Surfactant Replacement Therapy for Preterm and Term Neonates with Respiratory Distress

Guidance for the Clinician in Rendering Pediatric Care

CLINICAL REPORT Surfactant Replacement Therapy for Preterm and Term Neonates With Respiratory Distress

Richard A. Polin, MD, FAAP, Waldemar A. Carlo, MD, FAAP, abstract and COMMITTEE ON FETUS AND NEWBORN Respiratory failure secondary to surfactant deficiency is a major cause KEY WORDS surfactant, antenatal steroids, respiratory distress syndrome, of morbidity and mortality in preterm infants. Surfactant therapy sub- meconium aspiration syndrome, neonatal pneumonia, neonatal stantially reduces mortality and respiratory morbidity for this popu- sepsis, congenital diaphragmatic hernia, pulmonary hemorrhage, lation. Secondary surfactant deficiency also contributes to acute persistent pulmonary hypertension, preterm, term respiratory morbidity in late-preterm and term neonates with meco- ABBREVIATIONS nium aspiration syndrome, pneumonia/sepsis, and perhaps pulmonary BPD—bronchopulmonary dysplasia hemorrhage; surfactant replacement may be beneficial for these in- CI—confidence interval CPAP—continuous positive airway pressure fants. This statement summarizes the evidence regarding indications, ECMO—extracorporeal membrane oxygenation administration, formulations, and outcomes for surfactant-replacement INSURE—intubation, surfactant administration, and extubation therapy. The clinical strategy of intubation, surfactant administra- LOE—level of evidence — fi tion, and extubation to continuous positive airway pressure and NNTB number needed to bene t RDS—respiratory distress syndrome the effect of continuous positive airway pressure on outcomes RR—relative risk and surfactant use in preterm infants are also reviewed. Pediatrics SP-B—surfactant protein B 2014;133:156–163 This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through INTRODUCTION a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any Surfactant replacement was established as an effective and safe commercial involvement in the development of the content of therapy for immaturity-related surfactant deficiency by the early this publication. 1990s.1 Systematic reviews of randomized, controlled trials confirmed The guidance in this report does not indicate an exclusive that surfactant administration in preterm infants with established course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be respiratory distress syndrome (RDS) reduces mortality, decreases the appropriate. incidence of pulmonary air leak (pneumothoraces and pulmonary interstitial emphysema), and lowers the risk of chronic lung disease or death at 28 days of age (Table 1).2–11 Subsequent trials indicated that prophylactic or early administration of surfactant resulted in fewer pneumothoraces, less pulmonary interstitial emphysema, and improved survival without bronchopulmonary dysplasia (BPD). How- ever, recent randomized clinical trials indicate that the benefits of prophylactic surfactant are no longer evident in groups of infants when continuous positive airway pressure (CPAP) is used routinely.5 This clinical report updates a 2008 report from the American Academy of www.pediatrics.org/cgi/doi/10.1542/peds.2013-3443 Pediatrics.1 As in the previous report, a number of clinically important doi:10.1542/peds.2013-3443 topics are reviewed surrounding use of surfactant, including pro- All clinical reports from the American Academy of Pediatrics phylactic versus rescue replacement, preparations and administration automatically expire 5 years after publication unless reaffirmed, techniques, the synergistic effects of surfactant and antenatal steroids, revised, or retired at or before that time. and surfactant therapy for respiratory disorders other than RDS. In PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). addition, the effect of CPAP on RDS and surfactant replacement and the Copyright © 2014 by the American Academy of Pediatrics

