This Article Full Text Full Text (PDF) Submit a response Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via Web of Science (18) Citing Articles via Google Scholar Google Scholar Articles by Horbar, J. D. Search for Related Content PubMed PubMed Citation Articles by Horbar, J. D. Related Collections Premature & Newborn Social Bookmarking                         What's this?

PEDIATRICS Vol. 113 No. 6 June 2004, pp. 1593-1602

Timing of Initial Surfactant Treatment for Infants 23 to 29 Weeks’ Gestation: Is Routine Practice Evidence Based?

Jeffrey D. Horbar, MD^*,, Joseph H. Carpenter, MS, Jeffrey Buzas, PhD, Roger F. Soll, MD^*,, Gautham Suresh, MD^*, Michael B. Bracken, PhD^||, Laura C. Leviton, PhD^¶, Paul E. Plsek, MS#^#, John C. Sinclair, MD^**, for the members of the Vermont Oxford Network

^* Department of Pediatrics, University of Vermont College of Medicine, Burlington, Vermont
Vermont Oxford Network, Burlington, Vermont
Department of Mathematics and Statistics, University of Vermont, Burlington, Vermont
^|| Center for Perinatal, Pediatric and Environmental Epidemiology, Yale University, New Haven, Connecticut
^¶ Robert Wood Johnson Foundation, Princeton, New Jersey
^# Directed Creativity, Atlanta, Georgia
^** Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
Center for Clinical Research and Evidence-Based Medicine, University of Texas Medical School, Houston, Texas

Objective. To describe the timing of initial surfactant treatment for high-risk preterm infants in routine practice and compare these findings with evidence from randomized trials and published guidelines.

Methods. Data from the Vermont Oxford Network Database for infants who were born from 1998 to 2000 and had birth weights 401 to 1500 g and gestational ages of 23 to 29 weeks were analyzed to determine the time after birth at which the initial dose of surfactant was administered. Multivariate models adjusting for clustering of cases within hospitals identified factors associated with surfactant administration and its timing. Evidence on surfactant timing from systematic reviews of randomized trials and from published guidelines was reviewed.

Results. A total of 47 608 eligible infants were cared for at 341 hospitals in North America that participated in the Vermont Oxford Network Database from 1998 to 2000. Seventy-nine percent of infants received surfactant treatment (77.6% in 1998, 79.4% in 1999, and 79.6% in 2000). Factors that increased the likelihood of surfactant treatment were outborn birth, lower gestational age, lower 1-minute Apgar score, male gender, white race, cesarean delivery, multiple birth, or birth later in the study period. The first dose of surfactant was administered at a median time after birth of 50 minutes (60 minutes in 1998, 51 minutes in 1999, and 42 minutes in 2000). Over the 3-year study period, inborn infants received their initial dose of surfactant earlier than outborn infants (median time: 43 minutes vs 79 minutes). Other factors associated with earlier administration of the initial surfactant dose were gestational age, lower 1-minute Apgar score, cesarean delivery, antenatal steroid treatment, multiple birth, and small size for gestational age. In 2000, 27% of infants received surfactant in the delivery room. There was wide variation among hospitals in the proportion of infants who received surfactant treatment in the delivery room (interquartile range: 0%–75%), in the median time of the initial surfactant dose (interquartile range: 20-90 minutes), and in the proportion of infants who received the first dose >2 hours after birth (interquartile range: 7%–34%). Six systematic reviews of randomized trials of surfactant timing were identified. No national guidelines addressing the timing of surfactant therapy were found.

Conclusion. Although the time after birth at which the first dose of surfactant is administered to infants 23 to 29 weeks’ gestation decreased from 1998 to 2000, in 2000 many infants still received delayed treatment, and delivery room surfactant administration was not routinely practiced at most units. We conclude that there is a gap between evidence from randomized controlled trials that supports prophylactic or early surfactant administration and what is actually done in routine practice at many units.

---

Key Words: surfactant • very low birth weight • Vermont Oxford Network • evidence • respiratory distress syndrome • preterm delivery

Abbreviations: RDS, respiratory distress syndrome • NICU, neonatal intensive care unit • VON, Vermont Oxford Network • CI, confidence interval • RR, relative risk

---

Received for publication Sep 15, 2003; Accepted Oct 23, 2003.

CiteULike    Connotea    Del.icio.us    Digg    Facebook    Reddit    Technorati    Twitter    What's this?

This article has been cited by other articles:

				L V Rubenstein, S Hempel, M M Farmer, S M Asch, E M Yano, D Dougherty, and P W Shekelle Finding order in heterogeneity: types of quality-improvement intervention publications Qual. Saf. Health Care, December 1, 2008; 17(6): 403 - 408. [Abstract] [Full Text] [PDF]

				W. A. Engle and and the Committee on Fetus and Newborn Surfactant-Replacement Therapy for Respiratory Distress in the Preterm and Term Neonate Pediatrics, February 1, 2008; 121(2): 419 - 432. [Abstract] [Full Text] [PDF]

				D Acolet Quality of neonatal care and outcome Arch. Dis. Child. Fetal Neonatal Ed., January 1, 2008; 93(1): F69 - F73. [Abstract] [Full Text] [PDF]

				J L Hughes, E McCall, F Alderdice, J Jenkins, and for the members of the Neonatal Intensive Care Out More and earlier surfactant for preterm infants. Arch. Dis. Child. Fetal Neonatal Ed., March 1, 2006; 91(2): F125 - F126. [Abstract] [Full Text] [PDF]

				D. Acolet, D. Elbourne, N. McIntosh, M. Weindling, M. Korkodilos, J. Haviland, J. Modder, M. Macintosh, and on behalf of the Confidential Enquiry Into Materna Project 27/28: Inquiry Into Quality of Neonatal Care and Its Effect on the Survival of Infants Who Were Born at 27 and 28 Weeks in England, Wales, and Northern Ireland Pediatrics, December 1, 2005; 116(6): 1457 - 1465. [Abstract] [Full Text] [PDF]

				R. O Mainous A collaborative quality improvement intervention was effective for promoting use of surfactant therapy in preterm infants Evid. Based Nurs., July 1, 2005; 8(3): 90 - 90. [Full Text] [PDF]

				J Jenkins, F Alderdice, E McCall, and on behalf of the Neonatal Intensive Care Outcomes Improvement in neonatal intensive care in Northern Ireland through sharing of audit data Qual. Saf. Health Care, June 1, 2005; 14(3): 202 - 206. [Abstract] [Full Text] [PDF]

				L. C. Leviton and J. D. Horbar Cluster Randomized Trials for the Evaluation of Strategies Designed to Promote Evidence-Based Practice in Perinatal and Neonatal Medicine The ANNALS of the American Academy of Political and Social Science, May 1, 2005; 599(1): 94 - 114. [Abstract] [PDF]

				D. R. Neuspiel Collaborative Quality Improvement Leads to Better Preterm Care AAP Grand Rounds, January 1, 2005; 13(1): 8 - 8. [Full Text] [PDF]

				J. D Horbar, J. H Carpenter, J. Buzas, R. F Soll, G. Suresh, M. B Bracken, L. C Leviton, P. E Plsek, and J. C Sinclair Collaborative quality improvement to promote evidence based surfactant for preterm infants: a cluster randomised trial BMJ, October 30, 2004; 329(7473): 1004. [Abstract] [Full Text] [PDF]