Guidelines for NICU

It isn’t unusual for twins, triplets or more to be born preterm (i.e. before their due date) and having to spend days, weeks or even months in the Neonatal Intensive Care Unit (NICU) as a result. For those families wishing to breastfeed, it is possible to do so by pumping and bringing in breast milk to the NICU to be fed to their babies.

To ensure the best quality milk for your babies, here are some recommended collecting and storage guidelines of breast milk. Remember that every drop counts and whatever is collected is the best thing for your infants. If you have any questions regarding your milk supply or how to conserve it, be sure to ask the NICU staff.

Storage and Sterilization

  1. Purchase some bottles and labels to store the milk. The bottles need to be boiled and sterilized before each use. Bags are not appropriate for storing milk in the NICU.
  2. Clearly label each bottle, including the babies’ names, date and time that the breast milk was collected.
  3. Ideally prepare bottles of 1 ounce, 2 ounces or 4 ounces, if you can, for storage.
  4. Do not overfill the bottles as breast milk expends when it is frozen.
  5. Make sure all pump material is properly cleaned and sterilized between uses.

Storage Times of Breast Milk for Preterm Infants

Storage time
Freshly expressed milk Room temperature 25C or 77F 4 hours
Refrigerated milk (store in back not on door)4C or 39F a)Refrigerator (fresh milk)

b)Refrigerator (thawed milk)

a) 48 hours

b) 24 hours

Frozen Milk (Store at back, not in door. DO NOT REFREEZE) a) Freezer compartment inside refrigerator door

b) Freezer compartment with separate door

c) Deep freezer not attached to refrigerator


b) 3 Months

c) 6 months

Transporting Milk
(freshrefrigerated or frozen)15C or 60F
Packed in insulated cooler with ice or “ blue ice” 24 hours

 Transporting Breast Milk to NICU

Fresh breast milk can be refrigerated and transported to the NICU on ice or “blue ice” packs in a little insulated cooler. Once at the NICU, give your labelled breast milk to the nurse in charge of your babies to be placed in the refrigerator or freezer.

If you have any questions regarding these procedures or about breast feeding in general, be sure and talk to the nurse in charge of your babies. Hospital staff will be most happy to answer your questions and help you at any point.

If you have any questions regarding pumping or storing your breast milk, do not hesitate to discuss them with the nurse or lactation consultant.

Your breast milk is important to your babies. Save ALL the milk that you pump.


  1. Lots and lots of great, supportive, every-topic-you-could-think-of information and resources on breastfeeding,
  2. Hamosh M, Ellis LA, Pollock Dr., Henderson TR and Hamosh P. Breastfeeding and the working mother: effect of time and temperature of short-term storage on proteolysis, lipolysis, and bacterial growth in milk.Pediatrics Vol. 97, issue 4 pp. 492-498
  3. Lauwers J, Shinskie D., Counseling the Nursing Mother: A Lactation Consultant’s Guide, 3rd edition p.351
  4. Riordan Jan, Breastfeeding and Human Lactation, 3rd edition. p.378-382

From Valerie Lavigne, Mom of three breastfed babies, including twins.
Adapted by Lynda P. Haddon, Multiple Birth Educator, 
Reviewed by Erin Shaheen, Child Birth Educator, Mom of 4 breast fed babies, including twins.

Other Resources:

Multiple Births Canada Fact Sheet: Breastfeeding Multiples: Pumping Tips

The Crying Baby: What is Baby Trying to Tell Us?

The Crying Baby:  What is Baby Trying to Tell Us?

Crying babyA baby’s main means of communication in the early weeks and months of life is to cry.  It doesn’t take too long for parents to note that not all of their baby’s cries sound the same.

Some are easily recognizable, e.g. hunger, anger and others which may not be so easy to “translate.”  As your multiples are individuals, it may be that one or more will not go through the same reactions at the same time.

What Do We Know?

