Challenges Faced in Translating the Benefits of Surfactant Replacement Therapy to a Resource-Limited Setting

Abstract

Aim To determine the challenges, if any, in translating the benefits of surfactant replacement therapy (SRT) to a resource-limited setting.

Method This was a retrospective descriptive study comparing the outcome of 75 cases who received surfactant and 69 controls who did not at the University Hospital of the West Indies during the period 2001 to 2011. Descriptive analyses were performed. Statistical significance was taken at the level p < 0.05.

Results Only 13% of neonates with respiratory distress syndrome received surfactant therapy. The median time of surfactant administration was 16.5 hours (interquartile range: 6–37 hours). The mean ± standard deviation time between repeat doses was 19.1 ± 14 hours. There was no difference in mortality between cases (67%) and controls (59%) (p = 0.32). However, the cases who survived were less mature (28.3 ± 2 weeks) and less clinically stable (CRIB II [Clinical Risk Index for Babies] score: 8.2 ± 3) than their controls who survived (30.0 ± 2 weeks; CRIB II score: 6.0 ± 3) (p = 0.01). There was no difference in mean gestational age or CRIB II scores between nonsurviving cases and controls. A high incidence of sepsis, pneumothoraces, and pulmonary hemorrhage was noted in both cases and controls.

Conclusion SRT did not improve the overall outcome in preterm neonates treated with RDS. Challenges encountered in optimizing SRT included affordability and accessibility of surfactant, supportive equipment, and supportive therapies, as well as a high incidence of complications related to prematurity.

Keywords

challenges of SRT in resource-limited settings - outcome of neonates with RDS in a resource-limited setting - SRT in neonates with RDS in resource-limited settings - SRT in low and- middle-income countries

• References

• 1 Rebello CM, Proença RS, Troster EJ, Jobe AH. Exogenous surfactant therapy--what is established and what still needs to be determined [in Portuguese]. J Pediatr (Rio J) 2002; 78 (Suppl. 02) S215-S226
• 2 Engle WA. ; American Academy of Pediatrics Committee on Fetus and Newborn. Surfactant-replacement therapy for respiratory distress in the preterm and term neonate. Pediatrics 2008; 121 (02) 419-432
• 3 Polin RA, Carlo WA. ; Committee on Fetus and Newborn; American Academy of Pediatrics. Surfactant replacement therapy for preterm and term neonates with respiratory distress. Pediatrics 2014; 133 (01) 156-163
• 4 Collaborative European Multicenter Study Group. Surfactant replacement therapy for severe neonatal respiratory distress syndrome: an international randomized clinical trial. Pediatrics 1988; 82 (05) 683-691
• 5 Liechty EA, Donovan E, Purohit D. , et al. Reduction of neonatal mortality after multiple doses of bovine surfactant in low birth weight neonates with respiratory distress syndrome. Pediatrics 1991; 88 (01) 19-28
• 6 Cooper PA, Saloojee H, Bolton KD, Mokhachane M. Survival of low-birth-weight infants at Baragwanath Hospital--1950-1996. S Afr Med J 1999; 89 (11) 1179-1181
• 7 Chotigeat U, Promwong N, Kanjanapattanakul W, Khorana M, Sangtawesin V, Horpaopan S. Comparison outcomes of surfactant therapy in respiratory distress syndrome in two periods. J Med Assoc Thai 2008; 91 (Suppl. 03) S109-S114
• 8 Verhagen AA, van der Meulen GN, Wiersma HE. , et al. Respiratory distress syndrome in Curaçao. Conventional versus surfactant treatment. West Indian Med J 2002; 51 (02) 68-73
• 9 Vidyasagar D, Velaphi S, Bhat VB. Surfactant replacement therapy in developing countries. Neonatology 2011; 99 (04) 355-366
• 10 Soll RF, Blanco F. Natural surfactant extract versus synthetic surfactant for neonatal respiratory distress syndrome. Cochrane Database Syst Rev 2001; (02) CD000144 . Doi: 10.1002/14651858.CD000144
• 11 Moya F. Synthetic surfactants: where are we? Evidence from randomized, controlled clinical trials. J Perinatol 2009; 29 (Suppl. 02) S23-S28
• 12 Parry G, Tucker J, Tarnow-Mordi W. ; UK Neonatal Staffing Study Collaborative Group. CRIB II: an update of the clinical risk index for babies score. Lancet 2003; 361 (9371): 1789-1791
• 13 Kirsten GF, Kirsten CL, Henning PA. , et al. The outcome of ELBW infants treated with NCPAP and InSurE in a resource-limited institution. Pediatrics 2012; 129 (04) e952-e959
• 14 Grupo Colaborativo Neocosur. Very-low-birth-weight infant outcomes in 11 South American NICUs. J Perinatol 2002; 22 (01) 2-7
• 15 Dani C, Corsini I, Bertini G, Fontanelli G, Pratesi S, Rubaltelli FF. The INSURE method in preterm infants of less than 30 weeks' gestation. J Matern Fetal Neonatal Med 2010; 23 (09) 1024-1029
• 16 Canadian Pediatric Society, Fetus and Newborn Committee Position Statement (FN2005–01). Recommendations for neonatal surfactant therapy. Paediatr Child Health 2005; 10 (02) 109-116
• 17 Duman N, Tüzün F, Sever AH. , et al. Nasal intermittent positive pressure ventilation with or without very early surfactant therapy for the primary treatment of respiratory distress syndrome. J Matern Fetal Neonatal Med 2016; 29 (02) 252-257
• 18 Ballot DE, Rothberg AD, Davies VA. The selection of infants for surfactant replacement therapy under conditions of limited financial resources. S Afr Med J 1995; 85 (07) 640-643
• 19 Boo NY, Puah CH, Lye MS. The role of expressed breastmilk and continuous positive airway pressure as predictors of survival in extremely low birthweight infants. J Trop Pediatr 2000; 46 (01) 15-20
• 20 Sankar MJ, Gupta N, Jain K, Agarwal R, Paul VK. Efficacy and safety of surfactant replacement therapy for preterm neonates with respiratory distress syndrome in low- and middle-income countries: a systematic review. J Perinatol 2016; 36 (Suppl. 01) S36-S48