The reduction in mortality and the increased ventilator-free days have important implications as very few trials in paediatric critical care suggest a favourable impact on mortality [28] . The present review suggests that surfactant could be an important adjunct in the management of paediatric respiratory failure. Uncertainty exists, however, about the reproducibility of treatment effects generated from relatively small unblinded trials; questions remain about adverse affects, which may be undetected or under-reported in this literature. Also, a large proportion of patients and events are reported in one trial [12] . Furthermore, issues of the optimal dose and the timing of administration, and which patients are most likely to derive benefit, should be studied in further adequately powered multicentre trials. The Pediatric Acute Lung Injury and Sepsis Investigators network is planning a large rigorous randomized trial enrolling children with acute hypoxemic respiratory failure to address these issues.