Adrianne R. Bischoff, Paula Dias Maia, Patrick J. McNamara
Despite decades of extensive investigation, the assessment and management of the patent ductus arteriosus (PDA) in preterm infants remain uncertain and controversial. To date, there is no universally accepted definition of a “hemodynamically significant PDA”, with existing studies varying in their reliance on clinical criteria, echocardiography parameters, or combined approaches - each with inherent limitations [ 1 , 2 , 3 , 4 ]. This heterogeneity extends to PDA screening, appraisal of shunt volume, management, and therapeutics, resulting in variable practices worldwide. Moreover, the relationship between the PDA and neonatal respiratory outcomes such as bronchopulmonary dysplasia, pulmonary vascular disease, pulmonary hypertension (PH), pulmonary hemorrhage, and overall mortality from respiratory failure remains unclear. Contemporary statements from leading pediatric societies and institutional clinical practice guidelines favor non-interventional or conservative approaches to PDA care [ 5 ]. These are driven by the recent results of randomized clinical trials (RCTs) and meta-analyses, which demonstrate a lack of clear benefit from available pharmacological treatments to close the PDA within the first 72 h in preterm neonates, along with concerns about potential harm [ 6 , 7 , 8 , 9 ]. The goal of this commentary is not to undermine the recently published RCTs of early ibuprofen, but to reframe their clinical relevance. While one may conclude that early ibuprofen is both ineffective and harmful, an alternative explanation is that the approach to treatment is based on an imprecise definition of PDA significance. It is the opinion of this group that what should be abandoned is the decision to treat the PDA based on an arbitrary threshold of PDA diameter >1.5 mm; instead, clinicians need to recognize that the most recent RCT data are not applicable to the practice of early intervention based on comprehensive characterization of shunt volume.