Postnatal SNAP-II scores in neonatal intensive care unit patients: Relationship to sepsis,necrotizing enterocolitis,and death

Objective.?To determine if daily SNAP-II scores (Score for Neonatal Acute Physiology) after the first day are useful in identifying neonatal intensive care unit (NICU) patients who die or develop sepsis or necrotizing enterocolitis.

Study design.?Prospective data were collected on all 141 admissions to a university level III NICU over 4 months. SNAPPE-II scores were calculated from the day of admission and SNAP-II scores from subsequent hospital days. The scores were compared between those who developed events and those who did not.

Results.?At least 64% of the daily SNAP-II scores on the day of and the preceding 4 days from the event were 0. Admission SNAPPE-II scores correlated with length of stay (r = 0.44, p < 0.01) but patient average SNAP-II did not (r = 0.02, p > 0.5).

Conclusions.?SNAP-II scores from after the first day of life did not accurately assess or predict neonatal morbidity and mortality.     

Improved outcome of preterm infants when delivered in tertiary care centers

OBJECTIVE: Previous studies that compared outcomes of infants born outside tertiary care centers (outborn) with those born in tertiary care centers (inborn) did not account for admission illness severity and perinatal risks. The objective of this study was to examine whether outborn status is associated with higher mortality and morbidity, after adjustment for perinatal risks and admission illness severity (using the Score for Neonatal Acute Physiology, Version II [SNAP-II]) among preterm infants who were admitted to Neonatal Intensive Care Units (NICUs). METHODS: Logistic regression analysis was used to compare the risk-adjusted outcomes of 3769 singleton infants born at or before 32 weeks' gestation, who were admitted to 17 Canadian NICUs during 1996-1997. RESULTS: Outborn and inborn infants had significantly different gestational ages, perinatal risk factors (maternal hypertension, prenatal care, antenatal corticosteroid therapy, 5-minute Apgar score, delivery type, small for gestational age) and admission SNAP-II. Outborn infants were at higher risk of death (adjusted odds ratio [OR] 1.7, 95% confidence interval [CI] 1.2, 2.5), grade III or IV intraventricular hemorrhage (adjusted OR 2.2, 95% CI 1.5, 3.2), patent ductus arteriosus (adjusted OR 1.6, 95% CI 1.2, 2.1), respiratory distress syndrome (adjusted OR 4.8, 95% CI 3.6, 6.3), and nosocomial infection (adjusted OR 2.5, 95% CI 1.9, 3.3), even after adjusting for perinatal risks and admission illness severity. CONCLUSIONS: Outborn infants were less mature and more ill than inborn infants at NICU admission. However, even after adjustment for perinatal risks and admission illness severity, inborn infants had better outcomes than outborn infants. Our results support in-utero transfer of high-risk pregnancies to a tertiary level facility.     

SNAP-II for prediction of mortality and morbidity in extremely preterm infants

Objective: To determine the specific Score of Neonatal Acute Physiology (SNAP-II) cut-off scores associated with outcomes in extremely preterm infants, and to examine its contribution to predictive models that include nonmodifiable birth predictors.

Study design: Retrospective observational study of 9240 infants born at 22–28 weeks’ gestation and admitted to the Canadian Neonatal Network from 2010 to 2015. Outcomes included early and hospital mortality, composite of mortality/morbidity and individual morbidities. The SNAP-II cut-off to predict each outcome was determined using the Youden index. Additional contributions were evaluated using a base model that adjusted for gestational age, birth weight z-score and sex and by comparing the area under the curve (AUC).

Results: The mortality/morbidity rate was 63% (5859/9240). Specific SNAP-II cut-offs ranged from 12 to 20 and were associated with each adverse outcome. Adding SNAP-II cut-offs to predictive models that included birth variables significantly improved (p?Conclusions: SNAP-II cut-offs were independently associated with each adverse outcome and using the proposed SNAP-II cut-offs improved the performance of predictive models for certain short-term outcomes.     

