What are the treatment options for ABA (Applied Behavior Analysis) and PDA (Patent Ductus Arteriosus) in pediatric patients?

Treatment of Patent Ductus Arteriosus (PDA) in Pediatric Patients

Device closure via transcatheter approach is the method of choice for PDA treatment in children and adults with suitable anatomy, achieving success rates exceeding 95% and complete closure approaching 100% in late-term follow-up. 1

Classification and Indications for Closure

The decision to close a PDA depends on hemodynamic significance rather than absolute size:

Class I Indications (Must Close):

• Left atrial and/or left ventricular enlargement indicating volume overload 2
• Pulmonary arterial hypertension (PAH) with net left-to-right shunting 2
• Prior history of endarteritis 2
• PAH with pulmonary artery pressure (PAP) <2/3 of systemic pressure OR pulmonary vascular resistance (PVR) <2/3 of systemic vascular resistance 2

Class IIa Indications (Reasonable to Close):

• Small asymptomatic PDA with continuous murmur but normal left ventricle and PAP 2
• PAH with PAP >2/3 systemic pressure or PVR >2/3 systemic vascular resistance BUT still demonstrating net left-to-right shunt (Qp:Qs >1.5) or pulmonary vascular reactivity on testing 2

Class III Indications (Must NOT Close):

• Eisenmenger physiology with net right-to-left shunt 2
• Silent duct (very small, no murmur, no hemodynamic consequences) 2
• Exercise-induced lower limb desaturation indicating shunt reversal 2

Treatment Algorithm by Age and Clinical Presentation

Preterm Infants:

Pharmacological Management is First-Line:

• Ibuprofen is preferred over indomethacin due to superior renal safety profile 1, 3, 4

  • Initial dose: 10 mg/kg IV, followed by two doses of 5 mg/kg at 24-hour intervals 1
  • Monitor renal function before and during treatment 1
  • Contraindications: renal dysfunction, active bleeding (especially intracranial or gastrointestinal) 1

• Indomethacin is an alternative but has higher risk of renal and gastrointestinal side effects 1, 3, 4

  • Avoid in patients with aspirin sensitivity or preexisting asthma 5
  • Monitor for GI bleeding, unexplained weight gain, or edema 5

• Serial echocardiograms are mandatory to monitor response; consider second course if first fails 1

• Surgical ligation is reserved for pharmacological failure in symptomatic cases 1

Term Infants, Children, and Adults:

Device Closure is the Method of Choice:

• Transcatheter device closure should be performed for all suitable anatomy 2, 1
  • Success rate exceeds 95% with complete closure approaching 100% 1
  • AMPLATZER Duct Occluder can close PDAs as large as 16 mm 1
  • Administer 50-100 U/kg unfractionated heparin at implantation 1

Surgical Closure is Indicated Only When:

• PDA is too large for device closure 2
• Distorted ductal anatomy precludes device closure (e.g., aneurysm or endarteritis) 2
• Calcified PDA in adults (consult ACHD interventional cardiologist first) 2
• Concomitant cardiac surgery is required for other indications 2
• Surgery must be performed by a surgeon experienced in congenital heart disease 2

Critical Diagnostic Workup Before Treatment

Echocardiography is the key diagnostic technique and must include: 2, 1

• Color Doppler in parasternal short-axis view for direct PDA visualization 1, 6
• Assessment of left ventricular volume overload (chamber size and function) 2, 6
• Transpulmonary gradient measurement with continuous-wave Doppler to estimate PAP 1, 6
• Right ventricular size and function to assess pressure overload 6
• Shunt direction and magnitude using color Doppler 6

Cardiac catheterization is indicated when: 2, 1

• PAP appears high on echocardiography to measure PVR 2, 6
• Determining operability in patients with PAH and PAP >2/3 systemic pressure 2, 6
• Echocardiography is non-diagnostic 1

Check oxygen saturation in all four extremities to detect differential cyanosis indicating right-to-left shunting 7

Common Pitfalls to Avoid

• Never close a PDA with Eisenmenger physiology (net right-to-left shunt), as this will cause acute right heart failure and death 2
• Do not rely on murmur alone; the continuous murmur disappears with development of severe PAH 2, 6
• Avoid NSAIDs (ibuprofen/indomethacin) in pregnant women at ≥30 weeks gestation due to risk of premature fetal ductus arteriosus closure 8
• Do not use indomethacin with diflunisal due to risk of fatal gastrointestinal hemorrhage 5
• Avoid prophylactic closure of silent ducts (very small, no murmur) as risks outweigh benefits 2

Post-Closure Follow-Up

• Patients can be discharged from follow-up once complete closure is documented by transthoracic echocardiography 2, 1
• Antibiotic prophylaxis is discontinued 6 months after PDA closure 2
• Follow-up approximately every 5 years for patients who received a device due to lack of long-term data 2
• For small PDAs without left-heart volume overload, routine follow-up every 3-5 years is recommended 1

---

Note on ABA (Applied Behavior Analysis)

Applied Behavior Analysis (ABA) is a behavioral therapy for autism spectrum disorder and is completely unrelated to Patent Ductus Arteriosus. 9, 10 The question appears to conflate two entirely separate medical topics. ABA uses principles of learning theory to improve specific behaviors through positive and negative reinforcement, and is the only intervention shown to produce comprehensive, lasting results in autism. 10 Treatment intensity (25-40 hours per week for young children) and early intervention are associated with better outcomes, with age moderating the relationship between treatment variables and behavioral mastery. 9