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TABLE 1 Meta-analyses of Surfactant Replacement: Prophylaxis and Rescue Treatment With prophylactic surfactant versus rescue 2,3,8,11 Animal-Derived and Synthetic Surfactant surfactant.14 However, when the studies Outcome Prophylactic Surfactant Rescue Surfactant that allowed for routine application of Animal Derived Synthetic Animal Derived Synthetic CPAP were included in the meta-analysis N RR (95% CI) N RR (95% CI) N RR (95% CI) N RR (95% CI) (National Institute of Child Health and Human Development SUPPORT Trial and Neonatal mortality 8 0.60 (0.47–0.77) 7 0.70 (0.58–0.85) 10 0.68 (0.57–0.82) 6 0.73 (0.61–0.88) Pneumothorax 9 0.40 (0.29–0.54) 6 0.67 (0.50–0.90) 12 0.42 (0.34–0.52) 5 0.64 (0.55–0.76) Vermont Oxford Network Delivery Room PIE 6 0.46 (0.36–0.59) 2 0.68 (0.50–0.93) 8 0.45 (0.37–0.55) 4 0.62 (0.54–0.71) Management Trial), the benefits of pro- a BPD 8 0.91 (0.79–1.05) 4 1.06 (0.83–1.36) 12 0.95 (0.84–1.08) 5 0.75 (0.61–0.92) phylactic surfactant on mortality (RR BPD/deatha 8 0.80 (0.72–0.88) 4 0.89 (0.77–1.03) 12 0.83 (0.77–0.90) 4 0.73 (0.65–0.83) 0.89; 95% CI 0.76–1.04) and air leak (RR N, number; PIE, pulmonary interstitial emphysema. a Defined at 28 d. 0.86; 95% CI 0.71–1.04) could no longer be demonstrated.5 Furthermore, infants receiving prophylactic surfactant had efficacy of the INSURE approach (intuba- born at less than 27 weeks’ gestation, tion, surfactant administration, and ex- may be increased with surfactant a higher incidence of BPD or death than tubation to CPAP) are reviewed. therapy. Surfactant replacement is did infants stabilized on CPAP (RR 1.12; 95% CI 1.02–1.24). Secondary analyses effective for larger and more mature of studies that did or did not use CPAP PRETERM INFANTS AND preterm infants with established RDS. SURFACTANT EFFECTIVENESS IN to stabilize infants demonstrated a trend to a lower risk of intraventricular CLINICAL TRIALS PROPHYLACTIC VERSUS RESCUE – SURFACTANT hemorrhage (RR 0.91; 95% CI 0.82 1.00) Surfactant trials have included infants and severe intraventricular hemorrhage born between 23 and 34 weeks’ ges- A prophylactic, or preventive, surfactant (RR 0.87; 95% CI 0.70–1.04) with pro- tation and/or with birth weight be- strategy is defined as intubation and phylactic surfactant. That finding cannot tween 500 and 2000 g.1–12 The results surfactant administration to infants at be explained; however, there was con- of subgroup analyses from such stud- high risk of developing RDS for the siderable heterogeneity in the trials in- ies indicated that surfactant therapy primary purpose of preventing wors- cluded in the meta-analysis. The risks of decreased mortality rates most effec- ening RDS rather than treatment of developing other complications of pre- tively in infants born at less than 30 established RDS; this has been oper- maturity, such as retinopathy of pre- weeks’ gestation or with birth weight ationalized in clinical studies as sur- maturity, patent ductus arteriosus, and <1250 g.12 In addition, surfactant re- factant administration in the delivery periventricular leukomalacia, were not placement reduced the incidence of room before initial resuscitation efforts significantly different. pneumothorax, pulmonary interstitial or the onset of respiratory distress or, When studies investigating infants born emphysema, and the combined out- most commonly, after initial re- at <30 weeks’ gestation were analyzed come of death or BPD, compared with suscitation but within 10 to 30 minutes separately,5 similar findings were no surfactant replacement12;these after birth. This contrasts with a rescue noted. However, there was a trend for findings suggest that lung injury is or treatment surfactant strategy, in an increased risk of chronic lung dis- mitigated after surfactant replace- which surfactant is given only to pre- ease in infants born at <30 weeks’ ment. The