Maternal hypertension and neonatal outcome among small for gestational age infants

OBJECTIVE: To determine whether maternal hypertension might improve perinatal outcome among small for gestational age (SGA) infants (< 10th percentile). METHODS: Our prospective cohort comprised 17 Canadian neonatal intensive care units (NICUs) and 3,244 SGA singletons. Multivariable regression was used to analyze the relation between maternal hypertension and each of the following: SNAP-II (Score of Neonatal Acute Physiology; ordinal regression) and neonatal survival and survival without severe intraventricular hemorrhage (logistic regression), adjusting for potential confounders. RESULTS: There were 698 (21.5%) neonates born to hypertensive mothers. Inversely associated with lower SNAP-II scores (healthier infant) were antenatal steroids (complete course: odds ratio [OR] 0.67, 95% confidence interval [CI] 0.54-0.83; incomplete: OR 0.71, 95% CI 0.56-0.88), lower gestational age (< 27 weeks: OR 0.06, 95% CI 0.05-0.08; 27-28 weeks: OR 0.11, 95% CI 0.07-0.17; 29-32 weeks: OR 0.28, 95% CI 0.23-0.35), 5-minute Apgar < 7 (OR 0.30, 95% CI 0.25-0.36), male gender (OR 0.80, 95% CI 0.70-0.92), and anomalies (OR 0.49, 95% CI 0.41-0.58). Maternal hypertension was associated with lower SNAP-II (healthier infant) (7.54 +/- 11.16 [hypertensive] versus 7.21 +/- 11.85 [normotensive]) on multivariable regression analysis (adjusted OR 1.25, 95% CI 1.05-1.49), as well as higher neonatal survival (93.0% versus 91.2%, and adjusted OR 1.9, 95% CI 1.2-3.0), but not survival without severe intraventricular hemorrhage (91.4% versus 87.0%, and adjusted OR 1.4, 95% CI 1.0-2.0), respectively. CONCLUSION: Among SGA neonates in NICU, maternal hypertension is associated with improved admission neonatal physiology and survival.     

Predictors of mortality and length of stay for neonates admitted to children's hospital neonatal intensive care units.

OBJECTIVE: Current scoring systems, which adjust prediction for severity of illness, do not account for higher observed mortality in neonatal intensive care units (NICUs) of children's hospitals than that of perinatal centers. We hypothesized that three potential predictors, (a) admission from another NICU, (b) presence of congenital anomalies and (c) need for surgery, would modify expected mortality and/or length of stay for infants admitted to NICUs in children's hospitals. STUDY DESIGN: We reviewed consecutive admissions to two NICUs in children's hospitals in Canada. We performed regression analyses to evaluate these potential predictors and severity-of-illness indices for the outcomes of mortality and length of stay. RESULT: Of 625 neonatal admissions, transfer from another NICU, congenital anomalies requiring admission and surgery were identified in 371 (59%). Using logistic regression, mortality was predicted based on admission from another NICU (odds ratio (OR) 1.92; 95% confidence interval (CI) 1.04, 3.57), congenital anomalies (OR 7.28; 95% CI 3.69, 14.36) and a validated severity-of-illness score, the Score for Neonatal Acute Physiology Perinatal Extension Version II (SNAPPE-II; OR 1.07; 95% CI 1.05, 1.09 per point). By contrast, surgical intervention was predictive of survival (OR 0.35; 95% CI 0.18, 0.67). Length of stay >or=21 days was predicted by SNAPPE-II (OR 1.02; 95% CI 1.01, 1.03 per point), congenital anomalies (OR 2.47; 95% CI 1.60, 3.79) and surgery (OR 2.73; 95% CI 1.77, 4.21). CONCLUSION: Fair performance comparisons of NICUs with different case-mixes, such as children's hospital and perinatal NICUs, in addition to severity-of-illness indices, should account for admissions from another NICU, congenital anomalies and surgery.     

Predicting neonatal outcomes: birthweight, body mass index or ponderal index?

AIMS: To compare birthweight (BW), body mass index (BMI) and ponderal index (PI) as predictors of selected short-term (ST) outcomes, namely Neonatal Intensive Care Unit (NICU) admission and prolonged hospitalization (PH), among newborn (NB) infants. METHODS: Data was collected prospectively on 9,226 infants born during one year at nine tertiary care hospitals in Greater Beirut, Lebanon. The predictive abilities of BW, BMI and PI were compared using the area under the receiver operator characteristic (ROC) curves and sensitivity analysis was performed at the optimal cut-off points for the best anthropometric measurement. RESULTS: The area under the ROC curve suggested superior discriminative power for BW as compared to BMI or PI, as a predictor of NICU admission (ROC area = 0.73) and PH (ROC area = 0.74). The optimal BW cut-off point was 2750 g (sensitivity: 0.49; specificity: 0.89) and 2950 g (sensitivity: 0.62; specificity: 0.78) for NICU admission and PH, respectively. CONCLUSION: In our population of NB infants, BW--a crude measure of fetal growth--is a better predictor than either BMI--a measure of adiposity in adults and children--or PI--a measure of thinness at birth--for selected ST outcomes in NB infants.     

