Having a baby in the NICU is a challenging time where hopes and fears can change daily. When your baby is born prematurely, the neonatologist will be looking to make sure that heart function, lung function, weight gain and ability to maintain body temperature are all stable before discharging your preemie. The length of time that can take will vary widely, according to how early your baby was born.

You’re still dealing with all the things that parents of babies born at term have to handle, such as choosing a pediatrician and installing a car seat. On top of that, your preemie has special needs. You surely wish you could take him home right away, but your premature baby requires more medical attention that you may have anticipated. Take heart -- there are things that can help parents of preemies along the journey to taking your baby home.

Recovery: A silver lining is we can use the time our baby is in the NICU to recover from the birth: to rest and be well nourished. Travel back and forth can be tough, but it’s critical to realize you will not serve your premature baby well by neglecting yourself. Just as the NICU is extending baby’s gestation phase, a new parent needs to take care of themselves to be ready for when your preemie comes home.

Educate: Take an infant CPR class before your preemie is discharged. If your baby is being discharged with a heart or apnea monitor, you will have to attend training on how to use these monitors before you take your baby home. If you plan to breastfeed, find an Internationally Board Certified Lactation Consultant who can work with you to maintain breastfeeding and weight gain once you're home.

If there are older siblings, explain that things will need to be calm for the baby at first, and establish strict hand washing protocols to prevent illness. Your hospital may also have a transitional stay room, where parents can practice taking care of baby for a day or two before coming home.

Support: Line up your support system, both physically and emotionally. First time mothers -- especially of preemies -- can feel very isolated. There are many online forums and support groups to connect with other moms going through this same experience. With babies, and especially with multiples, an extra pair of hands helps. As our job will be to care for the baby, help with shopping, cooking, and laundry becomes very valuable. Enlist friends and family so that you have more room to focus on the baby.

Time and Transport: Preemies can usually only travel an hour at a time. In urban environments or hospitals far away, anticipate a rest stop on the way home. Once your baby is home, you will not have time to waste on finding papers or scheduling time off. Establish a baby medical file -- log doctor and insurance company phone calls. Extend, space (e.g. use one week to take every Wednesday for five weeks) or delay maternity or paternity leave to map out which parent is with the baby and when, and pull in relatives or childcare where necessary.

Coming home from the NICU can be filled with relief but also trepidation. While it is natural to be nervous about being up to the task of taking care of such a fragile baby, obstetrician Dr. George Mussali puts it beautifully: “The fact is that a preemie parent matures faster as a parent due to the adversity they faced at the beginning.”

The first year with your preemie often involves juggling many check-ups and appointments. Because our babies’ brains and bodies are so plastic, early intervention is a critical tool for supporting preemies. Premature babies are always evaluated based on their ‘adjusted’ age rather than their actual age. This means that if your baby was born at 32 weeks, when they are two months old (8 weeks) they are evaluated as a newborn.

Dr. Yasmin Lyons is a pediatrician who has worked extensively with preemies. She emphasizes that: “Often the baby is doing what is completely normal for their corrected age, and it’s important for parents not to compare the progress with that made by other babies.” You’ll quickly decide who to talk to about your baby being a preemie. Margie, a mother of a preemie born at twenty weeks, told me: “I just always gave the adjusted age of my preemie because I just didn’t want to have to have the whole conversation with strangers."

As parents of preemies, we start feeling more confident when we see our baby eating and reaching textbook milestones. This can vary dramatically depending on how premature our baby is. In other words, a “30-weeker” will have a very different roadmap in the first year then a “34-weeker.” Hospital preemie clinics can be a good resource for reassurance. Premature baby clinics in addition to a pediatric neurologist often include an occupational therapist and a physical therapist, allowing a more thorough evaluation of the premature infant. Susan, a mother of a 33 week preemie, told me: “I was worried because Isabel wasn’t holding her bottle. The neurologist at the preemie clinic told me, ‘Oh she can totally do it, she is just choosing not to!’ I was so relieved that she was on track and making her own decisions!”

