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Dear Editor,

We read with interest the paper by Paul et al. that aimed to compare the effects of poractant alfa versus beractant on mortality and other morbidities in preterm infants less than 32 weeks gestation retrospectively.[1] They found no significant differences in the outcomes between two types of surfactants. Recently, we have prospectively evaluated the differences in clinical responses and short-term outcomes in 126 preterm infants with respiratory distress syndrome (RDS) randomised to treatment with poractant (n = 61) or beractant (n = 65).[2] Patients were followed until 40 weeks of corrected gestational age or death. Significantly, more patients in the beractant group required two doses of surfactant compared with the poractant group (31% vs. 12%, P = 0.023). Extubation rate within the first 3 days after surfactant administration was higher in the poractant group than in the beractant group (81% vs. 55.9%, P = 0,004). Post-treatment FiO2 requirement in the poractant group was significantly lower than in the beractant group on days 1, 3 and 5. Overall mortality and morbidities were similar between groups. Survival free of bronchopulmonary dysplasia (BPD) at the end of study period was 78.7% and 58.5% in poractant and beractant groups, respectively (P = 0.015).

As BPD is defined as the need for oxygen at 36 weeks' postmenstrual age and >28 days of age, infants who die within this period are excluded when determining BPD rates. This may result in exclusion of a subgroup with high frequency of respiratory problems and high risk of developing BPD if they lived longer. Therefore, we believe that ‘survival free of BPD’ is a more rational outcome, and we showed that poractant is more efficacious in this regard.

European Panel of expert neonatologists who developed consensus guidelines also reported updated recommendations on May 2013.[3] They stated that poractant alfa in an initial dose of 200 mg/kg has a survival advantage compared with 100 mg/kg of poractant alfa or 100 mg/kg beractant for treatment of RDS.

We propose that contradictory results in the study of Paul et al. and our study might be secondary to its retrospective nature and discrepancy of gestational ages in study groups as also stated by the authors.

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