Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2025 Mar 18;20(3):e0309520.
doi: 10.1371/journal.pone.0309520. eCollection 2025.

Active versus restrictive approach to isolated hypotension in preterm neonates: A Systematic Review, Meta-analysis and GRADE based Clinical Practice Guideline

Viraraghavan Vadakkencherry Ramaswamy  1 , Gunjana Kumar  2 , Abdul Kareem Pullattayil S  3 , Abhishek S Aradhya  4 , Pradeep Suryawanshi  5 , Mohit Sahni  6 , Supreet Khurana  7 , Kiran More  8 ; National Neonatal Forum, India, Clinical Practice Guidelines Group on Neonatal Shock
Affiliations
Meta-Analysis

Active versus restrictive approach to isolated hypotension in preterm neonates: A Systematic Review, Meta-analysis and GRADE based Clinical Practice Guideline

Viraraghavan Vadakkencherry Ramaswamy et al. PLoS One. .

Abstract

Objective: Isolated hypotension (IH) without any clinical or biochemical features of poor perfusion is a common occurrence in very preterm infants (VPTI). There exists no recommendations guiding its management.The objective of this review was to compare the effect of active vs. restrictive approach to treat IH in VPTI.

Methodology: Medline, Embase and Web of Science were searched until 1st April 2024. RCTs and non-RCTs were included. Mortality, major brain injury (MBI) (intraventricular hemorrhage > grade 2 or cystic periventricular leukomalacia), mortality or neurodevelopmental impairment (NDI) at 18-24 months' corrected age were the critical outcomes evaluated.

Results: 44 studies were included: 9 were synthesized in a meta-analysis and 35 studies in the narrative review. Clinical benefit or harm could not be ruled out for the outcomes from the meta-analyses of RCTs. Meta-analysis of 3 non-RCTs suggested that active treatment of IH in VPTI of < 24 hours of life possibly increased the odds of MBI (aOR: 95% CI 1.85 (1.45; 2.36), very low certainty). Meta-analysis of 2 non-RCTs that had included VPTI < 72 hours indicated a possibly decreased risk of MBI (aOR: 95% CI 0.44 (0.24; 0.82), very low certainty) and NEC ≥ stage 2 (aOR: 95% CI 0.61 (0.41; 0.92), very low certainty) with active treatment of IH. Active treatment of IH in the first 24 hours possibly increased the risk of mortality or long-term NDI (aOR: 95% CI 1.84 (1.10; 3.09), very low certainty) and the risk of hearing loss at 2 years (aOR: 95% CI 3.60 (1.30; 9.70), very low certainty). Clinical benefit or harm could not be ruled out for other outcomes. There was insufficient evidence with respect to preterm neonates of ≥ 32 weeks.

Conclusions: IH may not be treated in VPTI in the first 24 hours. However, IH occurring between 24 hours - 72 hours of life may be treated. The evidence certainty was very low.

PubMed Disclaimer

Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. PRISMA flow.
Fig 2
Fig 2. Forest plot depicting the effect estimates from randomized controlled trials and non-randomized controlled trials for the various outcomes.
See this image and copyright information in PMC

References

    1. Dempsey EM, Barrington KJ, Marlow N, O’Donnell CPF, Miletin J, Naulaers G, et al.. Hypotension in Preterm Infants (HIP) randomised trial. Arch Dis Child Fetal Neonatal Ed. 2021;106(4):398–403. doi: 10.1136/archdischild-2020-320241 - DOI - PMC - PubMed
    1. Pereira SS, Sinha AK, Morris JK, Wertheim DF, Shah DK, Kempley ST. Blood pressure intervention levels in preterm infants: pilot randomised trial. Arch Dis Child Fetal Neonatal Ed. 2019;104(3):F298–305. doi: 10.1136/archdischild-2017-314159 - DOI - PubMed
    1. Batton B, Li L, Newman NS, Das A, Watterberg KL, Yoder BA, et al.. Use of antihypotensive therapies in extremely preterm infants. Pediatrics. 2013;131(6):e1865-73. doi: 10.1542/peds.2012-2779 - DOI - PMC - PubMed
    1. Dempsey EM, Barrington KJ. Treating hypotension in the preterm infant: when and with what: a critical and systematic review. J Perinatol. 2007;27(8):469–78. doi: 10.1038/sj.jp.7211774 - DOI - PubMed
    1. Batton BJ, Li L, Newman NS, Das A, Watterberg KL, Yoder BA, et al.. Feasibility study of early blood pressure management in extremely preterm infants. J Pediatr. 2012;161(1):65-9.e1. doi: 10.1016/j.jpeds.2012.01.014 - DOI - PMC - PubMed