Birth order and morbidity and mortality to hospital discharge among inborn very low-birthweight, very preterm twin infants admitted to neonatal intensive care: a retrospective cohort study

Objective To know the association of birth order with the risk of morbidity and mortality in very low-birthweight (VLBW) twin infants less than 32 weeks’ gestational age (GA). Design Retrospective cohort study. Setting Infants admitted to the collaborating centres of the Spanish SEN1500 neonatal network. Patients Liveborn VLBW twin infants, with GA from 23 +0 weeks to 31 +6 weeks, without congenital anomalies, admitted from 2011 to 2020. Outborn patients were excluded. Main outcome measures Respiratory distress syndrome (RDS), patent ductus arteriosus, bronchopulmonary dysplasia (BPD), necrotising enterocolitis, major brain damage (MBD), late-onset neonatal sepsis, severe retinopathy of prematurity, survival and survival without morbidity. Crude and adjusted incidence rate ratios were calculated. Results Among 2111 twin pairs included, the second twin had higher risk (adjusted risk ratio (aRR) of RDS (aRR 1.08, 95% CI 1.03 to 1.12) and need for surfactant (aRR1.10, 95% CI 1.05 to 1.16). No other significant differences were found, neither in survival (aRR 1.01, 95% CI 0.99 to 1.03) nor in survival without BPD (aRR 1.02, 95% CI 0.99 to 1.05), survival without MBD (aRR 1.02, 95% CI 0.99 to 1.06) nor in survival without major morbidity (aRR 0.97, 95% CI 0.92 to 1.03). However, second twins born by caesarean section (C-section) after a vaginally delivered first twin had less overall survival and survival without MBD. Conclusion In modern perinatology, second twins are still more unstable immediately after birth and require more resuscitation. After admission to the neonatal intensive care unit, they are at increased risk of RDS, but not other conditions, except for second twins delivered by C-section after a first twin delivered vaginally, who have decreased overall survival and survival without major brain injury.