  • All babies cry, even healthy ones receiving excellent care.
  • By crying, babies can express their pain, hunger, anger, fear and boredom, but sometimes they will cry for no specific reason.
  • By approximately 3 months of age, crying usually drops off as babies find other ways of communicating, e.g. babbling or cooing, and spend more time exploring their environment.
  • Continued crying can be anxiety provoking for parents and make parents feel worried, upset, incompetent and overwhelmed about their ability to meet their babies’ needs.
  • When babies cry excessively and are inconsolable, they are commonly referred to as “colicky.”
  • A colicky baby might cry for 3 hours a day, at least 3 days a week, for 3 weeks in a row.

5 Characteristics

There are 5 specific characteristics of normal, excessive crying or infant colic:

1)  The crying is unexpected, unpredictable and inconsolable;

2)  It often starts at the end of the afternoon or early evening;

3)  Can last 35-40 minutes or a long as 2 hours;

4)  Increases as the weeks go by and is most intense when baby is about two months old, then decreases until about the age of 5 months; and

5)  The baby/babies seem to be suffering.

These characteristics can make parents feel powerless, discouraged and incompetent.  It can create problems with the parent-child relationship because the parent may become less involved and less comforting with their child.*

*Adapted from a brochure by Centres of Excellence for Early Childhood Development, Crying:  Listen, they’re talking to you!

What Can Parents Do?

Situation:  Pay attention to your child’s crying and listen if you can identify any differences between what you are hearing.  If an infant is hungry, for example, the crying will sound quite different from when s/he is angry or fearful.

Response:  Respond quickly and calmly to the child and hold them close to your body as often as possible to see if the crying calms down.

Situation:  If you find yourself provoked by and anxious due to inconsolable crying.

Response:  If you become upset, overwhelmed or frustrated with the incessant crying, pull back for a few moments.  Put your child in his/her crib, leave the room, take a deep breath and return a few minutes later when you are calmed down.   If you are unable to calm yourself down, ask someone else to take over.

Babies will often respond positively to Kangaroo care** or being swaddled.  Trying either or both techniques may help calm a crying baby.

Letting a baby cry through the event on his/her own is not a good idea.  Picking up a crying baby as early and calmly as possible for cuddling can prevent things from escalating.  Humming or shushhhing gently into baby’s ear may help him/her calm down.

If you are feeling particularly overwhelmed, bundle babies into their carriage and walk around the block or go to the park.  Talking to other parents can be helpful for you and fresh air and a changed environment with new interactions, will often settle babies.

If your baby or babies continue to cry excessively for no apparent reason and do not respond to cuddling, Kangaroo care or swaddling, make an appointment with their doctor to ensure that the babies are healthy and there is not some underlying reason for their feelings.

Ask for help if you need it.

**Kangaroo Care:  Baby or babies are placed naked, except for diaper, onto Mom or Dad’s bare chest and securely/warmly wrapped onto the chest.  Babies are generally calmed by hearing parent’s heartbeat, as well as the warmth and feeling of security with the closeness.  The position simulates being in the womb and can be soothing for them.

Kangaroo Care For Infants


Kangaroo care has become increasingly popular for newborn infants, especially preterm or low birth weight, whereby an infant is held skin-to-skin against the chest of an adult, usually the parents.  Ideally kangaroo care will begin right after birth and continue for as long as is possible, although short periods of time are also beneficial to babies and parents.


Kangaroo care - mother and twinsMom and/or Dad/partner are usually wearing an over-sized shirt, large hospital gown or loose clothing exposing their chest.  The nearly naked (diaper only) infant is placed directly on mother/father’s exposed chest and the shirt wrapped snugly around baby, drawing him into the parent’s chest where he settles and snuggles.  Instead of a shirt, a warm blanket can be used to cover the infant(s) on parent’s chest to draw her close.

Two babies, and sometimes more, can be held at the same time on a parent’s chest with support from a nurse or the other parent.  If there are tubes and wires on a baby, be sure and check with the nursing staff before going ahead with kangaroo care.  It is also good for the babies to be together.  Every hospital has its own policy regarding Kangaroo Care, so check with your hospital to find out what their policy is.