Indicated and non-indicated preterm delivery in twin gestations: impact on neonatal outcome and cost.

OBJECTIVE: To identify the etiology and impact of preterm delivery in twin gestations. STUDY DESIGN: Twin gestations delivered at 33.0 to 36.9 weeks were identified in a perinatal database, and categorized by indication for delivery. Deliveries were identified as indicated, or non-indicated (discretionary). Neonatal outcomes were measured by birth weight, length of stay, NICU admission, and ventilator utilization. Data were divided and analyzed by indicated or discretionary delivery, and gestational age at delivery. RESULTS: Analyzed were 3252 twin gestations (6504 infants), with 78% having indicated delivery. Of the 22% with discretionary delivery, nearly 40% required NICU admission. With each advancing week of gestation, there was a significant decrease in incidence of NICU admission and nursery days. CONCLUSION: The majority of preterm deliveries were indicated, though 22% were discretionary. It is vital to consider neonatal morbidity and costs related to gestational age when choosing discretionary delivery.     

Ethnic differences in risk factors for neonatal mortality and morbidity in the neonatal intensive care unit.

OBJECTIVE: Although our knowledge about how to care for high-risk neonates who require intensive care is continually improving, disparities in health outcomes among various ethnic groups living in developed countries are becoming more evident. The purpose of this study was to identify the risk factors for neonatal intensive care unit (NICU) mortality among Canadian-born minority infants and, furthermore, to determine whether ethnicity was in itself an independent predictor of mortality or major morbidity in the NICU. STUDY DESIGN: Data were prospectively gathered on 6528 infants admitted to nine regionally located NICUs across Canada. Multiple logistic regressions were used to develop risk-adjusted models for NICU mortality and major morbidity. RESULT: Despite adjusting for differences in small for gestational age (SGA), outborn status and gestational age less than or equal to 28 weeks, South Asian infants still had significantly greater odds of mortality in the NICU. Neonatal sepsis was the strongest predictor of mortality among African infants, even greater than birth at 28 weeks or less. At significantly greater odds of survival with major morbidity were Aboriginal males and East Asian females. CONCLUSION: There are ethnic disparities in the risks of neonatal mortality and morbidity in the NICU. Understanding these differences is important to be able to determine specific areas to target in improving healthcare delivery and reducing disparities in health outcomes among Canada's diverse population.     

Outcome of small-for-gestational-age fetuses according to umbilical artery Doppler: Is there any yield from additional middle cerebral artery Doppler?

Abstract

Objective.?To investigate the outcome of small-for-gestational-age (SGA) fetuses in relation to the features of umbilical artery (UA) Doppler and to explore the prognosticator of middle cerebral artery (MCA) Doppler in SGA fetuses with normal UA impedance.

Methods.?Two hundred ninety-seven patients were classified into Group 1 with normal UA and MCA pulsatility index (PI), Group 2 with normal UA but abnormal MCA PI and Group 3 with abnormal UA PI/absent or reversed end diastolic flow. Neonatal outcomes were compared between each group.

Results.?Neonatal intensive care unit (NICU) admission, duration of hospital stay and perinatal mortality were higher in Group 3 as compared to the others. Group 2 had a lower birth weight and more fetuses with 5-min Apgar score <7 than Group 1; NICU admission and need for ventilators were also significantly higher than Group 1.

Conclusions.?SGA fetuses with abnormal UA Doppler suffered more morbidity and mortality compared to those with normal UA Doppler. SGA fetuses with normal UA PI but abnormal MCA PI had worse outcomes compared to those with normal UA and MCA PI.     

Snap-II predicts severe intraventricular hemorrhage and chronic lung disease in the neonatal intensive care unit.

