Diuretics for Management of Bronchopulmonary Dysplasia Associated Pulmonary Hypertension in Preterm Infants—A Systematic Review

ABSTRACT

Bronchopulmonary dysplasia associated pulmonary hypertension (BPD‐PH) in preterm infants results from impaired pulmonary vascular development and contributes significantly to morbidity and mortality. Diuretics are commonly used to reduce pulmonary vascular congestion and improve oxygenation, but their efficacy and safety remain unclear. This systematic review aimed to evaluate the efficacy and safety of diuretic use in preterm infants with BPD‐PH. Primary outcomes were mortality and need for home respiratory support; secondary outcomes were echocardiographic and clinical parameters, and adverse effects such as hyponatremia, nephrocalcinosis. We searched MEDLINE, Embase, Cochrane Central, and ClinicalTrials.gov from inception to October 2025. We included randomized controlled trials (RCTs) and non‐randomized studies of interventions (NRSI) evaluating diuretics in preterm infants (< 32 weeks' gestation) with BPD‐PH diagnosed by echocardiography at 36 weeks postmenstrual age. Two reviewers independently performed data extraction and risk‐of‐bias assessment (ROBINS‐I). Outcomes were synthesized narratively, and a meta‐analysis was performed where sufficient data were available. Of 492 studies identified, 2 NRSI ( n  = 49) met inclusion criteria, both were at serious risk of bias. No RCTs exist on diuretics for BPD‐PH in preterm infants. Mortality, respiratory, discharge outcomes and adverse effects were reported inconsistently. Meta‐analysis of limited data demonstrated small improvements in echocardiographic markers, but the certainty of evidence was very low due to heterogeneity between the two included studies. To conclude, evidence supporting the use of diuretics in BPD‐PH in preterm infants remains limited and of low certainty. High quality studies are needed to better define their safety and efficacy.