title: What happens when the patent ductus arteriosus is treated less aggressively in very low birth weight infants?
abstract: OBJECTIVE
  It remains unclear whether indomethacin (INDO) and/or surgical ligation (LIGATE) are necessary to improve outcomes in premature infants with a patent ductus arteriosus (PDA). We have adopted a conservative approach to PDA management that emphasizes waiting for spontaneous closure unless certain cardiorespiratory distress criteria are met.
  
  
  METHODS
  This was a before-after observational study in infants born 501 to 1,500 g in two distinct epochs. Era 1 (January 2005 to December 2007) featured traditional management with INDO and LIGATE used early to close all moderate and large PDAs in infants receiving any respiratory support. Era 2 (January 2008 to June 2009) emphasized modest fluid restriction, watchful waiting and limited INDO and LIGATE to only those infants with large PDAs who met certain cardiorespiratory distress criteria.
  
  
  RESULTS
  Era 1 included 139 infants with a PDA, mean (s.d.) gestational age 27.5 (2) weeks; Era 2 72 infants, mean (s.d.) gestational age 27.5 (2) weeks. In Era 2, INDO use significantly decreased (79% of infants to 26%, P<0.001), and 28 day total fluids decreased (140 vs. 130  ml kg(-1) day(-1), P<0.001). LIGATE rate was 45% in Era 1, 33% in Era 2 (P=0.11). There were no significant differences in supplemental oxygen, nasal continuous positive airway pressure, or mechanical ventilation days. There were no significant differences in mortality or individual morbidities. The combined outcome of chronic lung disease (CLD) or mortality after Day 7 significantly increased (Era 1, 40%, Era 2, 54%, P=0.04). More infants were discharged home with a PDA in Era 2, but most resolved spontaneously and the need for closure therapy after discharge from the neonatal intensive care unit (NICU) did not increase. Multiple regression analysis demonstrated Era 2 management did not predict an increased risk of one or more interlinked morbidities.
  
  
  CONCLUSIONS
  Tolerance of the PDA with watchful waiting for spontaneous closure, modest fluid reduction, and less INDO use is a reasonable treatment strategy that is not associated with significant changes in NICU mortality or individual morbidities. We did note an increase in the combined outcome of CLD or mortality after Day 7, thus our investigation supports the urgency of a randomized controlled trial comparing traditional PDA management with a true control group similar to our Era 2 management to answer important questions of short and long-term outcomes.
authors.affiliation: Providence St Vincent Medical Center, Women and Children's Program, Neonatal Intensive Care Unit, Portland, OR, USA. joe@nnspc.com
authors.forename: J W
authors.initials: JW
authors.lastname: Kaempf
authors.forename: Y X
authors.initials: YX
authors.lastname: Wu
authors.forename: A J
authors.initials: AJ
authors.lastname: Kaempf
authors.forename: A M
authors.initials: AM
authors.lastname: Kaempf
authors.forename: L
authors.initials: L
authors.lastname: Wang
authors.forename: G
authors.initials: G
authors.lastname: Grunkemeier
mesh_terms: D006348:Cardiac Surgical Procedures / Q000379:methods / Q000401:mortality; D015331:Cohort Studies; D003131:Combined Modality Therapy; D016861:Cyclooxygenase Inhibitors / Q000008:administration & dosage / Q000627:therapeutic use; D004374:Ductus Arteriosus, Patent / Q000000981:diagnostic imaging / Q000188:drug therapy* / Q000401:mortality / Q000601:surgery*; D005260:Female; D005865:Gestational Age; D017052:Hospital Mortality / Q000639:trends*; D006801:Humans; D007213:Indomethacin / Q000009:adverse effects / Q000627:therapeutic use*; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight; D007363:Intensive Care Units, Neonatal; D008026:Ligation / Q000379:methods / Q000401:mortality; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016012:Poisson Distribution; D011237:Predictive Value of Tests; D011247:Pregnancy; D011379:Prognosis; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment; D015996:Survival Rate; D014463:Ultrasonography
chemical_list: D016861:Cyclooxygenase Inhibitors; D007213:Indomethacin