EBNEO COMMENTARY: REEVALUATING DOPAMINE FOR HYPOTENSION IN EXTREMELY PRETERM INFANTS: INSIGHTS FROM THE HIP TRIAL FOLLOW-UP

Narasimha Rao & H Gowda, from UK review the paper "Marlow N, Barrington KJ, ODonnell CPF, Miletin J, Naulaers G, Cheung PY, Corcoran JD, Khuffash E, Boylan GB, Livingstone V, Pons G, Straňák Z, Van Laere D, Macko J, Wiedermannova H, Dempsey EM; HIP consortium. Outcomes of extremely preterm infants who participated in a randomised trial of dopamine for treatment of hypotension (the HIP trial) at 2 years corrected age. Arch Dis Child Fetal Neonatal Ed. 2025 Jan 19:fetalneonatal-2024-327894. PMID: 39832819." for EbNeo.org.

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ACTA Commentary:

Acta Paediatrica - 2025 - Rao - EBNEO Commentary Reevaluating Dopamine for Hypotension in Extremely Preterm Infants .pdf

"Hypotension is common in extremely preterm infants, affecting nearly half of those weighing under 1000 g in the early postnatal period (1). However, there is no consensus on a definition, and thresholds for intervention vary widely. Many NICUs initiate treatment when mean arterial pressure (MAP) falls below gestational age in weeks (2). Dopamine is often used as first-line therapy and is effective in increasing MAP, though its long-term benefits remain uncertain (3,4).

 The Hypotension in Preterm Infants (HIP) trial was the first multicentre RCT to compare dopamine versus placebo in treating hypotension in infants under 28 weeks (5). The initial trial was stopped early due to recruitment challenges and found no significant difference in survival to 36 weeks without severe brain injury. The follow-up assessed 55 infants at 2 years of corrected age (6).

 Outcomes
• Primary Outcome:
Survival without neurodevelopmental impairment (NIDD) was 48% in the dopamine group compared to 25% in the placebo group (OR ~2.8, p=0.078). Although this difference was not statistically significant, the trend indicates potential benefits.
• Secondary Outcomes:
Rates of cerebral palsy, hearing or vision impairment, and Bayley-III cognitive and motor scores were similar across groups. However, dopamine-treated infants were significantly shorter and lighter at 2 years, raising concerns about growth suppression, potentially linked to dopamine’s known endocrine effects (7).

 These findings suggest that avoiding dopamine did not worsen neurodevelopmental outcomes in this small sample; however, a significant difference cannot be ruled out. The study raises two key clinical concerns: whether a restrictive approach may reduce survival without impairment, and whether dopamine may influence postnatal growth.

Clinical Implications

This study supports a nuanced approach to managing hypotension. In stable infants showing signs of adequate perfusion, the immediate use of dopamine can be safely deferred. The results emphasise the importance of evaluating systemic status (e.g., capillary refill, lactate, urine output) rather than focusing on an isolated BP value (8). However, the lower survival rate without impairment in the placebo group suggests that some infants might benefit from early inotropic support, indicating that a purely restrictive approach could be inadequate in specific cases.

The observed growth impairment also requires clinical attention. Practitioners should consider monitoring both growth and endocrine function in infants exposed to dopamine. If future research confirms this effect, it could influence vasopressor choice and treatment thresholds.

 Conclusion

The HIP trial follow-up underscores the complexity of managing hypotension in extremely preterm infants. While it does not provide definitive answers, it raises significant questions about long-term outcomes and emphasises the necessity for individualised care. Until larger trials offer clearer guidance, clinicians must carefully evaluate the potential benefits and risks of dopamine in the early neonatal period."