It occurred to me the other day when I was doing a site visit with one of my students and her preceptor that something was different here. When I walked into the NICU and looked around, I saw that 9 of the 10 isolettes were filled with triplets. In this unit they were all co-bedded and snuggling together. They looked very cute, but it really made me think: What is happening here? I realized I had been hearing about more people having twins and triplets, I just hadn’t realized what a big change this has been.
Upon looking into the incidence of twins and multiples, the trend is obvious. According to the National Center for Health Statistics (2004), prior to the 1980s, twins occurred approximately in 1 of 80 live births. By 2002, the rate for twins and other higher-order multiples was nearly 1 in 33 live births—quite the increase! There are several reasons for this trend. One major contributing factor is that women are delaying childbearing. Older mothers have more twins and higher multiples, even those who do not undergo fertility treatments (Tough et al., 2002). Age does matter! Of course, fertility treatment also is a major factor contributing to the increase in multiples. One change that is currently affecting the trend in higher-order multiples is the recommendation by the Society for Assisted Reproductive Technology (2004) that no more than two embryos be transferred in patients younger than 35 years. Whatever the cause, the multiples are here, and we as pediatric health care providers have the pleasure of helping these families cope with parenting a suddenly expanded family.
The point at which we encounter a family with multiples will vary. For some, the first care will be provided in the NICU. Unfortunately, preterm birth occurs in approximately 59% of twins and 93% of triplets (Martin et al., 2006). Thus many of these babies will be spending weeks, if not months, in the hospital, and the families face a very stressful time. When these little ones are discharged home, they often continue to have significant medical problems that will need to be closely monitored. Therefore, these are very challenging families to work with, and they really can use our expertise in helping them to meet physical and psychosocial challenges they face.
One of the first tasks for the parents is to prepare for life with multiple infants. Preparation is always important, and one excellent resource is parent groups, such as the National Organization of Mothers of Twins Clubs (www.nomotc.org) or local groups of parents with twins or triplets. One aspect of preparation that is helpful is to get the support that the family will need. Some families may have volunteers from the community who can help out with daily tasks; others luckily have family members close by who are ready and willing to help. Parents need to see that seeking such help is necessary. It is not a sign that they are coping poorly; rather, it shows they know what is best for them, their infants, and the family. Parents can strategize ahead of time regarding how they will utilize such volunteer help; each family will have different views on how they want others to help. Some families may want help in caring for the infants, while others may want help with tasks such as running errands or cleaning so the parents can focus on the babies. Thinking about such issues ahead of time can make the time after hospital discharge easier for these families.
Parents of multiples immediately face several important tasks and decisions. For example, bonding with more than one baby can be a challenge. A parent may find it is easier to bond with one infant than another. That is perfectly normal, and we can help parents understand that and hopefully reduce some of the parental guilt that occurs in such situations. Also, just because they are twins or triplets doesn’t mean they are exactly alike; each infant has his or her own unique temperament, and parents will need to learn how best to treat each child individually. Feeding decisions are another challenge parents face. Of course, breastfeeding is best, and many mothers successfully breastfeed twins and even triplets. Parent support groups often can give mothers specific advice about how to master the feeding of multiples. Mothers who choose to breastfeed multiples will need extra support because they will be spending a great deal of time just feeding and pumping, and this time feeding is time they are not able to spend with other children or family members, or even catching up on rest or sleep.
Families also face other decisions, such as what to name the babies and even how to tell them apart. Generally, the literature on twins and multiples recommends giving the infants (twins, triplets, or higher multiples) distinct names, that is, names that do not rhyme and do not begin with the same letter. Also, from early on parents should try not to refer to the babies as the “twins” or the “triplets”; rather, they should use their specific names, which helps with the individuation process. As parents are learning to tell their babies apart, they might choose to color code the clothing, so one baby is always in green and another yellow. Parents also may paint a toenail a given color to help keep the babies apart when they are naked. Focusing on each child as an individual is important. Interviews with adult twins have revealed that they did not like being valued for the twinship and not as individuals. They also reported not liking insensitive comparisons, such as one being the smart one and one the pretty one (Cooper, 2004).
As they get older, multiples should have their own toys and be encouraged to develop their own interests. They also will need time apart, both individual time with a parent as well as time with other friends and playmates. One decision parents will face is whether multiples should be in the same or separate classrooms. There is no one approach that fits all multiples; thus parents need to be included in school decisions regarding placement decisions (Cooper, 2004).
Families with twins and multiples face many stresses. Indeed, many couples come to the pregnancy and childbirth after a long history of infertility and assisted reproductive therapies. Such families may then begin parenting facing economic and psychological burdens above and beyond the daily challenges of caring for a child. Thus these families really need the expertise of a pediatric nurse practitioner. Indeed, caring for families with multiples might be an interesting specialty area! I hope all of you who have opportunities to work with these families are helping them to become the best parents possible—that’s what we do best.
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