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Rabinowitz D, Dysart K, Itkin M. Neonatal lymphatic flow disorders: central lymphatic flow disorder and isolated chylothorax, diagnosis and treatment using novel lymphatic imaging and interventions technique. Curr Opin Pediatr 2022; 34:191-196. [PMID: 35102115 DOI: 10.1097/mop.0000000000001109] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Neonatal lymphatic disorders (NLDs) are conditions that are relatively rare and difficult to treat. The recent development of lymphatic imaging, such as Dynamic Contrast-Enhanced MR Lymphangiography and Intranodal Lymphangiography has led to a new, better understanding of the anatomical substrate and pathophysiological mechanisms of the diseases. Consequently, this has allowed the development of new targeted therapeutic interventions as well as prognostication for this population with lymphatic flow disorders. RECENT FINDINGS The underlying causes of all NLD is an obstruction or altered flow of the central lymphatic flow. Two types of NLD have been described: isolated neonatal chylothorax and central lymphatic flow disorder (CLFD). Isolated neonatal chylothorax can be treated successfully with oil-based contrast (lipiodol) embolization. CLFD secondary to obstruction of the thoraco-venous junction can be successfully treated with surgical thoracic duct-venous anastomosis. CLFD caused by elevated central pressure and/or thoracic duct dysplasia can be treated medically, including with new systemic therapies such as mammalian target of rapamycin inhibitors. SUMMARY New diagnostic and interventional tools have recently allowed for classification, prognostication, and targeted interventions for neonatal patients with lymphatic flow disorders. Further research will build on these discoveries.
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Affiliation(s)
- Deborah Rabinowitz
- Division of Interventional Radiology, Department of Medical Imaging, Nemours Children's Hospital, Delaware, Wilmington, Delaware
- Department of Radiology and Pediatrics, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kevin Dysart
- Division of Neonatal-Perinatal Medicine, Department of Neonatology, Nemours Children's Hospital, Delaware, Wilmington, Delaware
| | - Maxim Itkin
- Center for Lymphatic Imaging, Penn Medicine, Hospital of the University of Pennsylvania
- Department of Radiology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Resch B, Sever Yildiz G, Reiterer F. Congenital Chylothorax of the Newborn: A Systematic Analysis of Published Cases between 1990 and 2018. Respiration 2021; 101:84-96. [PMID: 34515211 DOI: 10.1159/000518217] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/28/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Congenital chylothorax (CCT) of the newborn is a rare entity but the most common cause of pleural effusion in this age-group. We aimed to find the optimal treatment strategy. MATERIAL AND METHODS A PubMed search was performed according to the PRISMA criteria. All cases were analyzed according to prenatal, perinatal, and postnatal treatment modalities and follow-ups. RESULTS We identified 753 cases from 157 studies published between 1990 and 2018. The all-cause mortality rate was 28%. Prematurity was present in 71%, male gender dominated 57%, mean gestational age was 34 weeks, and birth weight was 2,654 g. Seventy-nine percent of newborns had bilateral CCT, the most common associated congenital anomalies with CCT were pulmonary lymphangiectasia and pulmonary hypoplasia, and the most common chromosomal aberrations were Down, Noonan, and Turner syndromes, respectively. Mechanical ventilation was reported in 381 cases for mean 17 (range 1-120) days; pleural punctuations and drainages were performed in 32% and 64%, respectively. Forty-four percent received total parenteral nutrition (TPN) for mean 21 days, 46% medium-chain triglyceride (MCT) diet for mean 37 days, 20% octreotide, and 3% somatostatin; chemical pleurodesis was performed in 116 cases, and surgery was reported in 48 cases with a success rate of 69%. In 462 cases (68%), complete restitution was reported; in 34 of 44 cases (77%), intrauterine intervention was carried out. CONCLUSION Respiratory support, pleural drainages, TPN, and MCT diet as octreotide remain to be the cornerstones of CCT management. Pleurodesis with OK-432 done prenatally and povidone-iodine postnatally might be discussed for use in life-threatening CCT.