The most important thing to understand is that your preemie will always be evaluated at their ‘adjusted’ age, allowing an equal playing field in the evaluation. Based on adjusted age, your doctor will be looking for the following things:

At three months: Gross motor skills: open hands, some holding/grasping, some neck control, visual tracking (i.e., following an object or person with their eyes), cooing vowel sounds, smiling.

At six months: Gross motor: rolling over, head control, pushing with their legs while you are holding them, spinning on their stomach, holding toys and shaking, bringing toys to their mouth, lots of prolonged eye contact, engaged with those around them.

9-12 months: Gross motor skills: “the army crawl” (pulling themselves forward on their tummy), sitting up on their own, holding and shaking toys, pulling upright. Language progresses to consonants and vowel sounds strung together, with a few words identified. Smiling and laughter is a regular part of your life.

As a general rule, pediatricians give premature babies a wide margin to be reaching targets based on how premature they were. Variations within a twelve week range can be normal, yet with good intervention concerning physical, occupational, and speech therapy, almost all premature babies are deemed “done” with being “premature” by 24 months!

With a preemie, it is important to understand that the first 100 days at home need to be treated like a “fourth trimester.” This means low stimulus, few visitors, and staying cozy.

As most babies will be discharged when they are exhibiting stable newborn ability and behaviors, your first three months caring for a preemie need to be treated as the “newborn phase,” regardless of the child’s age. Parents need to take time to get used to the physical around-the-clock effort of being a parent. It is realistic to expect your preemie will sleep more than the average newborn, yet will probably wake at more frequent intervals for feeds.

A lot of what your baby is doing may look random to you, but he or she is actually making small developmental steps every day, such as holding eye contact for longer and longer periods, slowly waking up for calmer and more alert periods, and moving (kicking legs and waving arms) in rhythm to your voice.

Feeding and weight gain is still a critical issue and your pediatrician will be watching weight carefully in your baby’s first two weeks after discharge. If you are bottle-feeding, it is easy to see if the baby is getting enough milk, but if you have transitioned to breastfeeding, frequent weight checks can help ensure that your baby is getting proper milk transfers. There can be challenges when premature babies first start nursing. Ayelet Kaznelson, an IBCLC lactation consultant, comments, “After a baby has been discharged, we can sometimes see a weight drop after two weeks. We really want to ensure good milk transfer, but not all preemies may be strong enough.”

Skin-to-skin contact in the early weeks at home is one of the best things you can do with your preemie. Undress your baby (except for their Pampers diaper), then lay them on your chest with their head on your left side (to hear your heartbeat!), and cover them with a blanket if needed. This “kangaroo care” fosters anti-stress hormones in your premature baby, as well as aiding in neurological development -- and that’s without the tired parent having to do very much! It’s nice to know that this helps them grow and cope, just while gently holding them!

We often worry whether we will be able to care for our little ones, especially when they’re preemies. One of my students, a mother of twins born at 32 weeks, describes the moment at which she knew everything would be okay: “We had brought Annabel home three weeks before little Natalie. When Natalie came home, I remember sitting with both of them on my lap, each only four pounds, wondering how I would ever be able to care for both girls. At that moment, Natalie, reunited for the first time with her sister, rolled into little Annabel’s arms, and I knew we would be okay. We were all together -- we were finally a family.”

Waiting five years to have a second baby wasn't something I planned; it just happened that way. As it turned out, the large gap suited me well. Sure, there was a small learning curve to master regarding changes in the labor and delivery process. But for the most part, having an older child made it easier to handle my second pregnancy. My daughter was four-going-on-five when I told her she was going to have a younger sibling, and she couldn't have been more excited. There's no doubt my second pregnancy was special. Here's why.    

