What is the recommended dose of surfactant (pulmonary surfactant) for newborns?

From the Guidelines

The recommended dose of pulmonary surfactant for newborns with respiratory distress syndrome (RDS) is typically 100-200 mg/kg of phospholipids, administered via endotracheal tube as a single dose, as supported by the most recent and highest quality study 1. The two main surfactant preparations used are beractant (Survanta) at 4 mL/kg and poractant alfa (Curosurf) at 2.5 mL/kg for the initial dose, with subsequent doses of 1.25 mL/kg if needed.

Key Considerations

• Administration should occur as soon as possible after birth for infants at risk of RDS, ideally within the first 2 hours of life, as early rescue surfactant treatment decreases the risk of mortality, air leak, and chronic lung disease in preterm infants 1.
• The surfactant should be warmed to room temperature before administration and given in small aliquots while temporarily disconnecting the ventilator, with the infant positioned to optimize distribution to all lung segments.
• Vital signs should be monitored during administration, and ventilator settings may need adjustment afterward as lung compliance improves.

Mechanism and Benefits

• Surfactant replacement works by reducing surface tension in the alveoli, preventing collapse during expiration, improving lung compliance, and enhancing gas exchange, which addresses the fundamental pathophysiology of RDS caused by surfactant deficiency in premature infants.
• Surfactant replacement has been shown to reduce the incidence of RDS, air leaks, and mortality in preterm infants with RDS, as well as improve oxygenation and reduce the need for ECMO in neonates with meconium aspiration syndrome 1.

Administration Techniques

• While the optimal method of surfactant administration has yet to be clearly proven, administration through an endotracheal tube either as bolus, in smaller aliquots, or by infusion through an adaptor port on the proximal end of the endotracheal tube are common practices, with clinicians needing to be aware of potential complications such as transient airway obstruction, oxygen desaturation, and alterations in cerebral blood flow 1.

From the FDA Drug Label

The initial dose was administered within 30 minutes of birth. If the patient remained intubated, repeat doses were administered every 12 hours (for up to a total of 3 doses). Each dose was divided in 2 equal aliquots and administered intratracheally in small bursts over 20 to 30 inspiratory cycles through a side port adapter into the proximal end of the endotracheal tube The recommended dose of INFASURF is 3 mL/kg (105 mg phospholipid/kg)

The recommended dose of surfactant for newborns is 3 mL/kg.

• The dose is administered intratracheally in small bursts over 20 to 30 inspiratory cycles.
• The initial dose is given within 30 minutes of birth.
• Repeat doses can be given every 12 hours, for a total of up to 3 doses 2

From the Research

Surfactant Dose for Newborns

The recommended dose of surfactant for newborns varies depending on the specific preparation and the individual patient's needs.

• A dose of 100-200 mg/kg is commonly used for preterm infants with respiratory distress syndrome (RDS) 3, 4, 5, 6.
• Some studies suggest that a higher initial dose of 200 mg/kg may be associated with improved outcomes, such as rapid weaning of FiO2 and decreased mortality 3, 4.
• The American Academy of Pediatrics and other organizations recommend the use of surfactant replacement therapy for preterm infants with RDS, but do not specify a particular dose.

Administration Methods

Different methods of surfactant administration have been studied, including:

• Intubation, surfactant administration, and extubation (INSURE) 7
• Minimally invasive surfactant therapy (MIST) 4
• These methods may have different effects on outcomes, such as hospitalization time and incidence of complications.

Specific Studies

• A study published in 2006 found that poractant alfa at a dose of 200 mg/kg was associated with improved outcomes in preterm infants with RDS 3.
• A 2022 study compared MIST with INSURE and found that MIST was associated with shorter hospitalization time and fewer complications 4.
• A 2020 study protocol described a planned study to compare the effects of low and high doses of surfactant on outcomes in preterm infants with RDS 5.
• A 1990 study found that a single dose of surfactant TA (100 mg/kg) was effective in reducing the severity of RDS and improving outcomes in preterm neonates 6.