The diagnosis and management of hypotension in neonates is a frequently encountered issue in the intensive care setting. There is an ongoing debate as to the appropriateness of blood pressure monitoring as an indicator of organ perfusion and tissue hypoxia. These ultimately determine morbidity and mortality in the sick newborn. This article explores the methods available for the assessment of organ perfusion and speculates on other means that may become available in the future. Different modalities of treatment currently in use are discussed, with the aim of using information gained from perfusion monitoring techniques to determine the optimal choice of therapy.