A randomized trial involving 653 extremely preterm infants found that conservative monitoring of patent ductus arteriosus produced equivalent outcomes to immediate pharmacological intervention with indomethacin or ibuprofen. The primary endpoint of death or bronchopulmonary dysplasia at 36 weeks occurred in similar rates between groups, challenging the reflexive treatment approach that has dominated neonatal intensive care. This finding represents a significant shift in pediatric cardiology thinking, where the persistent opening between the aorta and pulmonary artery was traditionally viewed as requiring urgent closure. The equivalence suggests that many preterm cardiovascular systems can naturally adapt to or resolve ductal patency without pharmaceutical intervention. For families facing NICU decisions, this evidence supports less aggressive approaches that avoid potential medication side effects including kidney dysfunction and gastrointestinal complications. The research adds to growing literature questioning early intervention paradigms in neonatal care. However, the study's focus on short-term respiratory outcomes leaves longer-term cardiovascular development questions unanswered, and individual patient factors may still warrant selective treatment in certain cases.