First-Line Treatment for Patent Ductus Arteriosus in Children
Intravenous ibuprofen is the first-line pharmacological treatment for patent ductus arteriosus (PDA) in children, with a recommended initial dose of 10 mg/kg followed by two doses of 5 mg/kg given at 24-hour intervals. 1
Diagnosis and Assessment
- Before initiating treatment, confirm a hemodynamically significant PDA through echocardiography with color Doppler in the parasternal short-axis view 2, 3
- Measurement of the transpulmonary gradient across the ductus with continuous-wave Doppler can estimate pulmonary artery pressure 2
- In cases with significant elevation of pulmonary vascular resistance, cardiac catheterization and angiography may be indicated 2
Pharmacological Management
Ibuprofen Protocol
- Initial dose: 10 mg/kg intravenously 1
- Follow with two doses of 5 mg/kg given at 24-hour intervals 1
- Monitor renal function before and during treatment 1
- Assess for signs of bleeding or bruising during treatment 1
Advantages of Ibuprofen over Indomethacin
- Ibuprofen has fewer renal complications compared to indomethacin 4
- Ibuprofen causes less reduction in cerebral, renal, and mesenteric blood flow 5, 4
- No gastrointestinal complications have been reported with ibuprofen in controlled trials 4
Alternative Pharmacological Options
- Indomethacin is an alternative NSAID for PDA closure but has higher risk of renal and gastrointestinal side effects 1, 5
- Aspirin is significantly less effective than indomethacin for PDA closure (43% vs 92% closure rate) 6
Monitoring Response to Treatment
- Serial echocardiograms are recommended to monitor response to therapy 1
- If first course of medical therapy fails, consider a second course of medical therapy 3
Surgical Management
- Surgical closure is indicated when pharmacological treatment fails to close a symptomatic PDA 3
- Consultation with ACHD interventional cardiologists is recommended before surgical closure is selected, especially in cases with a calcified PDA 2
- Surgical ligation has been associated with increased risk of pneumothorax and retinopathy of prematurity compared to medical management 7
Catheter-Based Interventions
- For older children with suitable anatomy, device closure is usually feasible and preferred over surgical approaches 2
- During cardiac catheterization for PDA closure, it is standard practice to administer at least 50-100 U/kg UFH at the time of implantation 2
Caveats and Pitfalls
- Ibuprofen should be used cautiously in infants with renal dysfunction 1
- Avoid ibuprofen in infants with active bleeding, especially intracranial or gastrointestinal 1
- The efficacy of pharmacological treatment is influenced by timing of initiation of therapy - earlier treatment generally yields better results 5
- In very low birth weight infants, persistence of PDA is associated with significant morbidity and requires careful monitoring 3