Triple Feeding, Scope of Practice, and Collaborative Care: A Conversation with Dr. Cindy Rubin

In this episode of Behind the Latch, Margaret Salty interviews Dr. Cindy Rubin, a pediatrician, IBCLC, and board-certified breastfeeding and lactation medicine physician, about her clinical approach to managing complex lactation cases—including the hotly debated topic of triple feeding. They explore when triple feeding is appropriate, how to support families through it, when to wean, the role of galactagogues, and how IBCLCs and breastfeeding medicine physicians can work together for better outcomes.Dr. Rubin’s Path to Breastfeeding MedicineDr. Rubin shares how her own struggles with breastfeeding as a pediatrician changed her perspective:Realized how little she truly knew about lactationBecame an IBCLC and later certified in breastfeeding and lactation medicineLeft the traditional system to open a home visit and telehealth practice in the Chicagoland areaHealing the Divide: Physicians and IBCLCs Working TogetherMargaret and Dr. Rubin discuss:The historic divide between providers and IBCLCsHow breastfeeding medicine fills a gap—not competes with IBCLCsThe importance of staying within scope and collaborating for comprehensive careWhy referring to each other strengthens—not weakens—practiceTriple Feeding: What It Is and When to Use ItDr. Rubin explains:Triple feeding = nursing at the breast, pumping, and supplementingIt’s a short-term tool—not a long-term solutionOften used when it’s unclear whether the issue is supply or transferMay be used as a “test” to guide next stepsWhen Triple Feeding May Not Be NecessaryKey points:If baby is nursing well but supply is low, pumping may not be neededSometimes nursing + supplementing (double feeding) is sufficientAlways consider mental health and sustainability for the parentPumping Frequency, Sleep, and Mental HealthDr. Rubin emphasizes:Seven pump sessions with one long stretch of sleep is often better than eight with no restNo amount of milk is worth compromising the parent’s mental or physical healthCustomize plans based on the parent’s needs, goals, and capacitySNS Use and Feeding Plan FlexibilityThey discuss:Why SNS can be helpful—but isn’t right for everyoneFeeding at the breast once or twice daily while pumping/bottle feeding the rest can reduce burnoutThe importance of patient choice and informed consentHow to Know When to Wean from Triple FeedingDr. Rubin recommends:Weighted feeds to assess if baby can take full or near-full volume at the breast“Boot camp” weekends where the dyad nurses ad lib without pumping or supplementingWatching for signs of success: swallowing, relaxed hands, diaper output, and steady weight gainThe Role of GalactagoguesDr. Rubin explains:She uses galactagogues selectively, often after trying triple feeding firstGoats’ rue may be beneficial in parents with insulin resistance or PCOSAlways considers side effects and tailors to the individualEmphasizes that IBCLCs should refer, not recommend or sell galactagoguesReferral Networks and Working Across DisciplinesDr. Rubin offers guidance:Use the NABBLM website to find breastfeeding medicine physicians in your areaUnderstand physician licensure restrictions across state linesAttend conferences like the Academy of Breastfeeding Medicine to networkOffer education (like grand rounds) at local hospitals to build...

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