OBJECTIVE: To determine whether the Score for Neonatal Acute Physiology, Version II (SNAP-II), improved prediction of severe (> or = grade III) intraventricular hemorrhage (IVH) and chronic lung disease (CLD) when compared to models using gestational age (GA) and traditional risk factors (e.g., Apgar score, small-for-gestational-age, sex, outborn status). STUDY DESIGN: We examined 4226 infants < or = 32 weeks' GA admitted to 17 Canadian neonatal intensive care units between 1996 and 1997. We compared prediction models for severe IVH and CLD, with and without SNAP-II. RESULTS: SNAP-II was a significant and independent predictor of severe IVH and CLD. Addition of SNAP-II to models using GA and traditional risk variables significantly (p<0.05) improved model prediction (AUC 0.8 for severe IVH; 0.83 for CLD). Models were well calibrated (p>0.05 for Hosmer-Lemeshow goodness of fit test). CONCLUSION: Addition of SNAP-II to models using GA and traditional risk factors significantly improves prediction of severe IVH and CLD.     

Evaluation of the pregnancy prolongation index (PPI) as a measure of success of obstetric interventions in the prevention of preterm birth and associated morbidities

OBJECTIVE: This study was undertaken to evaluate the validity of the pregnancy prolongation index (PPI) as a measure of preterm labor treatment success. STUDY DESIGN: Analysis of prospectively collected maternal and neonatal data from a national clinical database (Matria Healthcare). Included were patients with singleton, twin, and triplet pregnancies who had outpatient surveillance initiated between 18 and 34 weeks and delivered at 24 to 36 6/7 weeks' gestation with NICU admission. Each patient's PPI score was calculated via the following equation: [(gestational age at delivery - gestational age at start of treatment) / (37.0 - gestational age at start of treatment)] x 100%. The impact of increasing PPI score was measured against NICU length of stay as a surrogate gauge of neonatal morbidity. Data were further stratified by gestational type and reason for delivery. RESULTS: Pregnancy outcomes of 12,642 patients (6,642 singletons, 4,326 twins, and 1,674 triplets) were analyzed. The PPI score increased in a direct, inverse linear relationship with decreasing number of NICU days. CONCLUSION: The PPI is a sensitive measure for the evaluation of treatment success in the inhibition of preterm labor and delivery.     

Some are old, some are new: life and death in the ICU

We compared 560 adults hospitalized in our Medical Intensive Care Unit (MICU) to 245 ventilated babies hospitalized in our Neonatal ICU (NICU). Both ICUs had comparable mortality rates - roughly 1 patient in 5 died. The average length of hospitalization for nonsurvivors versus survivors was disproportionately short for NICU babies (13d v 33d) and long for MICU adults (15d v 12d). This phenomenon resulted in a redistribution of ICU bed-days and resources in favor of survivors for NICU babies (approximately 9 of every 10 NICU beds were devoted to babies who survived), and nonsurvivors for MICU adults (roughly 1 MICU bed in 2). Both ICUs had comparable percentages of patients predicted to die - roughly 1 patient in 3. The predictive power of an intuition of die was comparable - and not all that great. Almost one third of patients in both ICUs with a single prediction of “die in hospital” survived to be discharged. However, the likelihood of finding a neurologically normal NICU survivor after a prediction of “die” was only 5 in 100. To the extent that informed decisions can be made with 95% certainty, we may have found a foothold on the slippery ethical slope of benefit/burden calculations in the NICU. Unfortunately, we have no comparable data for MICU survivors.     

The ninety-fifth percentile for growth discordance predicts complications of twin pregnancy

OBJECTIVE: Our purpose was to define twin growth discordance on the basis of perinatal outcome. STUDY DESIGN: Twins delivered at >23 weeks' gestation between 1995 and 2000 were identified by use of our computerized perinatal database. Birth weight (BW), chorionicity, and the following outcomes were recorded: cesarean delivery for nonreassuring fetal status (NRFS), umbilical artery (UA) pH, 5-minute Apgar score, neonatal intensive care unit (NICU) admission, and stillbirth. Discordance was calculated as 100 x(Larger BW - Smaller BW)/Larger BW. The distribution of discordance values for the study population was determined. Outcomes were compared for twins with and without discordance at thresholds defined by population percentile. RESULTS: The mean discordance for 346 twins was 11.4% +/- 10.5%. The 75th percentile was 16% discordance, the 90th was 23%, and the 95th was 31%. Discordance was independently associated with outcomes. The 95th percentile was the threshold most predictive of cesarean section NRFS, UA pH <7.1, 5-minute Apgar score <7, and NICU admission. CONCLUSION: Defining pathologic discordance as the 95th percentile, or >30% difference, enhances its predictive value.     

