Surfactant use and outcomes in middle-income versus high-income countries

Preterm birth remains a leading cause of neonatal mortality, disproportionately affecting low-and middle-income countries (LMICs). Surfactant replacement therapy (SRT) is a key intervention for neonatal respiratory distress syndrome (RDS). However, due to cost and differing guidelines there are likely differences in SRT in different parts of the world. This study compared surfactant use, timing of administration, and associated neonatal outcomes in very low birth weight (VLBW) infants born in high-income countries (HICs) versus middle-income countries (MICs), with further analysis of public and private centers within MICs. This secondary analysis of prospectively collected data using the Vermont Oxford Network database included 271 826 inborn VLBW infants from 2018 to 23. Data were stratified by country income classification and ownership (public center vs. private center) in MICs. Surfactant use was highest in private MIC centers (64.1%), followed by HICs (55.3%), and public MIC centers (43.5%). Median time to first surfactant dose was shortest in private MIC centers (60 min) and longest in public MIC centers (120 min). Infants in HICs were more likely to receive delivery room continuous positive airway pressure and earlier surfactant. Survival post-SRT was highest in HICs (88.1%) and lowest in public MIC centers (69.5%) with sepsis being a particular problem in MICs. Disparities in the proportion of infants receiving SRT, the timing of doses, and neonatal outcomes such as mortality and sepsis rates persist between HICs and MICs, and between public and private sectors in MICs.