Patent Ductus Arteriosus: Are Current Neonatal Treatment Options Better or Worse Than No Treatment at All?

Abstract

Although a moderate-size PDA needs to be closed by the time a child is 1–2 years old, there is great uncertainty about whether it needs to be closed during the neonatal period. While 95% of neonatologists believe that a moderate-size PDA should be closed if it persists in infants (born before 28 weeks) who still require mechanical ventilation, the number that treat a PDA when it occurs in infants that do not require mechanical ventilation varies widely. Both the high likelihood of spontaneous ductus closure and the absence of RCTs, specifically addressing the risks and benefits of neonatal ductus closure, adds to the current uncertainty. New information suggests that early pharmacologic treatment has several important short-term benefits for the preterm newborn. On the other hand, ductus ligation, while eliminating the detrimental effects of a PDA on lung development, may create its own set of morbidities that counteract many of the benefits derived from ductus closure.

Persistent Ductus Arteriosus in Critically Ill Preterm Infants

“…Pegoli reported a PDA incidence of 80% in preterm infants with RDS and Smith [6] hypothesized that increased circulating prostaglandin E2 concentrations during RDS are responsible for ductus arteriosus persistence [61,62]. In agreement with data reported by other authors, the need for surfactant administration, which is taken to reflect the severity of RDS, was significantly increased in preterm infants with PDA after the first week of life (p=0.000), [16,28,35,36,49]. According to Clyman et al surfactant alters pulmonary vascular resistance, favouring early left-to-right shunting through the DA [49].…”

“…Prenatal corticosteroid prophylaxis decreases the risk for PDA [14,16,49,54,55], even if administered after chorioamnionitis [24]. In the present study, similar proportions of infants with and without PDA received prenatal corticosteroids, and even if more infants received a complete course, the difference between the two groups was not significant p>0.050.…”

“…[ [14,16]. Nor was any difference found between infants with and without PDA when comparing the mean ponderal index and the proportions of SGA infants even though SGA was reported in other studies as a risk factor for PDA [27,49].…”

“…In preterm infants, PDA is diagnosed significantly more often than in term infants, 40-60% according to gestational age in preterm infants [17,18,49] versus 57/10.000 live births in term infants [7,20], and is associated with considerably increased morbidity and mortality [14]. Functional closure of DA in preterm infants with GA≥30 weeks gestation occurs towards the fourth day of life, while in those with GA<30 weeks or with RDS the incidence of PDA is about 65% [5,19,51].…”

“…In the short term, PDA is associated with decreased blood pressure [5,8], decreased renal function [5], cardiac congestive failure [18,37,38], pulmonary haemorrhage [8,39], apnea and ventilator-dependency [6,38], bronchopulmonary dysplasia (BPD) [5,14,20,21,25,34,41,42], necrotizing enterocolitis (NEC) [8,9,11,19,20,34,39,43,44], intraventricular hemorrhage (IVH) [5,19,20,39,42,45,46], periventricular leukomalacia (PVL) [5], retinopathy of prematurity (ROP), cerebral palsy [24], delayed growth [11], and increased mortality rate [6,34,45,[47][48][49][50].…”