• I had less time to worry about my symptoms. Okay, I admit to being nervous throughout the entire nine months of my first pregnancy. From morning sickness to labor pains, I feared the unknown. Like any second pregnancy, I now knew what to expect. Happily, busy days with my daughter occupied my thoughts this time around. At her age, she could carry on a conversation, she was potty-trained, and she was well on her way to forging her own friendships. Life was good -- and easier than it had been for a while.  

• My first child was old enough to understand. Now that my daughter was more mature and had plenty in her own life to focus on, jealousy over the new baby wasn't a problem. Other than making arrangements for a babysitter during the labor and delivery process, there wasn't much we had to do to prepare her. We simply needed to engage her in the process. As soon as I saw the "Welcome Home" signs that she made to greet her new brother, I realized there were several small tasks she could do to feel special and included.  

• It wasn't impossible to get the rest I needed. One of the biggest challenges of any second pregnancy is that there's less time to rest because you're busy taking care of another child. Because my daughter was five years old, I didn't have to carry around a heavy diaper bag, and I certainly didn't have to carry her. Even better, she understood that I occasionally got tired. If that meant spending some extra time watching her favorite show, coloring or solving a puzzle, we didn't sweat it.

Everything comes with some challenges, and a five-year gap in pregnancies is no exception. For starters, five years is a long time in today's fast-paced world of fashion. Truth is, my maternity clothes from the first pregnancy were already out of style. I also had to educate myself about some minor updates delivery process. None of this was a big deal, but necessary all the same. Today I can happily reflect on my five-year gap between pregnancies. It was a special time for all of us.

Photo by ???????? Janko Ferlič on Unsplash

Twins run in the family, but I never really thought about it. My oldest, Rowan, had bad reflux and was up a lot crying, and we thought, ‘We’ll just have the next baby close to this one. That way we’re not doing this for 10 years!’ We didn’t think it would happen so quickly.

When we had the ultrasound, I think my husband, Michael, was probably more shocked to find out we were having twins than I was. He said, ‘I have to sit down, I don’t think I ate breakfast.’ I’m a planner, so I immediately thought, ‘Okay, how are we going to do this? What are the steps?’ There are only 16 months between Rowan and the twins!

During my second pregnancy, I wondered how I could share my love with another child so soon after the first, let alone three children. That was one thing I had to realize would all work out. I didn’t know what to expect from Rowan, and everyone said to me, ‘Oh, she might be jealous.’ But honestly, she was too young to know. As a 16-month-old she was very self-absorbed and she just did things the way she wanted to.

Physically, it’s hard; there you are with two car carriers. I think my arms were in the best shape they had ever been!  And Rowan was young, so doing everything was a lot more time consuming. You don’t always want to go around with a stroller for three -- it’s physical juggling.

One of my good friends had twins, and her main advice to me was to schedule. You need to be as scheduled as possible, and don’t let those two babies deviate from each other and Rowan. That’s not as true at the beginning, but as soon as we could get them situated on an eating and sleeping schedule, we stuck to it. It really did work and that was probably the best advice I’ve received.

The best advice I can give: Leave extra time for everything. That way you have a few extra minutes to catch up if things don’t go perfectly. Oh, and always take a change of clothes for yourself, because now you have two kids who might throw up on you instead of one.

Consider yourself lucky to have twins the second pregnancy. You learn so much from the first baby. The transitions through stages for the twins were so much easier because I’d already done it with Rowan. You think to yourself, ‘I’ve seen this before.’ I really thought I was remembering it all. As I got older, I thought, ‘What was their first this again?’ There are days when you just feel like you have no idea. Just go on with the next thing. Try to enjoy it and realize that it is different and it is special.

It’s really been great. The kids always have someone to play with, and my first three have always had each other pretty much from the start. They have their own unique relationships with each other, and for Rowan, it’s an experience that others don’t necessarily have, having twins as siblings. I think that’s been a pretty neat thing. We can’t imagine it being any different.

Photo by frank mckenna on Unsplash