incidence of other medical term infants with established RDS. gestation who received prophylactic morbidities, such as BPD, intraven- Rescue surfactant is most often ad- surfactant (RR 1.13; 95% CI 1.00–1.28) tricular hemorrhage, necrotizing en- ministered within the first 12 hours and a significant increase in death or terocolitis, health care–associated after birth, when specified threshold chronic lung disease (RR 1.13; 95% CI infections, retinopathy of prematurity, 1.02–1.25) with use of prophylactic and patent ductus arteriosus, has not criteria of severity of RDS are met. surfactant. changed with surfactant replacement, The meta-analysis of studies conducted but this may be attributable, in part, before routine application of CPAP EARLY VERSUS DELAYED to the large reduction in mortality demonstrated a lower mortality rate SELECTIVE SURFACTANT with surfactant replacement ther- (relative risk [RR] 0.69; 95% confidence TREATMENT OF RDS apy.13 The onset of clinical signs of interval [CI] 0.56–0.85; number needed patent ductus arteriosus may occur to benefit [NNTB] 20) and a decrease in Although there are no statistically earlier, and the incidence of pulmo- the risk of air leak (RR 0.79; 95% CI significant benefits to prophylactic use nary hemorrhage, especially in infants 0.63–0.98) in preterm infants receiving of surfactant when compared with

PEDIATRICS Volume 133, Number 1, January 2014 157 Downloaded from www.aappublications.org/news by guest on September 29, 2021 prophylactic CPAP, several studies have CPAP without surfactant.15 When com- of surfactant protein B (SP-B). SP-B investigated whether administration of pared with the group of infants re- enhances the rate of adsorption of surfactant early in the course of receiving prophylactic surfactant and phospholipids at the air-water inter- spiratory insufficiency improves clini- continued ventilation, the RR of death face, is involved in the formation of tu- cal outcomes. Early rescue is defined or BPD was 0.78 (95% CI 0.59–1.03) for bular myelin, and has antiinflammatory as surfactant treatment within 1 to 2 the INSURE group and 0.83 (95% CI properties. However, it is unclear hours of birth, and late rescue is de- 0.64–1.09) for the CPAP group. How- whether significant differences in fined as surfactant treatment 2 or ever, in the nasal CPAP group, 48% clinical outcomes exist among the more hours after birth. A recent meta- were managed without intubation and available animal-derived products. analysis of early (within 2 hours) 54% without surfactant treatment. A A synthetic surfactant (lucinactant) that versus delayed surfactant treatment recent meta-analysis demonstrated contains a 21-amino acid peptide that concluded that the risks of mortality that prophylactic surfactant (with mimics SP-B activity has recently been (RR 0.84; 95% CI 0.74–0.95), air leak rapid extubation to CPAP) was associ- approved for the prevention and (RR 0.61; 95% CI 0.48–0.78), chronic ated with a higher risk of death or BPD treatment of RDS in preterm infants.18,19 lung disease (RR 0.69; 95% CI 0.55– (RR 1.12; 95% CI 1.02–1.24; number When compared with animal-derived 0.86), and chronic lung disease or needed to harm of 17) when compared surfactant (beractant or poractant), death (RR 0.83; 95% CI 0.75–0.91) were with early stabilization with CPAP and lucinactant was shown to be equiva- significantly decreased. There were no selective surfactant administration.5 In lent.18,19 Neonatal morbidities (intra- differences in other complications of infants with birth weight ≥1250 g and ventricular hemorrhage, periventricular prematurity.7 mild to moderate RDS, elective intuba- leukomalacia, pulmonary hemorrhage, tion and administration of surfactant sepsis, patent ductus arteriosus, ret- EARLY ADMINISTRATION OF decreased the need for mechanical ven- inopathy of prematurity, necrotizing SURFACTANT FOLLOWED BY BRIEF tilation but had no effect on the