Benefits for Babies:

  • Father and newborn, kangaroo carehelps stabilize heart rate and regulates breathing
  • improves oxygen saturation levels
  • more rapid weight gain
  • helps maintain baby’s body warmth
  • babies easily accessible for easier breast feeding
  • helps relax and sooth babies, spends less time crying
  • more alert time
  • can hear heart beat, replicating womb experience
  • earlier hospital discharge
  • all newborns benefit from kangaroo care, not just low birth weight and/or preterm infants

Benefits for Parents

  • builds confidence knowing you are offering your infants intimate care and a loving start
  • early closeness to the babies promotes bonding
  • baby easily accessible for breast feeding (when with mother)
  • slows parents down to focus on their infants and less worry about other matters
  • can offer “closure” to having Neonatal Intensive Care Unit (NICU) babies



Multiples and Co-bedding

Co-bedding is the term used to describe putting your babies down to sleep together in the same crib. Most parents co-bed their babies for at least part of the time once the babies arrive home. Our girls slept in the same crib for 4 months until they began to disturb each other. Co-bedding for multiple birth babies just seems to make sense and there are some practical reasons to do so.

Some parents of low birth weight (LBW) or preterm multiples wish to co-bed their babies right after birth in the Neonatal Intensive Care Unit (NICU) but not all hospitals have a co-bedding policy. It’s a tough call and hospitals have some valid reasons for not co-bedding, not the least of which is that the beds may not be big enough to comfortably accommodate two babies. Thankfully though, some Canadian hospitals are rethinking co-bedding issues and as a result, there could soon be some good news for parents of multiples.

Babies co-beddingA quick poll of parents with twins regarding their experiences resulted in the following comments regarding the co-bedding of their babies in NICU:

  • takes less room by your hospital bed, which is important if you are sharing a room;
  • there seems to be less confusion in the nursery as the staff only has to worry about one bassinet;
  • helps the babies conserve body heat, regulate their temperatures;
  • helps the babies settle better as they seem to comfort each other;
  • one mother felt it helped them get over the trauma of their births as they took comfort in being together once again;
  • continuity of their being together from the womb;
  • sometimes babies have been placed in their own bassinet in different nurseries within a hospital setting, making it difficult for the parents to split their time between the two babies and leaving them feeling guilty about whom they were not with. Or the parents would split up to spend time with each baby, thereby not permitting parents to take joy together in their babies;
  • parents generally felt better themselves that their babies continue to be together, as they were in the womb;
  • one family reported that one of their sons was too sick. It just wouldn’t have worked for them; and
  • it is very cute in pictures!

Healthcare professionals have some valid concerns regarding co-bedding

  • if one (or both) babies are sick and are co-bedded, there could be a mix up with their medications. In separate bassinets, the potential for medication error is minimized;
  • if only one baby is ill, there could be cross-contamination to the other baby;
  • if one baby has a birth anomaly, e.g. spina bifida or Downs, it would be better for the babies to be in separate bassinets;
  • there could be unnecessary exposure of a baby to oxygen;
  • there could be sleep disturbances which may impact on a baby’s ability to become healthier;
  • bassinets are not large enough to hold two babies;
  • one baby may interfere with the tubing of the other baby; and
  • there could be temperature instability between the babies.

There may be a specific time when NICU hospital staff would decide, or it might be hospital policy, not co-bed multiple birth infants. Such a decision occurs when one, or both babies, is ill (usually due to their prematurity) and to be in close proximity might have an adverse affect on one or both of their health, e.g. disturb their sleep, thus impeding healing. In such cases, a co-bedding decision is based on the best possible outcome for each baby.

Once the babies are home, most parents of multiples, have co-bedded their twins (and sometimes triplets or quads) for various ranges of time. What usually brings co-bedding to an end is when one baby or toddler continually disturbs the other, as in one likes his sleep and the other likes to play and may be looking for a playmate. At the end of the day in this scenario, there are at least two cranky babies and two cranky parents, which makes for a very cranky household. The solution = separate beds, maybe even separate bedrooms, and pronto!

