For one active California family, the key to managing life with four babies is sticking to routine.

It’s 7 a.m. in the Ferraro household, and 7-month-old quadruplets Charlie, Claire, Henry, and Dillon are crying for breakfast.

Two-year-old Molly is hungry, too.

Already awake for some time, Mom and Dad answer the call. Another lively day is underway.

Mom is Katie Ferraro, registered dietitian and assistant clinical professor at the University of San Diego and University of California.

Dad is Charlie Ferraro, a business aviation executive.

The two were married in 2012 with a plan to start a family right away. Just a few years later, they’re parents to four babies and a toddler.

From that early morning breakfast cry until the babies hit the cribs at 8 p.m., the house is bustling.

In an interview with Healthline, Katie said it helps that both she and Charlie have careers that are somewhat flexible. As for running their full house, committing to a schedule has proven to be invaluable.

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There was no history of multiple births on either side of the family. Katie was taking fertility drugs, but they didn’t expect quite the bundle they received.

When the couple first learned they were expecting quadruplets, the news wasn’t all good.

“The data presented was frightening,” said Katie. “We were told there was a 50 percent chance the quads would have major handicaps, mostly due to premature birth. We had the option of selective reduction, but we decided against that.”

The babies were born at 34 weeks, which gave them a little more time than anticipated. They stayed in the neonatal intensive care unit (NICU) for a month, but none had major health issues.

“We were so fortunate,” said Katie. “Other babies in the NICU were severely ill.”

Katie said it was difficult going back and forth between the hospital and home. Things settled down a bit once all the babies were home, but they quickly realized they needed help at night.

“That first night when they were all home and not connected to monitors or oxygen and we were on our own — we didn’t sleep,” said Katie.

The nurses from the NICU suggested Katie and Charlie hire nursing students to lend a hand during the night, so they decided to give it a try. It turned out that nursing students are eager to experience working with premature babies. Plus, they’re more affordable than other helpers.

For the first four months, student nurses took the 11 p.m. to 8 a.m. shift. Katie and Charlie took turns getting up to help feed the babies.

“That was pretty brutal. Slowly, we transitioned to a single feeding during the night,” Katie recalled.

By the time they reached 6 months of age, the quads were sleeping through the night.

“They have their last bottle at 6 p.m., are in bed at 8 p.m., and the house is quiet until morning,” Katie says.

As for big sister Molly, she made the adjustment beautifully. Right from the start, she knew which baby was which. She even enjoys helping out with feedings.

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Times are already changing as the children grow.

Having started out in a noisy NICU, the quads aren’t bothered by a little commotion.

“They all sleep in the same room, but one who cries doesn’t wake the others,” said Katie.

But the days of sleeping two-to-a-crib are coming to an end. The babies are gaining mobility and starting to crowd each other out. Just one of the many changes to come.

With Molly still in diapers, the family goes through about 30 diapers a day. They also use $16 to $17 in formula every day.

Changings and feedings are time-consuming, but the Ferraros generally have two people helping out at any given time.

Besides having an active 2-year-old running around, the babies are beginning to move off in different directions to explore the world.

“It’s entertaining,” said Katie.

Leaving the house takes planning. Car seats and a pair of double strollers get the job done. It takes two adults to go anywhere, but they do manage. And they do get attention.

“People can’t help themselves,” said Katie. “They have to ask questions. A total stranger asked me if I delivered them vaginally. Really? But it is an interesting way to connect with people.”

For all the time and energy it takes, Katie and Charlie are keenly aware of their good fortune.

“You hear a lot of sad stories involving multiples. Ours is truly a happy outcome,” said Katie. “When they’re sleeping peacefully, I have to pinch myself that they’re all here and all healthy. It could have been so different.”

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Dr. Danelle Fisher, chair of pediatrics at Providence Saint John’s Health Center in Santa Monica, California, spoke to Healthline about the special health concerns of triplets and quadruplets.

“The first thing is to try to get them as close to term as possible,” she said. ”Most are born prematurely and stay in the NICU for several weeks to several months, depending on their needs.”

Once the babies go home, it’s important to keep an eye on their pattern of development.

“We’ll watch development in all areas,” she explained. “Are they meeting growth and motor milestones? Can they roll over, sit up, crawl? How are their fine motor movements? Can they grasp objects and feed themselves? We watch language and social development. We have to make sure they’re getting the stimulation and help they need to develop at a normal pace.”

Fisher said each case is unique and must be approached that way. There are no hard and fast rules of scheduling doctor visits for triplets or quadruplets.

“With multiples who have health issues, we need to see them more often, especially in the first year of life. It depends on the children’s and parents’ needs,” she said.

As children start to walk and run, subtler things can come up, according to Fisher. You may discover a child has low muscle tone or needs more help with some movements. These children can benefit from physical therapy at an early age.

“It really is a group effort. The parents should never be afraid to ask for help. Resources are available in every state and, hopefully, parents can get what they need,” said Fisher.

“Quads are not necessarily in for a life of being behind everyone else. We can identify problems better than we used to and have the ability to help them lead normal, healthy lives,” she said.

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Having one child is a life-changer. Having multiples can strain even the happiest parents.

Dr. Jon Sarnoff, pediatrician at Premier Pediatrics and The First Month Program, told Healthline that multiple births are associated with moderate to severe postpartum depression more frequently than single births.

“Although the reason has not been studied, intuitively, it makes sense that the additional stress of feeding, bathing, and caring for multiple babies would increase the risk for a postpartum depression,” said Sarnoff.

“In addition, multiple births are often preterm, the result of IVF, or associated with additional medical challenges,” he continued. “These additional risk factors compound the likelihood of a postpartum depression. Interestingly, parents of twins, triplets, and quadruplets all have the same level of risk.”

Sarnoff said parents often describe anxiety rather than depression as the primary symptom. Others experience fatigue, sadness, hopelessness, appetite and sleep disturbances, over-concern for the baby, uncontrollable crying, lack of interest in the baby, guilt, and exaggerated highs and lows.

“It is also important to keep in mind that expectant moms, as well as partners, are at a significant risk,” he said.

“I do not mean to minimize the postpartum anxiety or depression experienced by mothers or fathers of singletons. All parents who feel that they are at risk or suffering from postpartum anxiety or depression should seek help. If you are concerned, please reach out to a partner, friend, obstetrics provider, pediatrician, or whoever you feel comfortable with,” said Sarnoff.

You can follow the adventures of the Ferraro family on their blog, Fourtified Family.