Surfactant therapy in neonatal care: advances, challenges, and practical considerations.

Surfactant therapy is a cornerstone of neonatal care for preterm respiratory distress syndrome (RDS). This review summarizes recent advances in surfactant therapy, focusing on surfactant composition and the clinical roles of surfactant proteins (SP-A, SP-B, SP-C, and SP-D), and highlights emerging strategies to optimize dosing and monitoring. We searched PubMed/MEDLINE, Embase, and the Cochrane Library for studies published between 2000 and 2025 using predefined keywords related to surfactant therapy, dosing, formulations, delivery techniques, monitoring, and outcomes. Evidence supports poractant alfa at an initial 200 mg/kg dose for improved early respiratory response and reduced need for re-treatment compared with lower dosing, and quantitative lung ultrasound is increasingly supported to guide surfactant timing and re-treatment decisions. Emerging innovations include SP-B/SP-C analog formulations and recombinant SP-D-based adjunct approaches, although several strategies remain investigational and require further validation.

Conclusion

Key ongoing challenges include optimizing dosing and delivery efficiency, harmonizing monitoring and outcome definitions across studies, and improving cost-effectiveness. Overall, this review provides an updated critical perspective on surfactant therapy and future directions toward more individualized neonatal respiratory care.