du- enterocolitis, and BPD) were not sig- VENTILATION AND EXTUBATION TO ration of oxygen therapy, ventilator nificantly different between preterm CPAP (INSURE STRATEGY) therapy, or hospital stay.16 infants treated with animal-derived The INSURE strategy is widely used surfactants and those treated with ANIMAL-DERIVED VERSUS throughout the world. In randomized synthetic surfactants. SYNTHETIC SURFACTANT clinical trials performed before 2008, SURFACTANT ADMINISTRATION the INSURE approach, compared with A wide variety of animal-derived and rescue surfactant administration in synthetic surfactants are available Surfactant administration strategies infants with RDS, was associated with commercially (Table 2); both are ben- have been based on manufacturer asignificantly reduced need for me- eficial as therapy for RDS in preterm guidelines for individual surfactants.1 chanical ventilation (RR 0.67; 95% CI infants. Animal-derived surfactants The dose of surfactant, frequency of 0.57–0.79) and a reduced need for ox- are modified or purified from bovine administration, and treatment proce- ygen at 28 days.6 In an analysis strati- or porcine lungs. Treatment with dures have been modeled after re- fied by fraction of inspired oxygen animal-derived surfactants (beractant search protocols. Furthermore, repeated requirement at study entry, a signifi- [Survanta; Abbvie Inc, North Chicago, doses of surfactants given at intervals cantly higher frequency of patent duc- IL], calfactant [Infasurf; ONY Inc, for predetermined indications have tus arteriosus was observed among Amherst, NY], and poractant [Curosurf; decreased mortality and morbidity infants in the rescue surfactant group, Chiesi Farmaceutici, Parma, Italy]) has compared with placebo or single who required a fraction of inspired several advantages over first-generation, surfactant doses.10 However, given the oxygen greater than 0.45 (RR 2.15; 95% protein-free synthetic surfactants long half-life for surfactant in preterm CI 1.09–4.23). The Vermont Oxford Net- (eg, colfosceril palmitate [Exosurf; infants with RDS,20 redosing should work Delivery Room Management Trial GlaxoSmithKline, Middlesex, UK]).3 not be needed more often than every (n = 648) randomly assigned infants These include lower mortality rates 12 hours, unless surfactant is being born at 26 to 29 weeks’ gestation to 1 (RR 0.86; 95% CI 0.76–0.98; number inactivated by an infectious process, of 3 treatment groups: prophylactic needed to harm of 40) and fewer meconium, or blood. Dosing intervals surfactant and continued ventilation, pneumothoraces (RR 0.63; 95% CI shorter than 12 hours recommended prophylactic surfactant and rapid ex- 0.53–0.75; NNTB 22).4 Animal-derived by some manufacturers are not based tubation to CPAP (INSURE), or nasal surfactants contain variable amounts on human pharmacokinetic data.

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TABLE 2 Composition and Dosage of Surfactants17 Surfactant Main Proteins Phospholipid Suggested Phospholipid per Phospholipids Concentration Dose Dose Animal-derived Beractant (Survantaa) minced bovine lung DPPC and PG (<0.1%) SP-B and (1%) 25 mg/mL 4 mL/kg 100 mg/kg extract SP-C Calfactant (Infasurfb) bovine calf lung lavage DPPC and PG (0.7%) SP-B and (1%) SP-C 35 mg/mL 3 mL/kg 105 mg/kg Poractant (Curosurfc) minced porcine lung DPPC and PG (0.6%)SP-B and (1%) SP-C 80 mg/mL 2.5 mL/kg and 100-200 mg/kg extract 1.25 mL/kg 100 mg/kg Synthetic Colfosceril (Exosurfd) DPPC (100%) None 13.5 mg/mL 5 mL/kg 67.5 mg/kg Synthetic, protein analog Lucinactant (Surfaxine) DPPC and POPG KL4 peptide as SP-B 30 mg/mL 5.8 mL/kg 175 mg/kg DPPC, dipalmitoyl phosphatidylcholine; PG, phosphatidylglycerol; POPG, palmitoyloleyl phosphatidylglycerol; SP-C, surfactant protein C. a Abbvie Inc, North Chicago, IL. b ONY Inc, Amherst, NY. c Chiesi Farmaceutici, Parma, Italy. d GlaxoSmithKline, Middlesex, UK. e Discovery Laboratories, Warrington, PA.

