To the Editor: We accolade the authors for their study on very-low-birth-weight (VLBW) mortality from tertiary care Indian setup [1]. However, a few concerns for the present study are summarized. Firstly, nearly 18% neonates of the enrolled neonates were treated with surfactant replacement therapy (SRT) for respiratory distress syndrome (RDS) and 60% of the SRT-treated RDS neonates were associated with mortality [1]. The present study aptly points out the ailments which contribute to high fatality rates amongst VLBW neonates. The burden of RDS mortality in developing countries is significant. From a public health point of view, the authors have suggested monitoring RDS-specific mortality in developing countries and evaluate causes of higher case fatality associated with RDS [2]. In line with these, monitoring the cause-specific neonatal mortality (e.g., RDS in preterm neonates) is one of the dashboard indicators of India Newborn Action Plan [3]. Since the present study enrolled only the inborn neonates, a physician-certified cause of deaths could have provided valuable data. Secondly, the study cohort’s fatality rate of the VLBW neonates is lower than published literature; an overall care improvement in India is possibly the most important reason [4]. It has been speculated that nearly 95% of the neonates with RDS can be managed with combined use of continuous positive airway pressure (CPAP), SRT, and invasive ventilation [2]. However, bridging the huge gap in neonatal survival with RDS between developing and developed nations remains a challenge. From an intensivist point of view, the literature suggests an improved diagnosis of persistent pulmonary hypertension of newborn (PPHN) in preterm neonates in the present era [5]. We believe PPHN is under-reported in the study and is possibly a hidden culprit contributing to higher fatality rates.