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Editor—We read with interest Morley’s review of prophylactic vs rescue surfactant,1 and noted his recommendation that all babies less than 32 weeks of gestation be treated with surfactant at intubation. The trials included in the review all have a relatively low use of antenatal corticosteroid, ranging from only 11% to 50%, with one trial not reporting this variable.2 Analysis of subgroups in one of the reviewed studies suggested that corticosteroids were as effective as surfactant.3 We therefore reviewed our admissions for 1996, to examine the effect of antenatal corticosteroids related to the need for surfactant. Our practice has been to administer surfactant as a rescue therapy, when the arterial:alveolar oxygen ratio is <0.22. The results are summarised in table 1.
There is a consistently high use of corticosteroids up to 32 weeks of gestation (77%; 181 of 236 infants). At 30 weeks and above of gestation, only 22% of infants required ventilation; surfactant was required in only 14% of infants receiving corticosteroids, and 8% of infants without. At 27–29 weeks of gestation, 65% of infants were ventilated; surfactant was required in a substantial but similar proportion of those with and without antenatal corticosteroids—50 and 69%, respectively. Similar results, with a higher proportion being ventilated, were seen at 26 weeks and less. The bottom two rows of the tables represent babies ventilated for apnoea, and therefore not given surfactant.
We suggest that antenatal corticosteroids do not preclude the need for surfactant in infants of 29 weeks of gestation or less, in whom prophylactic surfactant at delivery seems reasonable. At 30 weeks of gestation and greater, only a minority of these infants, regardless of corticosteroid status, require surfactant. Similar proportions of these more mature infants require ventilation for surfactant deficiency (14 of 116 = 12%), and for apnoea (11 of 116, 9.5%). It would therefore be reasonable in these infants either to give surfactant when intubation is required as recommended by Morley,1 or to be selective, depending on the clinical diagnosis of hyaline membrane disease.
We do not imply that antenatal corticosteroids be withheld from any woman in preterm labour, as their benefits are now well established.4-6 However, the need for surfactant is still substantial at 29 weeks of gestation or less despite treatment.
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