low blood flow state is defined as insufficient cardiac output to maintain adequate cellular metabolism at the organ level. A low blood flow state can be measured by reduced organ perfusion, such as reduced superior vena cava flow[1,2] or high resistance flow in superior mesenteric doppler scan [3]. The combination of capillary refill time of greater than 4 seconds and serum lactate greater than 4 mmol/litre has 97% sensitivity of identifying low blood flow state [4]. In the presence of the above markers of a low blood flow state, the blood pressure may be normal or high in the first 48hours of life due to high systemic resistance [5]. Therefore, high, or normal blood pressure should be interpreted with great caution. CONCLUSIONThe pharmacological treatment of a low blood flow state should be guided by thorough clinical assessment. The prophylaxis or stress dose hydrocortisone treatment of low flow state is gaining grounds mainly when there is evidence of adrenal insufficiency. The choice and titration of pharmacological treatment should be guided by functional echocardiography. The use of Dobutamine as first-line treatment is advised when myocardia dysfunction on echocardiography is noted.Milrinone use is reserved for extreme preterm neonates with myocardia dysfunction before patent ductus arteriosus ligation. Dopamine and noradrenaline remain the commonly used first and second-line vasopressors, respectively, to manage low blood flow states secondary to poor vasomotor resistance.