A new drug to improve perfusion in VLBW infants?

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Neonatology is littered with the skeletons of failed therapies inherited without validation from adult and pediatric medicine. Presently we are unsure what are acceptable blood pressures in VLBW infants and at a loss to know which drugs to use when we think perfusion or blood pressure needs pharmacologic support. Milrinone is frequently used to improve cardiac output but there was no information on dose, efficacy, or safety in preterm infants. Paradisis et al report in a pilot study the use of milrinone to support superior vena cava blood flow within the context of pharmacokinetics modeling to determine a dose regime for milrinone in VLBW infants. This study is exemplary in its use of physiologic assessments to evaluate drug dose in a pilot study, in contrast to the usual report of clinical responses to an agent using an unvalidated dose. This study is the appropriate first step in evaluating the efficacy and safety of milrinone in VLBW infants. The multiple gaps in our knowledge about the management of blood pressure in the preterm are highlighted by the editorial by Barrington and Dempsey.