Long-term neurodevelopmental outcome of preterm infants treated with "surfactant without intubation" procedure

Surfactant and antenatal corticosteroid therapies led to significant advancements in postnatal care. In 2001, a German center started applying a new technique for the administration of surfactant without intubation. The new procedure uses a thin endotracheal catheter during spontaneous breathing with nasal continuous positive airway pressure (nCPAP) in preterm infants with respiratory distress syndrome. This approach reduced mortality and short-term morbidity among children, as demonstrated in historical control studies, reduced the need for mechanical ventilation (MV) and additional intensive care procedures. Moreover, it was associated with a lower incidence of severe intraventricular hemorrhage and with less exposure to pain. Since these factors are assumed to improve long-term neurodevelopmental and behavioural outcomes, a follow-up study was carried out on 6-year-old children born prematurely (≤27 gestational age) who received "surfactant without intubation" (SWI) procedure.
In particular, a historical control cohort (n=47) was compared with an interventional (SWI) cohort (n=51), when the nCPAP method had become part of primary respiratory support. According to the overall results of different psychometric and neurological examinations, children were classified as showing no functional impairment, minor or major impairments.
Fifty-four out of 79 surviving children were assessed at a median age of 6 years and 5 months. Survival at 6 years was 88% in the interventional cohort and 72% in historical controls (p<0.05). Differences in overall neurodevelopmental outcome at 6 years of age between both cohorts did not reach statistical significance. Thirteen out of 31 (42%) babies in the interventional cohort and 8 out of 21 (38%) children in the historical cohort had no functional impairment. Sixteen (52%) vs. 9 (43%) showed minor impairments, and 2 (7%) vs. 4 (19%) showed major impairments. The influence of respiratory management on neurodevelopmental impairment was further assessed by comparing outcomes of infants stabilised on nCPAP to that of infants stabilised with intubation and MV. Logistic regression analysis showed that initial stabilisation with nCPAP was associated with a higher probability of having no functional impairment at follow-up (OR 5.22, 95% CI 1.02-26.72).
In conclusion, no differences were observed in terms of neurodevelopmental school age outcomes in children treated before and after the implementation of the nCPAP procedure. Though this follow-up study is limited by the lack of randomization or stratification and by the small number of available patients, these findings suggest that application of the SWI technique has not lead to any deterioration of long-term outcomes.

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