Surfactant therapy in late preterm and term neonates with respiratory distress syndrome: a systematic review and meta-analysis

Background There are no evidence-based recommendations for surfactant use in late preterm (LPT) and term infants with respiratory distress syndrome (RDS). Objective To investigate the safety and efficacy of surfactant in LPT and term infants with RDS. Methods Systematic review, meta-analysis and evidence grading. Interventions Surfactant therapy versus standard of care. Main outcome measures Mortality and requirement for invasive mechanical ventilation (IMV). Results Of the 7970 titles and abstracts screened, 17 studies (16 observational studies and 1 randomised controlled trial (RCT)) were included. Of the LPT and term neonates with RDS, 46% (95% CI 40% to 51%) were treated with surfactant. We found moderate certainty of evidence (CoE) from observational studies evaluating infants supported with non-invasive respiratory support (NRS) or IMV that surfactant use may be associated with a decreased risk of mortality (OR 0.45, 95% CI 0.32 to 0.64). Very low CoE from observational trials in which surfactant was administered at FiO(2) >0.30-0.40 to infants on Continuous Positive Airway Pressure (CPAP) indicated that surfactant did not decrease the risk of IMV (OR 1.20, 95% CI 0.40 to 3.56). Very low to low CoE from the RCT and observational trials showed that surfactant use was associated with a significant decrease in risk of air leak, persistent pulmonary hypertension of the newborn (PPHN), duration of IMV, NRS and hospital stay. Conclusions Current evidence base on surfactant therapy in LPT and term infants with RDS indicates a potentially decreased risk of mortality, air leak, PPHN and duration of respiratory support. In view of the low to very low CoE and widely varying thresholds for deciding on surfactant replacement in the included studies, further trials are needed. Uncertainty exists on surfactant in late preterm and term infants with RDS. Surfactant therapy in neonates >= 340/7 weeks may be associated with decreased risk of mortality and short-term respiratory morbidities. However, there is wide variation in thresholds for surfactant therapy.