Management of patent ductus arteriosus in preterm neonates ≤32 weeks: a national survey of physician practices in Indian NICUs

Introduction: Patent Ductus Arteriosus is very common in preterm neonates ≤ 32 weeks gestation, and practice variations, particularly in high-income countries have been reported, with minimal reports from LMIC countries like India. We aim to determine the current physician practices prevalent in the management of preterm PDA in neonates ≤ 32 weeks, in India. Methods: This 25-question survey was sent to physicians working in in Level III, II, and I NICUs in India. Results: 238 neonatal physicians responded to the survey (response rate 57.8%), revealing that 81.5% worked in Level III units. 60% respondents had access to an echo machine in the NICU, while 13.9% did not have an echo machine in their units. 39.9% physicians reported being formally trained in neonatal echocardiography/proficient through experience, whereas 20.2% did not perform neonatal echocardiography. 40.7% respondents reported that echocardiography was performed by adult/ paediatric cardiologists. 62.2% preferred an 'early-symptomatic treatment' strategy, while 29.4% favoured an 'early-targeted treatment' approach for ELBW neonates. Paracetamol was the first-line drug choice for 80% respondents (intravenous preferred over oral), followed by oral Ibuprofen (16.4%). 57.6% clinicians repeated the same drug for the second course when needed, and a similar number performed an echo-reassessment after completion of the full treatment course. 68.9% attempted medical closure up to two times, whereas access to surgical closure was limited for 70.5% of physicians. Conclusions: Access to echocardiography machines has improved in the last few years in India, though, even now, less than half of our neonatal physicians are appropriately trained in performing neonatal echocardiography. Physicians prefer an 'early symptomatic treatment' strategy and use Paracetamol as the first-line management, which differs from international practices. Access to surgical options in Indian NICUs is limited. Though management approaches are similar among physicians, critical areas such as echo availability, access to advanced echo training, and surgical (device) closure of PDA still need improvement to ensure equitable and optimal care for neonates with HsPDA.