Surfactant administration in late preterm and term neonates: is LISA ready for routine use?

Minimally invasive surfactant administration, including less invasive surfactant administration (LISA) and minimally invasive surfactant therapy (MIST), is increasingly preferred in very preterm infants receiving non-invasive ventilation despite unresolved physiological and methodological questions regarding its benefits. Furthermore, evidence supporting its use in late preterm (LPT) and term neonates remains limited. This narrative review summarises physiological and clinical aspects and evidence on current surfactant administration methods in LPT and term infants based on relevant original studies, reviews, and international guidelines. Compared to very preterm infants, these relatively more mature infants differ significantly in respiratory pathophysiology, surfactant requirement, and procedural tolerance and are at limited risk of prematurity-related complications such as bronchopulmonary dysplasia and intraventricular haemorrhage. Potential risks of LISA/MIST in this population include procedural instability, need for sedation, surfactant reflux, airway obstruction, and uncertain surfactant distribution. Current evidence remains insufficient to support routine use of LISA/MIST in LPT and term neonates.

Until adequately powered randomised controlled trials are available, surfactant administration should be individualised and should be selected based on clinical context, infant stability, and available expertise.

• Minimally invasive surfactant administration techniques are often preferred in preterm neonates although physiological, methodological, and outcome-related uncertainties remain.

• Evidence for the use of appropriate surfactant replacement technique in late preterm and term neonates is sparse. Adequately powered randomised controlled trials are needed to determine the efficacy, safety, and patient selection criteria in this population.