Animal-derived surfactants: where are we? The evidence from randomized, controlled clinical trials

Animal-derived surfactants, as well as synthetic surfactants, have been extensively evaluated in the treatment of respiratory distress syndrome (RDS) in preterm infants. Three commonly available animal-derived surfactants in the United States include beractant (BE), calfactant (CA) and poractant alfa (PA). Multiple comparative studies have been performed using these three surfactants. Prospective as well as retrospective studies comparing BE and CA have shown no significant differences in clinical or economic outcomes. Randomized, controlled clinical trials have shown that treatment with PA is associated with rapid weaning of oxygen and ventilatory pressures, fewer additional doses, cost benefits and survival advantage when compared with BE or CA. Recently, a study using an administrative database that included over 20,000 preterm infants has shown a significant decrease in mortality and cost benefits in favor of PA, when compared with BE or CA. Differences in outcomes between these animal-derived surfactants may be related to a higher amount of phospholipids and plasmalogens in PA. To date, animal-derived surfactants seem to be better than synthetic surfactants during the acute phase of RDS and in decreasing neonatal mortality. Further studies are needed comparing animal-derived surfactants with the newer generation of synthetic surfactants.