The CDH Study Group and advances in the clinical care of the patient with congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) occurs in 1 of every 2000 to 4000 births and accounts for 8% of all major congenital anomalies. Recurrence risk for a subsequent pregnancy is estimated at 2%. The mortality rate for CDH when diagnosed antenatally, varies with fetal age and with the presence or absence of hydramnios and degree of pulmonary hypoplasia. The prognosis has improved dramatically in recent years, primarily due to advances in neonatal and surgical interventions. Neonatal survival rates with an antenatal diagnosis now exceed 80% in some centers. Treatment for infants with CDH reflects other pediatric surgical problems in that a majority of the clinical research that shapes treatment is retrospective in nature. Because CDH is a relatively rare disease, using a compilation of cases, such as the CDH database provides, greatly aids our understanding of this disease process. Moreover, the application of a quality assessment scale provides the practitioner with a knowledge base to critically evaluate the published retrospective data.     

Does limited access to NICU services account for higher neonatal mortality rates among blacks?

During a 2-year period in the Finger Lakes region of upstate New York, black infants were admitted to the NICU 2.6 times as often as white infants. The relative risk of NICU admission among black low birthweight infants was 9.2 times that of normal birthweight black infants. The relative risk of NICU admission among white low birthweight infants was 16.4 times that of normal birthweight white infants. Thus, higher rates of low birthweight among blacks did not account for the increased utilization of NICU services by blacks. Within the NICU, 30% of the deaths among black normal birthweight infants could be attributed to complications of asphyxia, persistent fetal circulation, or meconium aspiration. Only 14.3% of the deaths among white normal birthweight infants were attributed to these cause. Higher black neonatal mortality rates did not appear to be due to limited access to NICU services, but more normal birthweight black babies may have died of potentially preventable causes.     

Induction of labor in patients with term premature rupture of membranes. Effect on perinatal outcome.

OBJECTIVE: To determine whether delayed induction of labor in patients with premature rupture of membranes (PROM) at term has beneficial effects on the mother or the infant. STUDY DESIGN: Retrospective analysis of our database revealed 576 patients >37 weeks of gestation with PROM, who delivered live-born infants without major congenital anomalies. We analyzed the frequencies of primary cesarean, neonatal intensive care unit (NICU) admissions, and oxytocin use by time since hospital admission and interval until onset of labor. RESULTS: NICU admission increased from 1.9% in <3 h between admission to onset of labor to 13.3% after >18 h. Admission-onset of labor interval, birth weight of <2,500 or >4,000 g and meconium were all more important determinants of NICU admission than gestational age, duration of labor, PROM, and ROM. Prolonged admission-onset of labor interval was associated with an increased risk of variable decelerations (p < 0.001). Primary cesarean rates increased progressively with longer intervals between admission and onset of labor. Stepwise discriminant function analysis revealed that labor duration, admission-onset of labor interval, gestational age, and birth weight of <2,500 g were all more important determinants of primary cesarean delivery than the durations of PROM or ROM. CONCLUSIONS: The increased frequencies of NICU admission, variable decelerations, and primary cesarean suggest that delayed labor induction after hospital admission was linked to worsened perinatal outcomes. These results may have been influenced by usually performing a single digital examination as part of initial evaluation of term patients who present with PROM. Based on our data, we suggest immediate induction for PROM at term, especially if digital examination has been performed.     

Congenital diaphragmatic hernia: intensive care unit or operating room?

Despite improvements in prenatal diagnosis and neonatal intensive care, the Congenital Diaphragmatic Hernia (CDH) Registry still records a 64% survival rate. Many reports demonstrate, however, that approximately 80% of CDH patients with no other malformations may survive if managed with permissive hypercapnia, gentle ventilation, high-frequency oscillatory ventilation (HFOV), surfactant, inhaled nitric oxide (iNO) and extracorporeal membrane oxygenation (ECMO), and delayed surgical repair. We wished to define the evolving outcome of CDH newborns using a protocol approach to management, which includes surgery in the neonatal intensive care unit (NICU) or operating room (OR). From January 1996, data were collected prospectively on 42 consecutive live-born infants with CDH. Newborns symptomatic at birth were sedated and paralyzed in the delivery room, and treated with elective HFOV, iNO, surfactant, and ECMO as necessary, delaying surgical repair until their clinical conditions were stable. Once the CDH newborn was stabilized, a trial on conventional ventilation was started at least 24 hours before surgery; however, if the patient was unstable, therapy was switched back to HFOV and surgery was performed in the NICU. Demographic and clinical parameters were compared between CDH newborns who underwent surgery in the NICU and in the OR. The two groups were comparable in terms of clinical characteristics and baseline ventilatory and blood gas values. Mean age at surgery was 3 +/- 2 days. After surgery, the NICU group had more infectious complications. However, the survival rate of uncomplicated CDH was 78% and a low rate of chronic lung disease was reported. A prolonged phase of presurgery stabilization is proposed and strict control of infection is recommended for the CDH newborns who might benefit from an exclusive HFOV and NICU surgery.     

