American Academy of Pediatrics Committee on Fetus and Newborn: Surfactant replacement therapy for respiratory distress syndrome.

Respiratory failure secondary to surfactant deficiency is a major cause of morbidity and mortality in low birth weight immature infants. Surfactant therapy substantially reduces mortality and respiratory morbidity for this population. The statement summarizes the indications for surfactant replacement therapy. Because respiratory insufficiency may be a component of multiorgan dysfunction in sick infants, surfactant should be administered only at institutions with qualified personnel and facilities for the comprehensive care of sick infants. Exogenous surfactant replacement has been established as an appropriate preventive and treatment therapy for prematurity-related surfactant deficiency. Surfactant therapy also may be indicated for more mature infants with primary pulmonary hypertension or meconium aspiration syndrome. Single and multicenter randomized controlled trials using synthetic, modified animal, purified animal, and human surfactants have shown that the use of surfactant replacement in preventive or treatment modes has been safe and efficacious.1–18 Reduced mortality rates and improved short-term respiratory status for preterm infants with surfactant-deficiency respiratory distress have been confirmed. However, coexistent morbidity, such as necrotizing enterocolitis, nosocomial infections, patent ductus arteriosus, intraventricular hemorrhage, and chronic lung disease, appear primarily unaffected. Reports of long-term outcome for infants enrolled in the randomized surfactant trials and evaluated at 1 to 2 years of age have shown neither beneficial nor adverse effects of surfactant use on growth and/or neurodevelopmental parameters.19 –26 Current studies continue to address refinements in surfactant use that may optimize its effectiveness. New products, timing, dosage, methods of administration, and modification for particular gestational age groups are among the issues that may improve the effect of surfactants. Two surfactants, one synthetic and the other modified bovine, have been licensed and are available commercially in the United States. Universal availability of these products raises the concern that surfactants may be used to address the respiratory component of multisystem disorders that affect high-risk, low birth weight infants when other diseases cannot be addressed appropriately. This is a critical issue because the target population for surfactant therapy is primarily the high-risk, low birth weight infants who may have multisystem disorders that are not affected beneficially by treatment with surfactants. Caring for these infants in nurseries without the full range of capabilities required may affect the overall outcome adversely.27,28 As systems of neonatal health care adapt to modified patterns of disease in low birth weight infants, the following recommendations should be incorporated.