Position statement on surfactant administration in neonates from Canadian pediatric society: Highlights.

Sir,

Respiratory distress syndrome (RDS) is common morbidity in preterms, for which exogenous surfactant is a proven therapy. In the absence of national guidelines on surfactant administration, we are currently dependent on the available international guidelines such as European consensus guidelines.[1] Recently, the Canadian pediatric society has proposed guidelines for surfactant replacement.[2] The key points are:

With the frequent use of delivery room continuous positive airway pressure (CPAP) and high antenatal steroid coverage, prophylactic surfactant is not recommended. Early selective surfactant (within 2 h of life) administration is preferred

Surfactant administration should be considered, if FiO2 requirement is >50%. However, exact positive end-expiratory pressure (PEEP) threshold in CPAP is not addressed. This is contrary to the FiO2 mentioned in the European guidelines of 30%, which however gives a threshold of PEEP as 6 cmH2O

Among animal-derived surfactants, porcine surfactant, especially in higher doses (>200 mg/kg), may be superior to bovine surfactant in reducing mortality, Bronchopulmonary dysplasia (BPD), or redosing. Repeat dose needs to be considered when there is evidence of moderate-to-severe RDS at least 6 h after the first dose

Intubated infants with RDS should receive surfactant before interfacility transport

For spontaneously breathing infants on CPAP with RDS, less invasive surfactant administration (LISA)/minimally invasive surfactant treatment (MIST) are preferable over INSURE. More evidence is needed for newer modalities of administration such as laryngeal mask airway, intrapharyngeal, and nebulization

Surfactant use for conditions other than RDS (e.g., meconium aspiration syndrome/pneumonia/pulmonary hemorrhage) may be considered at clinician’s discretion.

IMPLICATIONS IN INDIAN SCENARIO

Surfactant is not easily available and affordable in many neonatal units. Improvement in antenatal steroid coverage and delivery room CPAP at level II units can reduce transfers and the need for surfactant.[3] Newer, less invasive methods such as LISA/MIST are preferred compared to INSURE if expertise is available and is known to reduce the risk of BPD. Since there are no gestation-specific recommendations, there is a risk of overuse of surfactant, especially in late preterm.[4] Hence, there is an urgent need for the synthesis of national guidelines addressing these practical issues.

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Conflicts of interest

There are no conflicts of interest.