The management of preterm infants with low blood pressure soon after birth remains unresolved. The definition of what constitutes low blood pressure is uncertain. At birth, mean blood pressure appears to be gestation specific and increases in the first few days of life. Antenatal steroids, delayed cord clamping, and the avoidance of mechanical ventilation are all associated with higher mean blood pressure and less hypotension after birth. Rates of hypotension of 15-50% have been reported in various studies of extremely preterm infants. However, only about 10% of all extremely preterm infants receive inotropes, suggesting that clinicians take into account other factors such as clinical, biochemical, and echocardiographic findings before deciding to intervene. The exact role of functional echocardiography in assessing the need for treatment of low blood pressure in extremely preterm infants remains to be determined. Near- infrared spectroscopy to assess cerebral perfusion may also have a role to play. Volume expansion (usually 10 mL/kg of saline) remains the most commonly used intervention for low blood pressure but evidence of benefit is lacking and there may be safety concerns. Whilst dopamine is the most commonly used inotropic drug, dobutamine, epinephrine, corticosteroids, milrinone, and vasopressin have also been utilised in preterm infants with low blood pressure. Clinical trials with long-term outcomes are needed to determine the most suitable inotrope and when to use it. Early hypotension differs from late hypotension with regard to cause, treatment, and outcome. A number of recent studies aimed at improving the evidence base for the treatment of early hypotension in extremely preterm infants have been terminated early because of poor recruitment. Currently, the answer to the question of what to do about low blood pressure in preterm infants remains unclear.

Lee J, Rajadurai VS, Tan KW: Blood pressure standards for very low birthweight infants during the first day of life. Arch Dis Child Fetal Neonatal Ed 1999;81:F168-F170.
Spinazzola RM, Harper RG, de Soler M, Lesser M: Blood pressure values in 500- to 750-g birthweight infants in the first week of life. J Perinatol 1991;11:147-151.
Watkins AM, West CR, Cooke RW: Blood pressure and cerebral haemorrhage and ischaemia in very low birthweight infants. Early Hum Dev 1989;19:103-110.
Hegyi T, Anwar M, Carbone MT, Ostfeld B, Hiatt M, Koons A, Pinto-Martin J, Paneth N: Blood pressure ranges in premature infants. II. The first week of life. Pediatrics 1996;97:336-342.
Hegyi T, Carbone MT, Anwar M, Ostfeld B, Hiatt M, Koons A, Pinto-Martin J, Paneth N: Blood pressure ranges in premature infants. I. The first hours of life. J Pediatr 1994;124:627-633.
Bada HS, Korones SB, Perry EH, Arheart KL, Ray JD, Pourcyrous M, Magill HL, et al: Mean arterial blood pressure changes in premature infants and those at risk for intraventricular hemorrhage. J Pediatr 1990;117:607-614.
Report of working group of the British Association of Perinatal Medicine and Neonatal Nurses Association on categories of babies requiring neonatal care. Arch Dis Child 1992;67:868-869.
Stranak Z, Semberova J, Barrington K, O'Donnell C, Marlow N, Naulaers G, Dempsey E; HIP consortium: International survey on diagnosis and management of hypotension in extremely preterm babies. Eur J Pediatr 2014;173:793-798.
Faust K, Hartel C, Preuss M, Rabe H, Roll C, Emeis M, Weig C, et al: Short-term outcome of very-low-birthweight infants with arterial hypotension in the first 24 h of life. Arch Dis Child Fetal Neonatal Ed 2015;100:F388-F392.
Batton B, Li L, Newman NS, Das A, Watterberg KL, Yoder BA, Faix RG, et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network: Evolving blood pressure dynamics for extremely preterm infants. J Perinatol 2014;34:301-305.
Laughon M, Bose C, Allred E, O'Shea TM, van Marter LJ, Bednarek F, Leviton A; ELGAN Study Investigators: Factors associated with treatment for hypotension in extremely low gestational age newborns during the first postnatal week. Pediatrics 2007;119:273-280.
Moise AA, Wearden ME, Kozinetz CA, Gest AL, Welty SE, Hansen TN: Antenatal steroids are associated with less need for blood pressure support in extremely premature infants. Pediatrics 1995;95:845-850.
