Assessing the Shifts: A 5-Year Analysis of Surfactant and Assisted Ventilation Trends in Neonatal Care in the United States (2016-2020)

Background: Respiratory distress syndrome is the most common cause of respiratory problems in preterm infants. Early nasal CPAP, combined with the INSURE method (INtubation-SURfactant-Extubation) as the primary respiratory support approach for preterm infants, has gained popularity over prophylactic surfactant with mechanical ventilation in recent years. Limited evidence exists to understand racial differences in resource usage among preterm infants. Objective: To investigate the trends, gender, and racial differences in the use of surfactant and assisted ventilation for > 6 hours among newborns in the United States. Methods: Using 2016-2020 population-based cohort data for all births from the Centers for Disease Control and Prevention’s WONDER natality database, we calculated rates, examined trends, and investigated gender and racial differences for surfactant use and assisted ventilation. Contingency tables analyses and Chi-square calculations were performed to detect differences between the groups with statistical significance set at p<.05. Results: Among >18 million newborn births, overall rates of surfactant use and assisted ventilation for the study period were 4.8 and 15.6 per 1000 live births, respectively. While surfactant use remained similar (p=.99), assisted ventilation rates increased from 13.6 to 17.8 per 1000 live births (p <.0001) during the study period. Subgroup analysis among term infants (37-42 weeks) showed statistically significant increases in surfactant use (4.3 to 5.1 per 1000 live births; p<.0001) and assisted ventilation (26.2 to 38.3 per 1000 live births; p< .0001). Late preterm infants (34-36 weeks GA) had increasing assisted ventilation rates (44 to 59 per 1000 live births; OR: 1.35; p<.0001) and trend toward lower surfactant use (11 to 10/1000 live births; OR: 0.95; p=.010) during the study period. Male and Black infants had the highest utilization rates of surfactant and assisted ventilation. Conclusion: Assisted ventilation rates steadily increased across all gestational ages, while surfactant use remained stable during the study period. Racial and gender differences exist for surfactant use and assisted ventilation needs. Contemporary trends toward “gentle” approaches in early respiratory management and guidelines for surfactant administration might have contributed to the changes in utilization rates. Clinicians and stakeholders should consider such information when allocating assets to hospitals and planning regional perinatal programs.