A neonatologist caring for an infant born at 26 weeks’ gestation and weighing 720 grams notes that the infant remains intubated and on high ventilator settings three days after birth. The presence of a wide pulse pressure and a continuous murmur raises concern for a hemodynamically significant patent ductus arteriosus (PDA).
Echocardiography confirms the diagnosis. Should the neonatologist manage this conservatively with watchful expectancy and close monitoring, or should pharmacologic closure with ibuprofen be initiated?
In term infants, the ductus arteriosus normally undergoes spontaneous closure soon after birth. However, in preterm infants, particularly those born extremely preterm, closure often is delayed. A PDA usually results in a left-to-right shunt, leading to increased pulmonary blood flow and systemic hypoperfusion.
The prolonged presence of a PDA has been associated with adverse outcomes such as bronchopulmonary dysplasia (BPD), necrotizing enterocolitis and even mortality. It remains uncertain, however, whether these outcomes are direct consequences of the PDA or are related to the broader comorbidities of prematurity.
Management of PDA has been debated since the 1970s, when surgical ligation and pharmacologic closure via prostaglandin inhibition were first described. Initially, widespread adoption of these interventions assumed that PDA closure would improve outcomes. However, randomized controlled trials failed to demonstrate significant benefits, leading clinicians to adopt a more conservative, permissive approach. In recent years, transcatheter closure has emerged as an alternative; its optimal timing and patient selection criteria remain uncertain.
The updated AAP clinical report Patent Ductus Arteriosus in Preterm Infants provides an evidence-based framework for managing hemodynamically significant PDAs. It reflects findings from multiple clinical trials and observational studies conducted since the prior clinical report was published in 2016.
The report, from the Committee on Fetus and Newborn and Section on Cardiology and Cardiac Surgery, is available at https://doi.org/10.1542/peds.2025-071425 and will be published in the May issue of Pediatrics.
Key considerations in PDA management
Clinical signs alone are insufficient to determine hemodynamic significance; echocardiography is necessary to assess characteristics and sequelae of a hemodynamically significant PDA.
Management strategies should include optimization of fluid balance, electrolytes and nutrition, as well as respiratory and cardiovascular support. Common approaches include fluid restriction, diuresis and the use of positive end-expiratory pressure and permissive hypercapnia.
Pharmacologic management
Systematic reviews indicate that prophylactic use of indomethacin, ibuprofen or acetaminophen within the first three days of life reduces the incidence of symptomatic PDA. However, these interventions do not improve survival or decrease the risk of BPD.
For confirmed PDA in the first two weeks of life, pharmacologic treatment is effective in closing the ductus but has not been shown to improve key outcomes compared to conservative management. A highly targeted approach incorporating hemodynamic screening and individualized therapy may hold promise but requires further study.
Procedural closure
Historically, PDA closure was performed surgically, but many centers now favor transcatheter device closure. The Amplatzer Piccolo Occluder and other devices have enabled successful transcatheter PDA closure in neonates, with new technologies and growing experience enhancing procedural safety. While these procedures effectively close the PDA, their impact on short-term outcomes (e.g., mortality, BPD, necrotizing enterocolitis) and long-term neurodevelopment require further investigation.
Key recommendations
Following are among the recommendations in the report for clinical practice and further research:
- Prophylactic medical treatment is not recommended at any gestational age or birth weight.
- Early closure (less than 14 days of life), whether pharmacologic, surgical or transcatheter, has not been shown to improve outcomes and is not recommended. A conservative approach awaiting spontaneous closure may reduce unnecessary exposure to medical or procedural interventions.
- Beyond two weeks of life, data guiding management of hemodynamically significant PDAs remain limited. The risks and benefits of conservative management, pharmacologic therapy, transcatheter closure and surgical ligation require further study.
- Many clinicians attempt medical closure with one or two courses of ibuprofen, with acetaminophen or indomethacin as acceptable alternatives. Transcatheter closure may be considered for infants with a persistent hemodynamically significant PDA beyond two weeks of life.
PDA management in preterm infants continues to evolve. While pharmacologic and procedural interventions can close the PDA, current evidence on major neonatal outcomes is limited. Ongoing clinical trials may provide critical data to refine best practices in PDA management.
Dr. Ambalavanan is a lead author of the report and a member of the AAP Committee on Fetus and Newborn. Lead authors Victor Y. Levy, M.D., M.S.P.H., FAAP, Arash Salavitabar, M.D., FAAP, and Susan W. Aucott, M.D., FAAP, contributed to this article.
