Early protocol-based echocardiographic assessment and management of patent ductus arteriosus in infants less than 29 weeks' gestation.

OBJECTIVE: To evaluate whether a protocol-based patent ductus arteriosus (PDA) screening pathway using targeted neonatal echocardiography (TnECHO) is associated with improved outcomes in extremely preterm infants. DESIGN: Single-centre pre versus post cohort study comparing a non-standardised care epoch with a prespecified PDA screening and management pathway. SETTING: Tertiary neonatal intensive care unit, Riyadh, Saudi Arabia. PATIENTS: Inborn infants <29 weeks' gestation cared for before and after implementation of the PDA pathway (non-standardised care n=122; protocol-based care n=122). INTERVENTIONS: Introduction of a structured PDA screening protocol incorporating TnECHO within 72 hours of birth and physiology-guided management. MAIN OUTCOME MEASURES: Bronchopulmonary dysplasia (BPD), major intraventricular haemorrhage (IVH) and death before discharge. Multivariable logistic regression adjusted for sex, mode of delivery, plurality, antenatal corticosteroid exposure and gestational age. RESULTS: The protocol-based care epoch was associated with lower adjusted odds of BPD (aOR 0.43, 95% CI 0.25 to 0.75; p=0.003) and major IVH (aOR 0.27, 0.12 to 0.61; p=0.002). Mortality did not differ significantly (aOR 0.60, 0.30 to 1.22; p=0.158). PDA diagnosis increased with early structured screening (61% to 76%), but treatment rates remained stable, reflecting a physiology-guided approach. Treated infants in the protocol-based epoch demonstrated more clearly defined haemodynamic significance on echocardiography. Infants in the protocol-based epoch also required fewer days of invasive ventilation (median 23 to 10 days), and no surgical ligation procedures occurred. CONCLUSIONS: A protocol-based PDA screening pathway using early TnECHO was associated with lower adjusted odds of BPD and major IVH, reduced invasive ventilation days and no increase in PDA treatment, without a change in mortality. Because pre versus post observational designs remain susceptible to residual confounding and secular practice changes, findings should be interpreted as associations rather than causal effects. Prospective multicentre evaluations using standardised echocardiographic criteria are needed to assess pathway impact and inform PDA screening strategies.