Why Hospitals Do Not All Treat a Baby's Open Heart Vessel the Same Way

A plain-language look at the Gowda 2026 survey of written patent ductus arteriosus guidelines in 44 North American children's hospital newborn units

Many babies born very early have a small blood vessel near the heart, called the ductus arteriosus, that has not closed yet. Doctors do not fully agree on when to treat it, so a research team asked children's hospital newborn units to share their written plans. The plans share a general approach but differ in the details, and this survey looked only at documents, not at how babies fared.

Before birth, a small blood vessel helps a baby's blood bypass the lungs.

Before a baby is born, the lungs are filled with fluid and do not yet breathe air. A short blood vessel called the ductus arteriosus connects the main artery leaving the heart to the artery that goes to the lungs, letting most of the blood skip the lungs. After birth, the vessel usually closes on its own within days. In many very premature babies it stays open, a condition called patent ductus arteriosus, or PDA.

A small PDA may cause no trouble at all. A larger one can let extra blood flow toward the lungs, and doctors use the term hemodynamically significant PDA, or hsPDA, for a vessel that seems to be affecting the baby's circulation. Researchers have linked a duct that stays open for a long time to lung problems and to high blood pressure in the lungs [1][2]. A link is not the same as proof that closing the vessel fixes those problems, and that difference sits at the heart of the story.

For years the usual plan was to close the vessel, and then doctors began to ask whether that was always needed.

For many years the common approach was to close an open ductus. Doctors gave medicines called indomethacin or ibuprofen, and when medicine did not work, surgeons could tie off the vessel in an operation called surgical ligation. The idea was simple: an open vessel seemed harmful, so closing it seemed helpful.

Over time, doctors started to wonder whether every baby needed treatment. Some vessels close by themselves, and medicines and operations carry their own risks. That led to a different plan called expectant management, in which the baby is watched closely and treated only if needed. Researchers put the question to the test in carefully designed studies. One early study looked at treating moderate-to-large PDAs at one week of age [3]. The BeNeDuctus trial compared expectant management with early ibuprofen [4]. The Baby-OSCAR trial studied selective early treatment with ibuprofen [5]. The National Institute of Child Health and Human Development (NICHD) Neonatal Research Network ran a randomised trial of expectant management versus medication [6]. Reviewers have also combined results from several studies of active treatment versus expectant management [7], and a clinical report in the journal Pediatrics summarizes what is known about the PDA in preterm infants [8]. The sources we used do not spell out where each trial took place, so we leave that out.

All of this meant that hospitals had to decide how their own written plans should change. Because plans are written by local teams, it was not clear how much they agreed with each other. A group of children's hospitals had already looked at how they managed PDA in babies born between 23 and 32 weeks of pregnancy [9]. The next question was what their written plans actually said.

Researchers asked 44 children's hospital newborn units to share their PDA plans.

The Children's Hospitals Neonatal Consortium, often shortened to CHNC, is a group of 44 North American children's hospital newborn intensive care units (NICUs). A research team led by Gowda [10] emailed every one of them between November 2023 and February 2024 and asked for the written PDA guideline. Thirty-eight units answered, and 25 of those 38, about two-thirds, sent a written plan. Of the 38 that answered, the other 13 said they did not have one.

The team then counted how many of the 25 plans covered each of ten topics, such as which babies to check, when to treat, which medicine to use, and when to close the vessel with a device or an operation. It is important to be clear about what this kind of study is. It counts what is written in documents. It does not follow babies, and it cannot say which plan is best.

The plans agree on the basic steps, but they differ on when and how to check for a PDA.

The researchers found that most plans follow a step-by-step approach that mixes what doctors see in the baby with what an ultrasound of the heart, called an echocardiogram, shows [10]. Most plans described checking babies at risk or babies with symptoms. Many described signs that a PDA is affecting the baby, such as needing breathing support, and most listed measurements on the heart ultrasound, such as the width of the vessel.

The plans differ in the details. Some wanted the first ultrasound very early, within a day and a half for the smallest babies, while others waited until later in the first week or even the second week. The plans also differed in exactly what counted as a significant PDA. Getting a consistent measurement from an ultrasound is not simple, since two skilled people can measure the same tiny vessel slightly differently, and researchers have studied how repeatable such measurements are [11]. Experts have also argued that heart-and-circulation specialists should be woven into newborn care and research [12]. Other teams have explored checking early and treating only selected babies [13], and some are trying to predict which babies will not respond to medicine [14].

Ibuprofen was the most common first medicine, and closing the vessel with a catheter appeared in most plans.