Demarini S, Dollberg S, Hoath SB, Ho M, Donovan EF: Effects of antenatal corticosteroids on blood pressure in very low birth weight infants during the first 24 h of life. J Perinatol 1999;19:419-425.
Elimian A, Figueroa R, Spitzer AR, Ogburn PL, Wiencek V, Quirk JG: Antenatal corticosteroids: are incomplete courses beneficial? Obstet Gynecol 2003;102:352-355.
Been JV, Kornelisse RF, Rours IG, Lima Passos V, De Krijger RR, Zimmermann LJ: Early postnatal blood pressure in preterm infants: effects of chorioamnionitis and timing of antenatal steroids. Pediatr Res 2009;66:571-576.
Rabe H, Diaz-Rossello JL, Duley L, Dowswell T: Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev 2012;8:CD003248.
Kluckow M, Evans N: Relationship between blood pressure and cardiac output in preterm infants requiring mechanical ventilation. J Pediatr 1996;129:506-512.
Evans N, Kluckow M: Early determinants of right and left ventricular output in ventilated preterm infants. Arch Dis Child Fetal Neonatal Ed 1996;74:F88-F94.
Lakkundi A, Wright I, de Waal K: Transitional hemodynamics in preterm infants with a respiratory management strategy directed at avoidance of mechanical ventilation. Early Hum Dev 2014;90:409-412.
Gopel W, Kribs A, Ziegler A, Laux R, Hoehn T, Wieg C, Avenarius, et al; German Neonatal Network: Avoidance of mechanical ventilation by surfactant treatment of spontaneously breathing preterm infants (AMV): an open-label, randomised, controlled trial. Lancet 2011;378:1627-1634.
Dempsey EM, Al Hazzani F, Barrington KJ: Permissive hypotension in the extremely low birthweight infant with signs of good perfusion. Arch Dis Child Fetal Neonatal Ed 2009;94:F241-F244.
Batton B, Li L, Newman NS, Das B, Watterberg KL, Yoder BA, Faix RG, et al; Eunice Kennedy Schriver National Institute of Child Health and Human Development Neonatal Research Network: Use of antihypotensive therapies in extremely preterm infants. Pediatrics 2013;131:e1865-e1873.
Dietrich CF, Goudie A, Chiorean L, Cui XW, Gilja OH, Dong Y, Abramowicz JS, et al: Point of care ultrasound: a WFUMB position paper. Ultrasound Med Biol 2017;43:49-58.
Noori S, Seri I: Evidence-based versus pathophysiology-based approach to diagnosis and treatment of neonatal cardiovascular compromise. Semin Fetal Neonatal Med 2015;20:238-245.
Giesinger RE, McNamara PJ: Hemodynamic instability in the critically ill neonate: an approach to cardiovascular support based on disease pathophysiology. Semin Perinatol 2016;40:174-188.
Norozi K, Beck C, Osthaus WA, Wille I, Wessel A, Bertram H: Electrical velocimetry for measuring cardiac output in children with congenital heart disease. Br J Anaesth 2008;100:88-94.
Noori S, Drabu B, Soleymani S, Seri I: Continuous non-invasive cardiac output measurements in the neonate by electrical velocimetry: a comparison with echocardiography. Arch Dis Child Fetal Neonatal Ed 2012;97:F340-F343.
Weisz DE, Jain A, McNamara PJ, El-Khuffash A: Non-invasive cardiac output monitoring in neonates using bioreactance: a comparison with echocardiography. Neonatology 2012;102:61-67.
Song R, Rich W, Kim JH, Finer NN, Katheria AC: The use of electrical cardiometry for continuous cardiac output monitoring in preterm neonates: a validation study. Am J Perinatol 2014;31:1105-1110.
Aziz K PE, Robertson M: Is volume expansion beneficial in hypotensive very low birth weight neonates? Clin Res 1993;41:50A.
Bauer K, Buschkamp S, Marcinkowski M, Kossel H, Thome U, Versmold HT: Postnatal changes of extracellular volume, atrial natriuretic factor, and diuresis in a randomized controlled trial of high-frequency oscillatory ventilation versus intermittent positive-pressure ventilation in premature infants <30 weeks gestation. Crit Care Med 2000;28:2064-2068.