Characteristics of obstetric intensive care unit admissions in New Jersey

Objective.?To assess the demographic characteristics, risk factors and perinatal outcomes among maternal intensive care unit (ICU) admissions in New Jersey from 1997 to 2005.

Methods.?Data were obtained from a perinatal linked database from MCH epidemiology programme in New Jersey. Chi-square test was used for bivariate analysis and stepwise logistic regression was used to assess the influence of the potential risk factors and pregnancy complications.

Results.?There were 15 447 (1.54%) ICU admissions and 23 maternal deaths (0.15%) among the 1 004 116 pregnancies. Analysis of demographic factors revealed that maternal age, race and smoking were significantly associated with ICU admission. Regression analysis adjusting for maternal age, parity, gravida, race, smoking status, maternal education and place of delivery found the following predictors for ICU admission, preeclampsia (odds ratio (OR): 2.8, 95% confidence interval (CI): 2.6–3.0), eclampsia (OR: 6.8, 95% CI: 5.4–8.6), placenta previa (OR: 3.0, 95% CI: 2.7–3.4), abruption (OR: 8.9, 95% CI: 8.3–9.6), multifetal pregnancy (OR: 4.2, 95% CI: 4.1–4.4), diabetes (OR: 3.1, 95% CI: 2.7–3.5), acute renal failure (OR: 22.1, 95% CI: 13.3–36.6) and cesarean delivery (OR: 1.9, 95% CI: 1.5–2.4). Infants born to ICU admitted mothers had higher rates of NICU admission, neonatal intubations and lower Apgar scores compared with infants born to non-ICU admitted mothers.

Conclusion.?Pregnancy complications are predictive of ICU admission amongst pregnant patients after adjusting for demographic factors.     

Admission volume is associated with mortality of neonatal respiratory failure in emerging neonatal intensive care units

Objective: The aim of this survey was to explore the relationship between admission volume and mortality of neonates with hypoxemic respiratory failure (NRF) in emerging neonatal intensive care units (NICUs).

Methods: NRF from 55 NICUs were retrospectively included with death risk as the major outcome. Perinatal comorbidities, underlying disease severity, respiratory support, facility utilization, and economic burden in the early postnatal period were compared among five NICU admission volume categories defined by NRF incidence, with score for neonatal acute physiology perinatal extension II (SNAPPE-II) also assessed as initial severity.

Results: Compared to NICUs with NRF?p?r?=?.282, p?p?Conclusions: Neonates in NICUs with smaller NRF admission volume and decreased magnitude of ventilator use had a higher risk of death as assessed by SNAPPE-II, which should be targeted in the quality improvement of newly established, resource-limited NICUs.     

The changing epidemiology of preterm twins and triplets admitted to neonatal intensive care units in Canada, 2003 to 2008

We describe trends in the rates of admission of preterm twin and triplet infants to neonatal intensive care units (NICUs) across Canada and compare their neonatal outcomes over a 6-year period. Temporal trends of admission rates for 5193 twins and triplets < 33 weeks' gestational age to participating NICUs in the Canadian Neonatal Network between 2003 and 2008 were assessed. Trends in infant outcomes were evaluated using logistic regression. The proportion of twins increased from 26.1 to 28.0 per 100 admissions between 2003 and 2008 (7% increase, p = 0.02). In contrast, the proportion of triplets decreased from 5.0 to 3.3 per 100 admissions (34% reduction, p = 0.04). These trends were significant in mothers ≥ 35 years of age. Neonatal outcomes improved for preterm twins (mortality, p < 0.01; survival without any major morbidity, p < 0.01; severe neurological injury, p = 0.02; and severe retinopathy of prematurity, p = 0.03). Similar improvements were observed for triplets, but the sample size was insufficient to reach statistical significance. The rate of NICU admissions for preterm twins at < 33 weeks' gestation has increased in recent years, whereas for triplets it has gradually declined. Neonatal outcomes of preterm twins improved over the study period.