# PDA in Prematurity: Rethinking a Decades-Old Debate in 2026

## TL;DR

This paper reviews the ongoing debate on managing patent ductus arteriosus in premature infants, suggesting a shift toward conservative care due to limited benefits and risks of current interventions.

## Contribution

The paper advocates for a paradigm shift toward expectant management of PDA in preterm infants, based on recent evidence of limited intervention efficacy and potential harm.

## Key findings

- Pharmacological treatments for PDA closure show limited efficacy and significant systemic toxicity risks.
- Recent trials and meta-analyses find no clear clinical benefit from early active PDA treatment in preterm infants.
- Expectant management is increasingly supported due to high spontaneous closure rates and potential harm from interventions.

## Abstract

The management of patent ductus arteriosus (PDA) in premature infants remains a significant debate in neonatology. Interventions aimed at accelerating ductal closure, often using nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, are common practice. However, recent evidence increasingly challenges this approach. Pharmacological agents for PDA closure demonstrate limited efficacy and carry significant risks of systemic toxicity, affecting renal, gastrointestinal, vascular, and pulmonary systems. Multiple recent randomized controlled trials (RCTs) and meta-analyses have largely failed to demonstrate that early active treatment improves crucial clinical outcomes such as mortality, bronchopulmonary dysplasia (BPD), intraventricular hemorrhage (IVH), or necrotizing enterocolitis (NEC). Some studies even suggest potential harm, particularly an increased risk of BPD and mortality in vulnerable extremely preterm infants. Procedural closure methods (surgical ligation, transcatheter techniques), while achieving anatomical closure, also pose significant risks and lack evidence of improved clinical outcomes. Given the high rates of spontaneous PDA closure, especially in extremely preterm infants, and the lack of proven benefit alongside potential harm from interventions, a paradigm shift towards expectant or conservative management is gaining support. This approach emphasizes supportive care, minimizing interventions, and may be complemented by the judicious use of postnatal corticosteroids in selected infants with significant lung disease, which might indirectly facilitate ductal closure by addressing underlying inflammation.