Dempsey EM, Barrington KJ: Treating hypotension in the preterm infant: when and with what: a critical and systematic review. J Perinatol 2007;27:469-478.
Goldberg RN, Chung D, Goldman SL, Bancalari E: The association of rapid volume expansion and intraventricular hemorrhage in the preterm infant. J Pediatr 1980;96:1060-1063.
Tammela OK, Lanning FP, Koivisto ME: The relationship of fluid restriction during the 1st month of life to the occurrence and severity of bronchopulmonary dysplasia in low birth weight infants: a 1-year radiological follow up. Eur J Pediatr 1992;151:367-371.
Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, et al; FEAST Trial Group: Mortality after fluid bolus in African children with severe infection. N Engl J Med 2011;364:2483-2495.
Dempsey EM, Barrington KJ, Marlow N, O'Donnell CP, Miletin J, Naulaers G, Cheung PY, et al; HIP Consortium: Management of hypotension in preterm infants (the HIP trial): a randomised controlled trial of hypotension management in extremely low gestational age newborns. Neonatology 2014;105:275-281.
Subhedar NV, Shaw NJ: Dopamine versus dobutamine for hypotensive preterm infants. Cochrane Database Syst Rev 2000;2: CD001242.
Osborn D, Evans N, Kluckow M: Randomized trial of dobutamine versus dopamine in preterm infants with low systemic blood flow. J Pediatr 2002;140:183-191.
Phillipos EZ, Barrington KJ, Robertson MA: Dopamine versus epinephrine for inotropic support in the neonate: a randomised blinded trial. Pediatr Res 1996;39:A238.
Evans N, Osborn D, Kluckow M: Mechanism of blood pressure increase induced by dopamine in hypotensive preterm neonates. Arch Dis Child Fetal Neonatal Ed 2000;83:F75-F76.
Pellicer A, Valverde E, Elorza MD, Madero R, Gava F, Quero J, Cabanas F: Cardiovascular support for low birth weight infants and cerebral hemodynamics: a randomized, blinded, clinical trial. Pediatrics 2005;115:1501-1512.
Paradisis M, Evans N, Kluckow M, Osborn D: Randomized trial of milrinone versus placebo for prevention of low systemic blood flow in very preterm infants. J Pediatr 2009;154:189-195.
Rios DR, Kaiser JR: Vasopressin versus dopamine for treatment of hypotension in extremely low birth weight infants: a randomized, blinded pilot study. J Pediatr 2015;166:850-855.
Pellicer A, Bravo MC, Madero R, Salas S, Quero J, Cabanas F: Early systemic hypotension and vasopressor support in low birth weight infants: impact on neurodevelopment. Pediatrics 2009;123:1369-1376.
Osborn DA, Evans N, Kluckow M, Bowen JR, Rieger I: Low superior vena cava flow and effect of inotropes on neurodevelopment to 3 years in preterm infants. Pediatrics 2007;120:372-380.
Bartels K, Moss DR, Peterfreund RA: An analysis of drug delivery dynamics via a pediatric central venous infusion system: quantification of delays in achieving intended doses. Anesth Analg 2009;109:1156-1161.
Schmidt N, Saez C, Seri I, Maturana A: Impact of syringe size on the performance of infusion pumps at low flow rates. Pediatr Crit Care Med 2010;11:282-286.
Seyberth HW, Kauffman RE: Basics and dynamics of neonatal and pediatric pharmacology. Handb Exp Pharmacol 2011;205:3-49.
Sherwin CM, Medlicott NJ, Reith DM, Broadbent RS: Intravenous drug delivery in neonates: lessons learnt. Arch Dis Child 2014;99:590-594.
van der Eijk AC, van Rens RM, Dankelman J, Smit BJ: A literature review on flow-rate variability in neonatal IV therapy. Paediatr Anaesth 2013;23:9-21.
Batton BJ, Li L, Newman NS, Das A, Watterberg KL, Yoder BA, Faix RG, et al; Eunice Kennedy Schriver National Institute of Child Health and Human Development Neonatal Research Network: Feasibility study of early blood pressure management in extremely preterm infants. J Pediatr 2012;161:65-69.e1.
Copyright / Drug Dosage / Disclaimer
Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher.
Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug.
Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.
You do not currently have access to this content.