The first 24 hours of a preterm infant’s life is often a period of cardiovascular instability. A complex relationship exists between the heart, brain and systemic and cerebral vasculature and in the immediate neonatal period in which low blood pressure, low systemic blood flow and low cerebral blood flow are common. The preterm infant is at risk of low systemic blood flow (and low blood pressure) due to a combination of intrinsic factors (immaturity of the preterm myocardium and vasculature) as well as extrinsic factors (including mechanical ventilation and vasoactive medications). Low systemic blood flow is common in preterm infants and contributes significantly to the perinatal brain injury, which manifests as peri/intraventricular haemorrhage (P/IVH) and white matter injury. These in turn contribute to the significant neurological and/or developmental disabilities in survivors that impact long term on their quality of life. This paper will look at the evidence currently available for the management of low systemic blood flow in preterm infants.