Of the 25 plans, 6 recommended giving medicine to prevent a PDA in babies at highest risk. Thirteen offered medicine during the first week of life, and 21 described medicine for a vessel that stays open after the first week. Ibuprofen was the most common first choice, followed by acetaminophen, which is also called paracetamol, and then indomethacin. We do not list doses, because those belong in the hands of each baby's care team.

Only 9 of the 25 plans talked about expectant management, the watch-and-wait approach, and all 9 mentioned limiting the amount of fluid a baby receives. None of the plans recommended holding back feeds. Researchers have also studied how feeding during treatment with indomethacin relates to bowel problems in babies [15].

For babies whose vessel needs to be closed, 23 of the 25 plans described closing it through a thin tube guided to the heart, called transcatheter closure, and 19 of those 23 recommended trying medicine first. Twelve plans described surgery, and 4 of those 12 kept surgery for babies too small for the catheter approach. Only one plan said anything about care after surgery. A published guideline offers advice on closing the PDA with a procedure in premature babies [16]. The authors describe catheter closure as increasingly favored, though a single snapshot like this cannot show change over time.

Families can ask questions, and the survey has clear limits.

Parents of a baby with a PDA are often told a great deal in a short time. Without giving medical advice, some questions families sometimes find helpful to ask the care team include: How is the PDA being watched, and what will tell the team it is getting better or worse? Is watchful waiting an option for my baby, and why or why not? Which treatment is being considered, and what are its benefits and risks? Who will explain what the heart ultrasound shows? Because hospitals write their plans differently, hearing a different approach at another hospital does not necessarily mean either team is wrong.

The survey has limits worth knowing. It looked only at written plans, which may differ from what happens at the bedside. It included large children's hospitals and may not represent smaller hospitals. It ended collecting plans in early 2024, before some of the newest trial results, and it has no information on how babies did. Because the survey looked at paperwork and not at babies, it cannot tell families whether a particular hospital's plan is better or worse than another's. Even the numbers in the paper are not perfectly consistent: two figures appear in slightly different forms in the summary and in the main text, so we used the main text.

Researchers want better tests, clearer definitions, and long-term results.

The authors say future studies should work out the best time and way to check for a PDA, sharpen the definition of a significant PDA, and compare long-term outcomes of watchful waiting with active treatment [10]. Others are looking for ways to use ultrasound findings and a baby's risk factors to choose who truly needs medicine. These are the kinds of studies that could turn today's differences of opinion into clearer answers, and the authors stress that they are still needed. Until such evidence grows, hospitals will likely keep writing plans that share a framework but differ in the details.

The main message is shared steps with local differences, not a single right answer.

Twenty-five written plans from 38 hospitals that responded show a common step-by-step structure, along with differences in when to check, how to define a significant PDA, and when to treat. The survey did not test which approach gives babies better outcomes, so it cannot say whether one hospital is doing better than another. For families, the practical message is that questions are welcome, and that a care team can explain the reasoning behind the plan it follows.

References

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  2. Villamor E, et al. Patent ductus arteriosus and bronchopulmonary dysplasia-associated pulmonary hypertension: a Bayesian meta-analysis. JAMA Netw Open. 2023;6(11):e2345299. doi:10.1001/jamanetworkopen.2023.45299 ↩
  3. Clyman RI, et al. PDA-TOLERATE trial: an exploratory randomized controlled trial of treatment of moderate-to-large patent ductus arteriosus at 1 week of age. J Pediatr. 2019;205:41-48.e6. doi:10.1016/j.jpeds.2018.09.012 ↩
  4. Hundscheid T, et al. Expectant management or early ibuprofen for patent ductus arteriosus (BeNeDuctus trial). N Engl J Med. 2023;388(11):980-990. doi:10.1056/NEJMoa2207418 ↩
  5. Gupta S, et al. Trial of selective early treatment of patent ductus arteriosus with ibuprofen (Baby-OSCAR). N Engl J Med. 2024;390(4):314-325. doi:10.1056/NEJMoa2305582 ↩
  6. Laughon MM, et al. Expectant management vs medication for patent ductus arteriosus in preterm infants (the NICHD Neonatal Research Network PDA randomized clinical trial). JAMA. 2026;335(7):588-599. doi:10.1001/jama.2025.23330 ↩
  7. Buvaneswarran S, et al. Active treatment vs expectant management of patent ductus arteriosus in preterm infants: a meta-analysis. JAMA Pediatr. 2025;179(8):877-885. doi:10.1001/jamapediatrics.2025.1025 ↩
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  10. Gowda SH, Levy PT, Hamrick S, et al. Variations in diagnosis and management of hemodynamically significant patent ductus arteriosus across neonatal intensive care units in the Children's Hospitals Neonatal Consortium. J Perinatol. 2026; article s41372-026-02910-8 (published online 24 September 2026). doi:10.1038/s41372-026-02910-8 ↩
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