A very low birth weight (VLBW) neonate (birth weight 980 g, 29 weeks) develops feed intolerance at day 7 of life. Examination shows a new grade 3/6 continuous machinery murmur below the left clavicle, bounding peripheral pulses, wide pulse pressure, and hyperdynamic precordium. Echo confirms a haemodynamically significant PDA with large left-to-right shunt. Which is the CURRENT first-line pharmacological option for medical closure in most NICU protocols?

• A Indomethacin IV (non-selective COX inhibitor)
• B Ibuprofen IV or oral (preferential COX-2 inhibitor)
• C Furosemide IV to reduce pulmonary oedema from the shunt
• D Paracetamol (acetaminophen) IV or oral — inhibits prostaglandin synthesis via peroxidase enzyme ✓

Explanation

Paracetamol (acetaminophen) has emerged as the preferred first-line pharmacological option for PDA closure in many contemporary NICU protocols, replacing indomethacin and ibuprofen. Paracetamol inhibits prostaglandin synthesis via the peroxidase component of COX enzymes (a different mechanism from NSAIDs). It is equally effective to ibuprofen and indomethacin for PDA closure but has a significantly safer renal and cerebrovascular profile — indomethacin causes renal impairment, reduces cerebral and mesenteric blood flow, and can cause NEC; ibuprofen also has renal and pulmonary effects. Multiple meta-analyses now support paracetamol as the preferred agent.

Reference: Ghai Essential Pediatrics, 10th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.