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

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Although a moderate-sized patent ductus arteriosus (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. Although 95% of neonatologists believe that a moderate-sized PDA should be closed if it persists in infants (born before 28 weeks) who still require mechanical ventilation, the number of neonatologists who treat a PDA when it occurs in infants who do not require mechanical ventilation varies widely. Both the high likelihood of spontaneous ductus closure and the absence of randomized controlled trials, specifically addressing the risks and benefits of neonatal ductus closure, add to the current uncertainty. New information suggests that early pharmacologic treatment has several important short-term benefits for the preterm newborn. By contrast, 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.

Section snippets

Incidence of Spontaneous Ductus Closure

Pulsed Doppler echocardiographic assessments of full-term infants indicate that functional closure of the ductus arteriosus occurs in almost 50% of the infants by 24 hours, in 90% by 48 hours, and in all by 72 hours after birth (Table 1). The rate of ductus closure is delayed in preterm infants; however, essentially in all healthy preterm infants (and 90% of those with respiratory distress syndrome) of ≥30 weeks' gestation, the ductus will close by the fourth day after birth. Preterm infants of

Surgical Ligation

Surgical ligation produces definitive ductus arteriosus closure; however, it is associated with its own set of morbidities: thoracotomy, pneumothorax, chylothorax, scoliosis, and infection.36 The incidence of unilateral vocal cord paralysis (which increases the requirements for tube feedings, respiratory support, and hospital stay) has been reported to be as high as 67% in infants with birth weights ≤1000 g, following PDA ligation.37, 38 Approximately 25%-30% of infants with birth weights ≤1000

PDA and Neonatal Morbidity: To Treat or Not to Treat

At this time, clear evidence is lacking for or against many of the current approaches to a PDA in the newborn period.7, 80, 81 Although indomethacin and ibuprofen have been shown to be effective in producing ductus closure,46 the long-term benefits of ductus closure on chronic lung disease, NEC, or survival have yet to be established.80, 82, 83, 84, 85 Published RCTs provide only a limited amount of information to help guide current PDA treatment choices. Unfortunately, most PDA-related RCTs

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    Supported in part by grants from U.S. Public Health Service (NIH grants HL46691 and HL109199), and by a gift from the Jamie and Bobby Gates Foundation.

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