{"doi":"10.1111/apa.70342","title":"<scp>EBNEO</scp> Commentary: Permissive Hypotension in Preterm Infants—Is Masterly Inactivity the Right Approach?","abstract":"Cerebral autoregulation is the ability to maintain stable cerebral blood flow (CBF) despite fluctuations in mean arterial blood pressure (MABP). The critical closing pressure (CrCP) represents the MABP threshold below which CBF decreases. In preterm infants, autoregulatory capacity is limited, and MABP often approximates the CrCP. Consequently, CBF in this population is highly sensitive to both hypotension and blood pressure fluctuations induced by vasoactive agents [1]. Lower regional cerebral oxygen saturation (rScO2), measured by near-infrared spectroscopy (NIRS), may indicate cerebral hypoperfusion. Whether hypotension should be treated universally or only when accompanied by evidence of hypoperfusion remains an ongoing debate. Treatment of Hypotension of Prematurity (TOHOP) is a randomised trial by Alderlisten et al. that compared standard treatment (ST) (solely based on MABP < gestational age, GA in weeks in mmHg) to a perfusion-based permissive hypotension (PH) approach in preterm infants (24 0/7–29 6/7 weeks GA) [2]. Treatment was initiated in the PH group if there were signs of hypoperfusion (Figure 1) or MABP was < GA −5 in weeks. Interestingly, the indication for the initiation of treatment was MABP < GA −5 in weeks in the majority of the infants in the PH group rather than markers of poor perfusion (Figure 2). Essentially, this trial compared the initiation of treatment for hypotension for MABP in mmHg < GA in weeks vs. < GA −5 in weeks. The primary outcome of neurodevelopmental outcome at 24 months postmenstrual age (PMA) was similar between the groups. Additionally, infants in the PH group had less frequent initiation and shorter duration of inotrope treatment. However, infants in the PH group spent more time with lower rScO2 suggesting cerebral hypoperfusion and had nearly twice as many deaths (7.5% vs. 13%) that may be clinically significant. Overall, the study was underpowered (57% of projected enrollment) with potential for a Type II error. These findings are similar to a recent trial. The Hypotension in Preterm Infants (HIP) trial included infants < 28 weeks GA who were randomised to receive a saline bolus followed by dopamine infusion or 5% dextrose (Figure 3). The HIP trial reported no difference in survival to 36 weeks PMA without severe brain injury [3]. However, on long-term follow-up, survival without neurodevelopmental impairment was observed in 48% in the dopamine group and 25% in the placebo group, with an odds ratio of 2.79 (95% CI 0.89, 8.72), p = 0.078 [4]. This study was also not adequately powered. While the PH approach in the management of systemic hypotension in the first 72 h after birth is feasible and facilitates individualised care, its safety is uncertain with a possible risk of cerebral hypoperfusion and hypoxemia. After excluding causes such as blood loss and sepsis, stratifying “idiopathic” hypotension by chronological age at onset (≤ 6, 6–24, and 24–72 h) may be valuable when evaluating treatment strategies. In addition to weighing the risks of untreated hypotension, iatrogenic risks of blood pressure fluctuations associated with vasoactive medications should be carefully considered [5, 6]. Pending performance of adequately powered trials evaluating PH vs. ST approach in preterm infants, the use of GA in weeks as a MABP (in mmHg) cut-off for initiating dopamine appears to be a reasonable approach and is not associated with increased risk of death or negative long-term outcomes in TOHOP and HIP trials. URL LINK: https://ebneo.org/ebneo-commentary-permissive-hypotension-in-preterm-infants The authors declare no conflicts of interest. The data that support the findings of this study are available from the corresponding author upon reasonable request.","journal":"Acta Paediatrica","year":2025,"id":577812,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9588,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2025-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":279257,"name":"Satyan Lakshminrusimha","orcid":"0000-0001-6098-2155","position":1,"is_corresponding":false},{"id":435627,"name":"Heather Siefkes","orcid":"0000-0003-3325-2821","position":2,"is_corresponding":false},{"id":697764,"name":"Deepika Sankaran","orcid":"0000-0002-6704-6949","position":0,"is_corresponding":true}],"reference_count":6,"raw_metadata":null,"created_at":"2026-07-19T02:58:16.148027Z","pmid":"41085238","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}