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. What is known: • Surfactant therapy is standard care for preterm neonatal RDS and reduces alveolar surface tension. • Surfactant proteins are essential for function, and exogenous surfactant improves respiratory outcomes and survival. What is new: • This review updates surfactant/protein biology and links it to current preparations and emerging formulations. • It summarizes evidence gaps and practical guidance on dosing, delivery, and monitoring to optimize surfactant use.
Marzban et al. (Sat,) studied this question.