Conservative Non-intervention Approach for Hemodynamically Significant Patent Ductus Arteriosus in Extremely Preterm Infants

Se In Sung,Misun Yang,So Yoon Ahn,Yun Sil Chang,Won Soon Park,Heui Seung Jo

doi:10.3389/fped.2020.605134

Abstract

While persistent patent ductus arteriosus (PDA) in preterm infants has been known to be associated with increased mortality and morbidities including bronchopulmonary dysplasia, and necrotizing enterocolitis, there is minimal evidence supporting their causal relationships, and most traditional medical and/or surgical treatments have failed to show improvements in these outcomes. As such, the pendulum has swung toward the conservative non-intervention approach for the management of persistent PDA during the last decade; however, the benefits and risks of this approach are unclear. In this mini review, we focused on whom, when, and how to apply the conservative non-intervention approach for persistent PDA, especially in extremely preterm infants.

Highlights

Persistent patent ductus arteriosus (PDA) in premature infants has been known to be associated with increased mortality and morbidities including bronchopulmonary dysplasia (BPD), and necrotizing enterocolitis (NEC) [1,2,3]; there is minimal evidence to support their causal relationship [3,4,5]
In our randomized controlled trial (RCT), the incidences of IVH in oral ibuprofen and non-intervention arms were 3 and 6%, respectively; and there was no pulmonary hemorrhage (PH) in both arms [38]. These findings suggest that prophylaxis alone is not enough for better therapeutic outcome of hemodynamically significant (HS) PDA, and that just applying the conservative non-intervention approach alone is not enough, but the accompanying meticulous neonatal intensive care is essential for the success of this approach [20, 38, 41, 54]
Despite the limitation of the previous studies including the retrospective nature of the study design, the seeming association between the presence and prolonged duration of HS PDA and mortality/morbidities may be primarily attributable to immaturity itself, and our data showing a favorable outcome of the conservative non-interventional approach for HS PDA in extremely preterm infants (EPTs) at least support the safety and feasibility of this approach over traditional medical/surgical treatments for managing HS PDA in EPTs [20]

Summary

INTRODUCTION

Persistent patent ductus arteriosus (PDA) in premature infants has been known to be associated with increased mortality and morbidities including bronchopulmonary dysplasia (BPD), and necrotizing enterocolitis (NEC) [1,2,3]; there is minimal evidence to support their causal relationship [3,4,5]. The risks and benefits of the conservative non-intervention approach still remain unclear with variable outcomes showing no effect [17,18,19], reducing [16, 20] or increasing bronchopulmonary dysplasia (BPD) incidence, or death compared with traditional medical/surgical therapies [9, 21] These controversial outcomes of the conservative non-intervention approach may be attributable to confounding PDA treatment indications or disease severity [16, 17, 19], bias of non-independent sampling [16, 17], or lack of patient stratification according to gestational age [9, 16, 21]. We focused on identifying those indicated for treatment, its optimal timing, and the method of applying the conservative non-intervention approach for HS PDA especially in extremely preterm infants (EPTs)

Conservative Approach for Preterm PDA

DISCUSSION

Findings

AUTHOR CONTRIBUTIONS