Co-bedding at home offers some other distinct advantages for both babies and parents

  • the babies usually enjoy being together and will often settle down quicker and more easily. As the babies grow, parents may continue to have their multiples share a room, each in their own beds, because they enjoy being with each other. Don’t be surprised to find them sleeping in one bed together when you go to get them up in the morning;
  • co-bedding cuts down on the amount of laundry with washing only one set of sheets and blankets at a time instead of two or three;
  • you can go to one spot in the room and attend to a baby while the other still has full visual contact with you;
  • initially some parents keep one crib upstairs and one downstairs (for the daytime naps). Not having to go up and down the stairs several times a day helps preserve energy levels; and
  • even parents with triplets have co-bedded their babies, initially lying each baby across the crib. A bonus is easy access to each baby as needed.

If you want your premature or LBW twins co-bedded while they are in the hospital, check out your hospital’s policy before you deliver. Ask your attending physician to make the corresponding note in your chart indicating that you want the babies co-bedded if at all possisble. The more often we ask for what we want or need, the more often the hospitals will listen and change will be implemented.

P.S. They do, indeed, take great pictures when they are snuggled up together in the same crib.

Got a co-bedding story you would like to share? Send me your story.

Occipital Plagiocephaly

Two of my triplets (they are aged 8 weeks) have flat spots on one side of their heads. How did this happen? What can we do about it?

While the rate of Sudden Infant Death Syndrome (SIDS) has greatly decreased since parents and caregivers have followed recommendations to put babies to sleep on their backs (“Back to Sleep” programme), another issue has come to the fore.

occipital-plagiocephaly-helmetBabies who lie for long periods of time in one position, can develop flat areas on their heads. It is well known that babies skull bones are very soft until about one year of age.

Further, multiple birth babies can be at a greater risk for occipital plagiocephaly (and/or torticollis) due to “stacking” in the womb, i.e. the lower baby may be engaged in the birth canal with one, two or more babies above it.

The combination of increased pressure from above that lower baby combined with gravity, can place a lot of pressure on the lower baby’s head and neck. In addition, prematurity and supine sleeping (i.e. placing a baby on its back to sleep) increase the liklihood of there being a risk of a flat spot occurring on the baby’s skull.

What is Occipital Plagiocephaly of Positional Orgin?

“Occipital Plagiocephaly” is a medical term for the flattening of one side of the back of the head, often caused by lying with the head in the same position. A flat area may develop very quickly or over several months.

Visually, your child may have one ear that is shifted forward of the other and may also have facial changes, e.g. forehead protrusion or cheek protrusion in more severe cases, on the flat side of the head.
Head Shapes (looking down from above at the top of the baby’s head)

original head shape positional plagiocephaly
Normal head shape Positional plagiocephaly

What can I do if my baby(ies) has a flat area on her head?

With proper positioning encouraged by the parents, the baby’s head shape usually quickly improves on its own. When a flattening of the head is noted, or you notice that your baby(ies) has a strong preference for always turning to the same side, it is important to take some action to rectify the situation.

After discussion with and agreement by your doctor, the following are some ideas for you to try to keep the baby off of the flat side:

