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When to treat with surfactant?
  1. David G Sweet
  1. Neonatal Unit, Royal Maternity Hospital, Belfast, Belfast, UK
  1. Correspondence to Dr David G Sweet, Neonatal Unit, Royal Maternity Hospital, Belfast, Belfast, UK; david.sweet{at}

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Synthesis of available data by different expert groups has resulted in differing fraction of inspired oxygen (FiO2) thresholds for surfactant therapy in babies with respiratory distress syndrome (RDS). Canadian Guidelines in 2021 suggested treatment when FiO2>0.5. Recent European Guidelines suggest treatment when FiO2>0.3. Branagan et al attempt through network meta-analysis to determine if there is an optimal FiO2 cut-off for surfactant therapy to reduce any of the important negative outcomes of prematurity including mortality and bronchopulmonary dysplasia (BPD). They show that there are no strong data from randomised trials supporting any particular cut-off, ranging between FiO2 0.3 and 0.5 and argue that randomised trials of different thresholds for surfactant are urgently needed.

What should neonatologists do now, while acknowledging that we do not know everything, and further research may refine what we do? Does this new meta-analysis mean we should wait longer before we expose infants to unpleasant laryngoscopy for thin surfactant catheter placement for less invasive surfactant administration (LISA)?

If we examine the studies included in Branagan’s systematic review, there are 14 trials involving 5298 infants spanning 23 years from 1991 to 2014, all from the era before LISA was conceptualised. The earlier studies around 1991/1992 were predominantly ventilated preterm babies randomised to prophylactic surfactant or rescue at the FiO2 threshold 0.4/0.5 with the aim of looking for improved survival. For the later studies from around 2013/2014, data are derived from populations of preterm babies initiated on continuous positive airways pressure (CPAP) and randomised to early prophylactic …

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  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests DGS is first author of the European Guidelines for the management of RDS published 2022 recommending FiO2 cut-off of 0.3. In the past, he has received honoraria from Chiesi Pharmaceuticals for lectures on these Guidelines.

  • Provenance and peer review Commissioned; externally peer reviewed.

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