Prophylactic versus selective use of surfactant for preventing morbidity and mortality in preterm infants at risk of respiratory distress syndrome.

Summary

Across 10 RCTs (n=3151), prophylactic surfactant offered little to no benefit over selective administration in the context of early CPAP and antenatal steroids. Modern-era trials suggest a slight mortality increase with prophylaxis and no reduction in chronic lung disease at 36 weeks’ PMA.

Key Findings

• Across all studies, prophylactic surfactant likely makes little to no difference in chronic lung disease risk at 36 weeks’ PMA versus selective use (RR 1.13, 95% CI 1.00–1.28).
• Modern trials with antenatal steroids and early CPAP show a slight mortality increase with prophylaxis compared to selective administration.
• Earlier trials (pre-CPAP era) suggested reduced mortality and pneumothorax with prophylaxis, highlighting era-specific effects.

Clinical Implications

Prefer selective surfactant for infants stabilized on CPAP; avoid routine prophylactic intubation and surfactant administration. Tailor thresholds for selective treatment based on FiO2 and clinical status.

Limitations

• Most trials from the 1990s with performance/detection bias risk
• Heterogeneity in FiO2 thresholds and surfactant administration methods; limited data on aerosolized delivery

Future Directions

Conduct pragmatic, modern-era RCTs comparing selective strategies with standardized FiO2 thresholds and non-invasive delivery; evaluate long-term neurodevelopmental outcomes.