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Letters
Survey of management of patent ductus arteriosus in neonatal units across England
  1. Anay Kulkarni,
  2. Justin Richards,
  3. Donovan Duffy
  1. Department of Neonatology, St George's Hospital NHS Trust, London, UK
  1. Correspondence to Dr Anay Kulkarni, Department of Neonatology, St George's Hospital NHS Trust, Blackshaw Road, London SW17 0QT, UK; kulkarni_anay{at}yahoo.co.uk

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We read with great interest the review ‘Patent ductus arteriosus: time to grasp the nettle’1 which highlighted the controversies in PDA management and variation in management. Evidence to support the routine closure of the ductus arteriosus to improve neonatal morbidity remains inconclusive.1 We recently conducted a survey on PDA management in neonatal units across England to understand current clinical practice.

A structured questionnaire (as shown in table 1) was emailed with an online hyperlink to consultant neonatologists working in tertiary neonatal units in England. The survey was conducted from August 2012 to November 2012.

Table 1

Survey questions

The response rate was 75%. The majority (68%) of neonatologists felt that a symptomatic strategy best describes their practice for treating PDA, while 25% felt that they practised a pre­symptomatic/echo-directed targeted strategy. Only two neonatologists (at the same unit) practice a prophylactic treatment strategy and two neonatologists felt that their practice does not fit in any of above categories. Significant variation was observed when percentage of preterm babies treated for PDA/year was compared within different units practising same symptomatic strategy (7%–75%). The drug of choice for treating PDA was ibuprofen for 74% of neonatologists, with only 26% using indomethacin.

Fluid intake is restricted in PDA by 18 neonatologists out of 63 (28%); 16 of these restrict fluids only in symptomatic babies, while two restrict fluid in all babies with PDA.

Most neonatologists continue feeds during medical treatment of a PDA with only six (10%) stopping. Just over half of neonatologists restrict fluids while treating baby for PDA (53%).

We asked a clinical question to all the neonatologists to understand the threshold for treatment, as outlined in table 1. Previously, a similar question was asked to neonatologists in the USA.2 Table 2 summarises the results in comparison to practice in the USA.

Table 2

Comparison of PDA management practice between neonatologists from United States of America and England

A second course of medical treatment is given by 80% neonatologists before ligating PDA, while 11% would give only one course of treatment before ligating the duct if baby has not responded. Of those that responded, only one neonatologist would give three courses of medical treatment before ligating, while five neonatologists felt that they would very rarely ligate a PDA in preterm babies (1–5/every 5 years).

Echocardiography was performed by 79% of neonatologists themselves to diagnose and treat PDA. In 46% of units, there is no cardiology service and the decision to treat PDA is made based on echocardiography findings of the neonatologists. In these units, babies require transfer to cardiology centre for cardiology input. On-site cardiology services are available in 18% of the units, with 20% of units having a paediatric cardiologist visiting twice a week. Two units get cardiology input within 24 h of request and a further two units have a paediatric cardiology visiting twice a month.

In conclusion, significant variations exist in practice amongst neonatologists when it comes to management of patent ductus arteriosus (PDA) in preterm babies. There are significant variations in the number of babies treated on different units by neonatologists claiming to follow same treatment strategy, suggesting different thresholds for treatment. The use of a prophylactic treatment strategy is becoming rare. Most of neonatologists do echocardiography themselves to make a decision regarding treatment of PDA, with a half of units responding not having access to specialist cardiology services on site.

References

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Footnotes

  • Contributors All authors contributed to the survey.

  • Competing interests None.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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