Surfactant administration procedures endotracheal tube occurred more of- All infants were maintained on CPAP. may be complicated by transient air- ten when the infusion technique was The administration of surfactant way obstruction, oxygen desaturation, used. Similar clinical outcomes were through a thin plastic catheter sig- bradycardia, and alterations in cere- also found when surfactant was ad- nificantly reduced the need for me- bral blood flow and brain electrical ministered as a bolus or as a 1-minute chanical ventilation and decreased activity. The delivery of surfactant can infusion through a side-hole adapter.24 the need for oxygen therapy at 28 also result in rapid improvement in Because data are conflicting and lim- days. More data are needed to rec- lung volume, functional residual ca- ited, the optimal method of surfactant ommend any of the alternative tech- pacity, and compliance. Thus, expedi- administration in preterm infants has niques for surfactant administration. tious changes in mechanical ventilator yet to be clearly proven. Additionally, settings may be necessary to minimize there is insufficient evidence to rec- SURFACTANT REPLACEMENT the risks of lung injury and air leak. ommend the optimal number of frac- THERAPY FOR RESPIRATORY Clinicians with expertise in these tional doses of surfactant or what DISORDERS OTHER THAN RDS procedures should be responsible for body position is best when surfactant surfactant administration whenever is administered. Surfactant inactivation and secondary dysfunction may occur with conditions surfactant is given. A number of alternatives to intratracheal such as meconium aspiration syndrome, Surfactant has traditionally been ad- administration of surfactant have been persistent pulmonary hypertension of ministered through an endotracheal evaluated in clinical trials.25–32 These the newborn, neonatal pneumonia, and tube either as bolus, in smaller aliquots,21 include use of aerosolized surfactant pulmonary hemorrhage.33,34 Surfactant or by infusion through an adaptor preparations, laryngeal mask airway- administration techniques, surfactant port on the proximal end of the en- aided delivery of surfactant, instillation dosage, patient populations, entry cri- dotracheal tube.19 In an animal model, of pharyngeal surfactant, and adminis- teria, and study outcomes in the small administration of surfactant as an in- tration of surfactant using thin intra- tratracheal bolus while disconnected tracheal catheters. Theoretically, each randomized trials and case series of from the mechanical ventilator re- of these methods could allow adminis- surfactant replacement in neonates fi sulted in more uniform distribution tration of surfactant without intubation with secondary surfactant de ciency 35–42 than an infusion administered over 30 in spontaneously breathing infants. In vary considerably. minutes through a side-hole adapter.22 a recent study, Göpel et al25 randomized Meconium aspiration syndrome with However, a small clinical trial of human 220 preterm infants born at 26 to 28 severe respiratory failure and persis- preterm infants showed no signifi- weeks’ gestation to receive either sur- tent pulmonary hypertension may be cant differences in clinical outcomes factant administered via a thin plastic complicated by surfactant inactivation. between methods.23 During surfac- catheter (using laryngoscopy) or surfac- Surfactant replacement by bolus or tant administration, reflux into the tant administered as a rescue therapy. slow infusion in infants with severe

PEDIATRICS Volume 133, Number 1, January 2014 159 Downloaded from www.aappublications.org/news by guest on September 29, 2021 meconium aspiration syndrome im- outcomes. In fact, the need for ECMO, exposed to antenatal steroids at 23 to proved oxygenation and reduced the the incidence of chronic lung disease, 25 weeks’ gestation.49 Infants born be- need for extracorporeal membrane and mortality rate were increased fore 32 weeks’ gestation who received oxygenation (ECMO) (RR 0.64; 95% CI with surfactant administration.41,42 both antenatal steroids and postnatal 0.46–0.91; NNTB 6).35 Surfactant did not surfactantwerefoundonsubgroup reduce mortality or decrease the fre- ANTENATAL STEROIDS AND analyses to have significant reductions quency of air leaks (pneumothoraces SURFACTANT REPLACEMENT in mortality, severity of respiratory