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  • Letter to the Editor
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Is there evidence for a mortality difference between natural surfactants?

Journal of Perinatology volume 33, pages 161–162 (2013)Cite this article

Subjects

I read with interest the recent paper by Ramanathan et al.,1 that compared outcomes among neonates treated with different animal-derived surfactants. The authors’ conclusion that poractant alfa may offer a survival advantage over calfactant or beractant contradicts everything we understand about the biology of natural surfactants, and virtually all prospective clinical data we have gathered for the past 30 years. They base their conclusion on a retrospective review using a limited administrative data set, an approach with inherent weaknesses that makes such a paradigm-shifting claim untenable.

Their claim is not entirely new. The authors have previously published abstracts of portions of this data set, and presented their findings at a variety of forums since 2007. What is particularly concerning is that in the present article the authors have omitted important information previously presented that would underscore some of the weaknesses of the present study. Specifically,

  1. 1)

    In a previous abstract that reported from the same data source from January 2003 through June 2006 (overlapping the present report's data set by 2 years) the authors note that nearly 60% of the cases were omitted due to incomplete data.2 Omitting such a large number of cases precludes any reliable conclusions. In the present study the authors do not state how many cases were omitted.

  2. 2)

    In a previous but separate abstract that reported from the same data source as above, the authors found that neonatal intensive care unit and hospital lengths of stay (LOS) were significantly lower in poractant alfa-treated infants than in either beractant- or calfactant-treated infants.3 Shorter LOS coupled with lower mortality suggests that poractant alfa-treated infants were significantly more mature, less ill or both. This is consistent with a large retrospective database analysis published earlier this year4 (although not cited by the authors in the present study).

  3. 3)

    In the present study, the authors do not report LOS and do not case-adjust for LOS in any of their analyses. Although they attempt to adjust for case mix and mortality risk by All Patient Refined Diagnosis Related Groups this approach has not been validated for this type of study, particularly when a large percentage of the cases are omitted due to incomplete data.

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References

  1. Ramanathan R, Bhatia JJ, Sekar K, Ernst FR . Mortality in preterm infants with respiratory distress syndrome treated with poractant alfa, calfactant, or beractant: a retrospective study. J Perinatol 2013; 33: 119–125.

    Article  CAS  Google Scholar 

  2. Bhatia J, Saunders WB, Friedlich P, Lavin PT, Sekar KC, York JM et al. Differences in mortality among infants treated with three different natural surfactants for respiratory distress syndrome. E-PAS 2007; 617935.16 (abstract).

  3. Sekar KC, Bhatia J, Ernst FR, Saunders WB, Lavin PT, Ramanathan R . Resource use in preterm neonates with respiratory distress syndrome (RDS) treated with one of three difference natural surfactants: analyses using a large hospital discharge database. Acta Paediatr 2007; 96 (Suppl 456): 109 (abstract).

    Google Scholar 

  4. Trembath AN, Clark RH, Bloom BT, Smith PB, Bose C, Laughon M . Trends in surfactant use in the United States: changes in clinical practice. E-Journal Neo Res 2011; 1 (1): 23–30.

    Google Scholar 

  5. Holm B, Cummings JJ . Is there evidence for a mortality difference between exogenous surfactant preparations in neonatal RDS? J Appl Res 2008; 8 (2): 78–83.

    CAS  Google Scholar 

  6. Carnielli VP, Zimmermann LJ, Hamvas A, Cogo PE . Pulmonary surfactant kinetics of the newborn infant: novel insights from studies with stable isotopes. J Perinatol 2009; 29: S29–S37.

    Article  CAS  Google Scholar 

  7. Ramanathan R, Rasmussen MR, Gerstmann DR, Finer N, Sekar K, North American Study Group. A randomized, multicenter, masked comparison trial of poractant alfa (Curosurf) versus beractant (Survanta) in the treatment of respiratory distress syndrome in preterm infants. Am J Perinatol 2004; 21 (3): 109–119.

    Article  Google Scholar 

  8. Halliday HL, Tarnow-Mordi WO, Corcoran JD, Patterson CC . Multicentre randomized trial comparing high and low dose surfactant regimens for the treatment of respiratory distress syndrome (the Curosurf 4 trial). Arch Dis Child 1993; 69: 276–280.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Pediatrics and Physiology, East Carolina University, The Brody School of Medicine, Greenville, NC, USA

    J J Cummings

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  1. J J Cummings
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Correspondence to J J Cummings.

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Competing interests

Dr Cummings has served as a consultant for ONY, manufacturer of calfactant, and for Discovery Labs, manufacturer of lucinactant. He currently has no financial interests with any surfactant manufacturer.

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Cummings, J. Is there evidence for a mortality difference between natural surfactants?. J Perinatol 33, 161–162 (2013). https://doi.org/10.1038/jp.2011.196

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