple births in the United States","volume":"101","author":"Russell","year":"2003","journal-title":"Obstet. Gynecol."},{"key":"ref_20","unstructured":"NICE (2021, June 20). Multiple Pregnancy: Twin and Triplet Pregnancies. NICE Quality Standard [QS46]. Available online: http:\/\/www.nice.org.uk\/guidance\/qs46\/resources\/guidance-multiple-pregnancy-pdf2013."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"528","DOI":"10.1111\/j.1471-0528.2006.00923.x","article-title":"Preterm birth and multiple preg-nancy in European countries participating in the PERISTAT project","volume":"113","author":"Blondel","year":"2006","journal-title":"BJOG Int. J. Obstet. Gynae-Cology"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"e004514","DOI":"10.1136\/bmjopen-2013-004514","article-title":"Trends in the incidence and mortality of multiple births by socioeconomic deprivation and maternal age in England: Population-based cohort study","volume":"4","author":"Smith","year":"2014","journal-title":"BMJ Open"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"158","DOI":"10.1111\/ajo.12048","article-title":"Multiple deliveries: The reduced impact of in vitro fertilisation in Australia","volume":"53","author":"Umstad","year":"2013","journal-title":"Aust. N. Z. J. Obstet. Gynaecol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"298","DOI":"10.1375\/twin.9.2.298","article-title":"Breastfeeding rates among singletons, twins and triplets in Japan: A population-based study","volume":"9","author":"Yokoyama","year":"2006","journal-title":"Twin Res. Hum. Genet."},{"key":"ref_25","first-page":"CD012003","article-title":"Breastfeeding education and support for women with twins or higher order multiples","volume":"2","author":"Wallis","year":"2017","journal-title":"Cochrane Database Syst. Rev."},{"key":"ref_26","first-page":"749","article-title":"Breastfeeding Twins: Factors Re-lated to Weaning","volume":"34","author":"Mikami","year":"2018","journal-title":"J. Hum. Lact."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"431","DOI":"10.1177\/0890334408316083","article-title":"Maternal self-concept and breastfeeding","volume":"24","author":"Britton","year":"2008","journal-title":"J. Hum. Lact."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1038\/sj.jp.7210860","article-title":"Site of care influences breastmilk feedings at NICU discharge","volume":"23","author":"Powers","year":"2003","journal-title":"J. Perinatol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"138","DOI":"10.1089\/bfm.2015.0161","article-title":"Factos associated with breast milk feeding of very preterm infants from birth to 6 months corrected age","volume":"11","author":"Morag","year":"2016","journal-title":"Breastfeed. Med."},{"key":"ref_30","doi-asserted-by":"crossref","unstructured":"Maastrup, R., Hansen, B.M., Kronborg, H., Bojesen, S.N., Hallum, K., Frandsen, A., Kyhnaeb, A., Svarer, I., and Hallstr\u00f6m, I.K. (2014). Breastfeed-ing progression in preterm infants is influenced by factors in infants, mothers and clinical practice: The results of a national cohort study with high breastfeeding initiation rates. PLoS ONE, 9.","DOI":"10.1371\/journal.pone.0108208"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"e012900","DOI":"10.1136\/bmjopen-2016-012900","article-title":"Changes in the prevalence of breastfeeding in preterm infants dis-charged from neonatal units: A register study over 10 years","volume":"6","author":"Ericson","year":"2016","journal-title":"BMJ Open"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Pinchevski-Kadir, S., Shust-Barequet, S., Zajicek, M., Leibovich, M., Strauss, T., Leibovitch, L., and Morag, I. (2017). Direct feeding at the breast Is associated with breast milk feeding duration among preterm infants. Nutrients, 9.","DOI":"10.3390\/nu9111202"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"237","DOI":"10.1111\/ppe.12457","article-title":"Portuguese EPICE (E ec-tive Perinatal Intensive Care in Europe) Network; et al. Prevalence and duration of breast milk feeding in very preterm in-fants: A 3-year follow-up study and a systematic literature review","volume":"32","author":"Rodrigues","year":"2018","journal-title":"Paediatr. Perinat. Epidemiol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1089\/bfm.2016.0206","article-title":"Breastfeeding challenges and the preterm mother-infant dyad: A conceptual model","volume":"13","author":"Lau","year":"2018","journal-title":"Breastfeed. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"23","DOI":"10.1016\/j.jpeds.2018.07.001","article-title":"Predictors of prolonged breast milk provision to very low birth weight infants","volume":"202","author":"Romaine","year":"2018","journal-title":"J. Pediatr."},{"key":"ref_36","first-page":"e070121","article-title":"How do characteristics of donors and their children influence volume and composition of banked milk?","volume":"7","author":"Quitadamo","year":"2018","journal-title":"J. Pediatric Neonatal Individ. Med."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1016\/j.socscimed.2005.05.026","article-title":"Trustful bonds: A key to \u2018\u2018becoming a mother\u2019\u2019 and to reciprocal breastfeeding. Stories of mothers of very preterm infants at a neonatal unit","volume":"62","author":"Flackinga","year":"2006","journal-title":"Soc. Sci. Med."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1177\/0890334410371211","article-title":"Breast milk expression and maintenance in mothers of very low birth weight infants: Supports and barriers","volume":"26","author":"Sisk","year":"2010","journal-title":"J. Hum. Lact."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"1421","DOI":"10.1016\/S0277-9536(02)00542-7","article-title":"Incidence and correlates of breast milk feeding in hospitalized preterm infants","volume":"57","author":"Espy","year":"2003","journal-title":"Soc. Sci. Med."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"374","DOI":"10.1177\/0890334412451055","article-title":"Breastfeeding at NICU discharge: A multicenter Italian study","volume":"29","author":"Davanzo","year":"2013","journal-title":"J. Hum. Lact."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"193","DOI":"10.1016\/S0378-3782(00)00116-X","article-title":"Early cessation of breast milk feeding in very low birth-weight infants","volume":"60","author":"Killersreiter","year":"2001","journal-title":"Early Hum. Dev."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"20","DOI":"10.1186\/1746-4358-1-20","article-title":"Hands-on approach during breastfeeding support in a neonatal intensive care unit: A qualitative study of Swedish mothers\u2019 experiences","volume":"1","author":"Weimers","year":"2006","journal-title":"Int. Breastfeed. J."},{"key":"ref_43","unstructured":"USAID\/SPRING (2021, June 20). The Integrated 1,000-Day Household Approach in Ghana. Available online: https:\/\/www.spring-nutrition.org\/publications\/briefs\/integrated-1000-day-household-approachghana."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"3628952","DOI":"10.1155\/2018\/3628952","article-title":"Might the Mothers of Premature Babies Feed Them and Devote Some Milk to the Milk Bank?","volume":"2018","author":"Quitadamo","year":"2018","journal-title":"Int. J. Pediatrics"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"278","DOI":"10.1046\/j.1523-536X.2002.00202.x","article-title":"Effect of maternal confidence on breastfeeding duration: An application of breastfeeding self-efficacy theory","volume":"29","author":"Blyth","year":"2002","journal-title":"Birth"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"296","DOI":"10.1177\/0890334405277501","article-title":"Explanation for Cessation of Breastfeeding in Mothers of Twins","volume":"21","author":"Damato","year":"2005","journal-title":"J. Hum. Lact."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"e1048","DOI":"10.1542\/peds.2009-1616","article-title":"The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis","volume":"125","author":"Bartick","year":"2010","journal-title":"Pediatrics"}],"container-title":["Nutrients"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2072-6643\/13\/9\/3099\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T06:55:27Z","timestamp":1760165727000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2072-6643\/13\/9\/3099"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2021,9,3]]},"references-count":47,"journal-issue":{"issue":"9","published-online":{"date-parts":[[2021,9]]}},"alternative-id":["nu13093099"],"URL":"https:\/\/doi.org\/10.3390\/nu13093099","relation":{},"ISSN":["2072-6643"],"issn-type":[{"type":"electronic","value":"2072-6643"}],"subject":[],"published":{"date-parts":[[2021,9,3]]}}}