dis- or pulmonary interstitial emphysema). tress, and air leaks when compared Surfactant trials that proved efficacy In a blinded randomized clinical trial of with subgroups that received neither were performed at a time when an- infants receiving ECMO, administration steroids nor surfactant, antenatal ste- tenatal steroid therapy was given in- of surfactant shortened the duration of roids only, or surfactant only.50–52 This frequently.43 By the late 1990s, most the ECMO. Notably, there were no finding corroborates evidence from an- mothers of preterm infants born at infants with congenital diaphragmatic imal models of RDS that the combina- less than 30 weeks’ gestation had re- hernia in that study.36 tion of antenatal steroids and postnatal ceived antenatal steroids (58% to surfactant improves lung function more Surfactant inactivation may be asso- 92%).44–46 Antenatal steroids signifi- than either treatment alone.53–55 ciated with pneumonia.37,38 In a small cantly reduce mortality (RR 0.62; 95% fi randomized trial of surfactant rescue CI 0.51–0.77; NNTB 23), RDS (RR 0.65; An important additional bene tofan- therapy, the subgroup of infants with 95% CI 0.47–0.75; NNTB 12), and sur- tenatal steroids is a reduction in risk sepsis showed improved oxygenation factant use in preterm infants (RR of intraventricular hemorrhage, an and a reduced need for ECMO com- 0.45; 95% CI 0.22–0.93; NNTB 9),47 most advantage not found with surfactant 56 pared with a similar group of control consistently in those born between 28 replacement alone. The effects of infants.37 Newborn infants with pneu- and 34 weeks’ gestation. antenatal steroids on other neonatal morbidities, such as necrotizing en- monia or sepsis receiving rescue surfac- Results of observational studies and terocolitis and patent ductus arterio- tant also demonstrated improved gas clinical trials have inferred that ante- sus, have been inconsistent. However, exchange compared with infants natal steroids may reduce the need for antenatal steroids have not signifi- without surfactant treatment. The prophylactic and early rescue surfac- cantly decreased the incidence of number of neonates who received tant replacement in infants born after BPD.50,51 surfactant for sepsis and pneumonia 27 to 28 weeks’ gestation,16,48 but no in these clinical reports is small, and randomized, controlled trials have CPAP AND SURFACTANT no recommendation can be made. addressed this issue. In infants born at Surfactant treatment of pulmonary or earlier than 27 weeks’ gestation, the Randomized clinical trials suggest that hemorrhage is plausible, because blood incidence of RDS is not reduced after nasal CPAP is acceptable as an alter- inhibits surfactant function. However, exposure to antenatal steroids; how- native to surfactant administration in only a few retrospective and observa- ever, in a recently published study, preterm infants with RDS. A clinical tional reports have documented the death or neurodevelopment impair- report from the American Academy of benefits of such therapy, and the mag- ment at 18 to 22 months was signifi- Pediatrics, “Respiratory Support of nitude of benefit remains to be estab- cantly lower for infants who had been the Preterm Infant,” is forthcoming.57 lished.39 Congenital diaphragmatic hernia may be associated with surfactant in- TABLE 3 Levels of Evidence59 sufficiency.40 Although measurements Recommendation LOE LOE Grade of Recommendation of disaturated phosphatidylcholine Preterm infants born at <30 wk of gestation who need 1 Strong Recommendation from lungs of infants with congenital mechanical ventilation because of severe RDS should be diaphragmatic hernia show synthetic given surfactant after initial stabilization. Using CPAP immediately after birth with subsequent selective 1 Strong Recommendation rates similar to those from infants surfactant administration should be considered as an without diaphragmatic hernia, pool alternative to routine intubation with prophylactic or early sizes and kinetics are altered.40 How- surfactant administration in preterm infants. Rescue surfactant may be considered for infants with hypoxic 2 Recommendation ever, surfactant treatment of a large respiratory failure attributable to secondary surfactant series of infants with congenital di- deficiency (eg, meconium aspiration syndrome or sepsis/ aphragmatic hernia did not improve pneumonia).

