Changing Management of the Patent Ductus Arteriosus: Effect on Neonatal Outcomes and Resource Utilization

Abstract

Objective This historical cohort study investigated how a shift toward a more conservative approach of awaiting spontaneous closure of the patent ductus arteriosus (PDA) in preterm infants has affected neonatal outcomes and resource utilization.

Methods We retrospectively studied very low birth weight infants diagnosed with a PDA by echocardiogram (ECHO) in 2006–2008 (era 1), when medical or surgical PDA management was emphasized, to those born in 2010–2012 (era 2) when conservative PDA management was encouraged. Multiple regression analyses adjusted for gestational age were performed to assess differences in clinical outcomes and resource utilization between eras.

Results More infants in era 2 (35/89, 39%) compared with era 1 (22/120, 18%) had conservative PDA management (p < 0.01). Despite no difference in surgical ligation rate, infants in era 2 had ligation later (median 24 vs. 8 days, p < 0.0001). There was no difference in clinical outcomes between eras, while number of ECHOs per patient was the only resource measure that increased in era 2 (median 3 vs. 2 ECHOs, p = 0.003).

Conclusion In an era of more conservative PDA management, no increase in adverse clinical outcomes or significant change in resource utilization was found. Conservative PDA management may be a safe alternative for preterm infants.

Keywords

patent ductus arteriosus - conservative management - preterm infant - outcomes - resource utilization - historical cohort

• References

• 1 Rolland A, Shankar-Aguilera S, Diomandé D, Zupan-Simunek V, Boileau P. Natural evolution of patent ductus arteriosus in the extremely preterm infant. Arch Dis Child Fetal Neonatal Ed 2015; 100 (01) F55-F58
• 2 Chorne N, Leonard C, Piecuch R, Clyman RI. Patent ductus arteriosus and its treatment as risk factors for neonatal and neurodevelopmental morbidity. Pediatrics 2007; 119 (06) 1165-1174
• 3 Kabra NS, Schmidt B, Roberts RS, Doyle LW, Papile L, Fanaroff A. ; Trial of Indomethacin Prophylaxis in Preterms Investigators. Neurosensory impairment after surgical closure of patent ductus arteriosus in extremely low birth weight infants: results from the Trial of Indomethacin Prophylaxis in Preterms. J Pediatr 2007; 150 (03) 229-234 , 234.e1
• 4 Pezzati M, Vangi V, Biagiotti R, Bertini G, Cianciulli D, Rubaltelli FF. Effects of indomethacin and ibuprofen on mesenteric and renal blood flow in preterm infants with patent ductus arteriosus. J Pediatr 1999; 135 (06) 733-738
• 5 Clement WA, El-Hakim H, Phillipos EZ, Coté JJ. Unilateral vocal cord paralysis following patent ductus arteriosus ligation in extremely low-birth-weight infants. Arch Otolaryngol Head Neck Surg 2008; 134 (01) 28-33
• 6 Benitz WE. Treatment of persistent patent ductus arteriosus in preterm infants: time to accept the null hypothesis?. J Perinatol 2010; 30 (04) 241-252
• 7 Kaempf JW, Wu YX, Kaempf AJ, Kaempf AM, Wang L, Grunkemeier G. What happens when the patent ductus arteriosus is treated less aggressively in very low birth weight infants?. J Perinatol 2012; 32 (05) 344-348
• 8 Jhaveri N, Moon-Grady A, Clyman RI. Early surgical ligation versus a conservative approach for management of patent ductus arteriosus that fails to close after indomethacin treatment. J Pediatr 2010; 157 (03) 381-387 , 387.e1
• 9 Jain A, Shah PS. Diagnosis, evaluation, and management of patent ductus arteriosus in preterm neonates. JAMA Pediatr 2015; 169 (09) 863-872
• 10 Mirea L, Sankaran K, Seshia M. , et al; Canadian Neonatal Network. Treatment of patent ductus arteriosus and neonatal mortality/morbidities: adjustment for treatment selection bias. J Pediatr 2012; 161 (04) 689-694.e1
• 11 Vanhaesebrouck S, Zonnenberg I, Vandervoort P, Bruneel E, Van Hoestenberghe MR, Theyskens C. Conservative treatment for patent ductus arteriosus in the preterm. Arch Child Fetal Neonatal 2007; 92: F244-F247
• 12 Finer NN, Carlo WA, Walsh MC. , et al; SUPPORT Study Group of the Eunice Kennedy Shriver NICHD Neonatal Research Network. Early CPAP versus surfactant in extremely preterm infants. N Engl J Med 2010; 362 (21) 1970-1979
• 13 Sehgal A, McNamara PJ. Echocardiographic markers of a haemodynamically significant ductus arteriosus. Congenit Cardiol Today. 2009; 7: 1-12
• 14 Chock VY, Punn R, Oza A. , et al. Predictors of bronchopulmonary dysplasia or death in premature infants with a patent ductus arteriosus. Pediatr Res 2014; 75 (04) 570-575
• 15 Chen S, Tacy T, Clyman R. How useful are B-type natriuretic peptide measurements for monitoring changes in patent ductus arteriosus shunt magnitude?. J Perinatol 2010; 30 (12) 780-785
• 16 Chock VY, Rose LA, Mante JV, Punn R. Near-infrared spectroscopy for detection of a significant patent ductus arteriosus. Pediatr Res 2016; 80 (05) 675-680
• 17 Wickremasinghe AC, Rogers EE, Piecuch RE. , et al. Neurodevelopmental outcomes following two different treatment approaches (early ligation and selective ligation) for patent ductus arteriosus. J Pediatr 2012; 161 (06) 1065-1072
• 18 Sung SI, Chang YS, Chun JY. , et al. Mandatory closure versus nonintervention for patent ductus arteriosus in very preterm infants. J Pediatr 2016; 177: 66-71.e1
• 19 Hagadorn JI, Brownell EA, Trzaski JM. , et al. Trends and variation in management and outcomes of very low-birth-weight infants with patent ductus arteriosus. Pediatr Res 2016; 80 (06) 785-792
• 20 Chen H-L, Yang R-C, Lee W-T. , et al. Lung function in very preterm infants with patent ductus arteriosus under conservative management: an observational study. BMC Pediatr 2015; 15: 167 . Doi: 10.1186/s12887-015-0480-y
• 21 Laughon MM, Langer JC, Bose CL. , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Prediction of bronchopulmonary dysplasia by postnatal age in extremely premature infants. Am J Respir Crit Care Med 2011; 183 (12) 1715-1722
• 22 Clyman RI. The role of patent ductus arteriosus and its treatments in the development of bronchopulmonary dysplasia. Semin Perinatol 2013; 37 (02) 102-107
• 23 Schmidt B, Davis P, Moddemann D. , et al; Trial of Indomethacin Prophylaxis in Preterms Investigators. Long-term effects of indomethacin prophylaxis in extremely-low-birth-weight infants. N Engl J Med 2001; 344 (26) 1966-1972