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Systematic review of prophylactic vs rescue surfactant
  1. C J Morley
  1. Department of Paediatrics, Addenbrooke’s Hospital, Cambridge
  1. Dr C J Morley University of Cambridge Department of Paediatrics Neonatal Intensive Care Unit, Box 226, Addenbrooke’s Hospital Cambridge CB2 2QQ. email:CMJ11{at}

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Surfactant treatment has been shown by careful randomised trials to reduce the mortality and morbidity of very premature babies.1 However, whether surfactant should be given as soon as the baby is born or withheld until the baby has respiratory distress syndrome (RDS) is controversial.

The objective of this review is to set out the reasons for and against giving surfactant at birth, present the clinical trial data available to date with a systematic review of those trials, and the conclusions that can be drawn from them.

“Prophylactic treatment” is defined as surfactant given down an endotracheal tube at initial resuscitation. “Rescue treatment” is when the surfactant given to an intubated baby several hours after birth when RDS has been diagnosed.

Reasons for prophylactic surfactant treatment

The lung epithelium of very premature babies is damaged within minutes of ventilation.2 This causes protein to leak on to the surface and interferes with surfactant function.3 4Animal studies have shown that surfactant treatment, given as soon as possible after birth, reduces the severity of RDS and airway damage,5 and improves blood gases, lung function, and survival.6 7 Clinical trials have shown that surfactant treatment for very premature babies is very beneficial and remarkably safe.1 For example, the Ten Centre Trial of ALEC8 used prophylactically showed a 30% reduction in the incidence of RDS compared with control babies and a 48% reduction in neonatal mortality with no side effects.

It is impossible to know which baby will develop RDS and who, therefore, might benefit from surfactant treatment. The shorter the gestation the more likely the baby is to develop RDS, but older babies who are compromised in some way are also at risk of RDS and its complications. Normal neonatal practice is to anticipate and try to prevent problems. To wait until …

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