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SUMMARY OF SCIENCE hernia does not improve clinical or uncomfortable with surfactant outcomes (LOE 2). 1. Surfactant replacement, given as administration or managing an in- prophylaxis or rescue treatment, 8. Antenatal steroids and postnatal fant who has received surfactant reduces the incidence of RDS, air surfactant replacement indepen- should wait for the transport team leaks, and mortality in preterm dently and additively reduce mor- to arrive. infants with RDS (level of evidence tality, the severity of RDS, and air leaks in preterm infants (LOE 2). LEAD AUTHORS [LOE] 1). Richard A. Polin, MD, FAAP 2. Both animal-derived and newer CLINICAL IMPLICATIONS (TABLE 3) Waldemar A. Carlo, MD, FAAP synthetic surfactants with SP-B– like activity decrease acute respi- 1. Preterm infants born at <30 weeks’ COMMITTEE ON FETUS AND NEWBORN, 2012–2013 ratory morbidity and mortality in gestation who need mechanical ventilation because of severe RDS should Lu-Ann Papile, MD, FAAP, Chairperson preterm infants with RDS (LOE 1). Richard A. Polin, MD, FAAP be given surfactant after initial stabi- 3. Early rescue surfactant treatment Waldemar A. Carlo, MD, FAAP < lization (Strong Recommendation). Rosemarie Tan, MD, FAAP ( 2 hours of age) in infants with Praveen Kumar, MD, FAAP RDS decreases the risk of mortal- 2. Using CPAP immediately after birth William Benitz, MD, FAAP ity, air leak, and chronic lung dis- with subsequent selective surfactant Eric Eichenwald, MD, FAAP ease in preterm infants (LOE 1). administration should be considered James Cummings, MD, FAAP as an alternative to routine intuba- Jill Baley, MD, FAAP 4. Early initiation of CPAP with subse- tion with prophylactic or early sur- quent selective surfactant adminis- CONSULTANT factant administration in preterm tration in extremely preterm infants Roger F. Soll, MD, FAAP infants (Strong Recommendation). results in lower rates of BPD/death 3. Rescue surfactant may be consid- LIAISONS when compared with treatment – ered for infants with hypoxic respira- Tonse N. K. Raju, MD, FAAP National Institutes with prophylactic surfactant ther- of Health tory failure attributable to secondary apy (LOE 1). CAPT Wanda Denise Barﬁeld, MD, FAAP – Centers surfactant deﬁciency (eg, pulmonary for Disease Control and Prevention 5. Surfactant replacement has not hemorrhage, meconium aspiration Erin Keels, MSN – National Association of been shown to affect the incidence syndrome, or sepsis/pneumonia) Neonatal Nurses of neurologic, developmental, be- Anne Jefferies, MD – Canadian Pediatric Society (Recommendation). Kasper S. Wang, MD, FAAP – AAP Section on havioral, medical, or educational 4. Preterm and term neonates who Surgery outcomes in preterm infants (LOE 2). George Macones, MD – American College of are receiving surfactant should Obstetricians and Gynecologists 6. Surfactant treatment improves oxy- be managed by nursery and trans- genation and reduces the need for port personnel with the technical STAFF ECMO without an increase in mor- and clinical expertise to administer Jim Couto, MA bidity in neonates with meconium surfactant safely and deal with DISCLOSURES aspiration syndrome (LOE 2). multisystem illness. Therefore, pedi- Dr Carlo is on the Mednax Board of Directors. 7. Surfactant treatment of infants atric providers who are without ex- Dr Polin is a consultant for Discovery Labora- with congenital diaphragmatic pertise, or who are inexperienced tories.

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PEDIATRICS Volume 133, Number 1, January 2014 163 Downloaded from www.aappublications.org/news by guest on September 29, 2021 Surfactant Replacement Therapy for Preterm and Term Neonates With Respiratory Distress Richard A. Polin, Waldemar A. Carlo and COMMITTEE ON FETUS AND NEWBORN Pediatrics 2014;133;156 DOI: 10.1542/peds.2013-3443 originally published online December 30, 2013;

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