  • Make sure that your baby(ies) is placed off of the flat area at all times. This can be accomplished by placing a small, rolled up blanket under your baby’s shoulder, on the same side as the flat area. This will help keep the baby’s head turned away from the flat side. Make sure that the baby’s underside arm is out so that there is extra protection against the baby accidentally rolling on its tummy.
  • Babies tend to look towards the door while lying in their cribs (as they wait for a parent to appear). Move the crib often to change the view of the door. Move toys and mobiles around and away from the flat side of his head. This will encourage your baby(ies) to look towards the toys. You could also regularly change the ends of the bed when putting your baby(ies) to sleep.
  • When holding, feeding or carrying your baby(ies), make sure that there is no undue pressure placed on the flat side.
  • With the new style of baby seats that go from table to car to stroller frame, your baby(ies) can potentially end up spending long periods of time sitting in the same position thereby increasing the chances of a flat spot developing. Be aware of this danger and avoid long periods where your babies may remain sitting in the same position.
  • Provide your baby(ies) with lots of SUPERVISED play on their tummies. This helps build and strengthen neck, shoulder and arm muscles. Appropriate toys can be used to encourage tummy and side lying play.
  • Provide lots of SUPERVISED time to play in a sitting position and in an ‘exersaucer’ as soon as each baby has achieved good head control.
  • Pay attention to bottle-feeding. It isn’t necessary to change a baby from side to side once the spot has been noticed, but the person feeding the baby(ies) will need to make sure that there is no undue pressure placed on the flat spot. For prevention of a flat spot occurring, change your baby(ies) from side to side at each feeding.
  • If you notice that one or more of your babies has difficulty turning her head(s), she may require some neck stretching exercises. Consult your physician who can refer you to appropriate physiotherapists, if this is the case.
  • For the best results, positional therapy needs to be started before the baby(ies) is four months old.

How do flat areas occur?

Before Birth:

  • One or more of your multiple birth babies may be born with flat areas on their heads due to lack of space to change positions in the womb.
  • One multiple birth baby may be engaged in the birth canal while the other(s) is “stacked” on top, putting pressure (gravity) on the lower baby’s head and neck.

After Birth:

  • As newborn skulls are very soft and malleable to help ease the baby through the birth canal, it is not unusual for newborn babies to have an unusual shape to their heads, due to the pressure of birth. This will generally rectify itself by about six weeks after birth.
  • However, some babies show a preference for sleeping or sitting with their head turned in the same position for the majority of time.
  • Some babies may have the additional problem of torticollis, a neck muscle problem, that prohibits them from properly turning their head to another position.
  • Premature babies have softer skull bones.

Does having Positional Plagiocephaly cause problems for my child?

In the majority of cases, having a flattened area will not affect a baby’s brain growth or mental development. When the hair grows in, it will cover the flat spot and it will not be visible. However, if there are visual changes in the baby’s appearance, i.e. one ear may be shifted forward of the other one, on the same side as the flattening, this can make a difference cosmetically with perhaps reduced perceived attractiveness and there is a potential for teasing and/or rejection amongst peers.

What do we do if positioning doesn’t help?

If positioning exercises do not help, it may be necessary for your child(ren) to wear a helmet(s). Your physician will guide you, if this is the case. Each case is different and each child unique but you may count on your child(ren) needing to wear a helmet for six to eight months from when it is initially recommended.

To Sum Up

  1. It is possible that more than one of your multiples may show signs of occipital plagiocephaly.
  2. With routine change of baby’s head position right from birth, the problem can be prevented;
  3. With early recognition and treatment after birth or at two to four months of age, positional therapy may be all that is required in the majority of cases;
  4. Only in the more severe cases will the use of a helmet be indicated.


  • Occipital Plagiocephaly: a one-sided occipital flattening that results in marked skull asymmetry.
  • Torticollis: shortening of the neck muscles on one side of the neck, making it difficult to turn the head. Rectified by stretching exercises.
  • Uterine Constraint; Uterine Packing; Stacking: All of these terms may be used to describe the positioning of multiple fetuses within utero. I have chosen to use ‘stacking’ in this text.

Additional Resources

  • Najarian, S.(1999). Infant Cranial Molding Deformation and Sleep Position: Implications for Primary Care. Journal of Pediatric Health Care, 13, 4, 173-177.
  • Neufeld, S. and Birkett, S. (1999). Positional plagiocephaly: A community approach to prevention and treatment. Alberta RN, 55, 1, 15-16.


Adapted from a pamphlet prepared by: The Children’s Hospital of Eastern Ontario, Ottawa and from: “Your Baby’s Head Shape”. 1999. The Alberta Infant Cranial Remodelling Program – Stollery Children’s Health Centre (CHA) and Alberta Children’s Hospital (CHRA)

With guidance and input from Karen Dube, Nurse Practioner/APN, Ottawa, Ontario.