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Affiliation(s)
- Bernhard Resch
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria.,Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
| | - Gülsen Sever Yildiz
- Research Unit for Neonatal Infectious Diseases and Epidemiology, Medical University of Graz, Graz, Austria
| | - Friedrich Reiterer
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Graz, Austria
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Ngeow AJH, Chan MY, Teoh OH, Sanamandra SK, Chan DKL. Non-immune hydrops fetalis secondary to congenital chylothorax with diffuse interstitial lung disease: a diagnostic conundrum. BMJ Case Rep 2021; 14:14/4/e240688. [PMID: 33863770 PMCID: PMC8055142 DOI: 10.1136/bcr-2020-240688] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A Chinese male infant was born at 35 weeks weighing 2935 g to a mother with polyhydramnios and prenatal hydrops fetalis. He developed marked respiratory distress secondary to bilateral congenital chylothorax and required pleural drainage, high frequency oscillation and inhaled nitric oxide therapy. He was extubated to non-invasive ventilation by day 14. There was no bacterial or intrauterine infection, haematologic, chromosomal or cardiac disorder. He was exclusively fed medium-chain triglyceride formula. High-resolution CT showed diffuse interstitial lung disease. He received a dexamethasone course for chronic lung disease to facilitate supplemental oxygen weaning. A multidisciplinary team comprising neonatology, pulmonology, haematology, interventional radiology and thoracic surgery considered congenital pulmonary lymphangiectasia as the most likely diagnosis and advised open lung biopsy, lymphangiography or scintigraphy for diagnostic confirmation should symptoms of chylothorax recur. Fortunately, he was weaned off oxygen at 5 months of life, and tolerated human milk challenge at 6 months of life and grew well.
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Affiliation(s)
- Alvin Jia Hao Ngeow
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
| | - Mei Yoke Chan
- Haematology/Oncology Service, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Oon Hoe Teoh
- Respiratory Medicine Service, Department of Paediatrics, KK Women's and Children's Hospital, Singapore
| | | | - Daisy Kwai Lin Chan
- Department of Neonatal and Developmental Medicine, Singapore General Hospital, Singapore
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Liviskie CJ, Brennan CC, McPherson CC, Vesoulis ZA. Propranolol for the Treatment of Lymphatic Malformations in a Neonate - A Case Report and Review of Literature. J Pediatr Pharmacol Ther 2020; 25:155-162. [PMID: 32071591 DOI: 10.5863/1551-6776-25.2.155] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Lymphatic malformations in neonates often manifest as a chylothorax, and although rare, morbidity and mortality can be significant. First-line treatment with medium-chain triglyceride-enriched formulas, or enteric rest with total parenteral nutrition, are not always successful. We describe the case of a premature neonate with trisomy 21 who presented with bilateral pleural effusions and a pericardial effusion that worsened with the initiation of enteral nutrition. Clinical improvement was not seen until the initiation of treatment with oral propranolol at a maximum dosage of 0.5 mg/kg/day divided every 8 hours with extubation 8 days after propranolol initiation. Two case reports have described the use of propranolol in similar patients receiving 2 mg/kg/day; however, our experience is the first to report treatment success at a much lower dose. A review of the literature for alternative medication treatments uncovered numerous case reports and series documenting variable results with incongruent definitions of treatment success in a diverse patient population. The rarity of this disease state makes accrual of patients difficult and more robust treatment data unlikely. Therefore, selection of the optimal adjunctive treatment must be based on individual patient and disease state characteristics as well as safety and efficacy profile of the medication.
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Pollak M, Gur M, Bronshtein M, Solt I, Masarweh K, Bentur L. Incidence of congenital thoracic malformations detected by prenatal ultrasound. Pediatr Int 2020; 62:89-93. [PMID: 31705721 DOI: 10.1111/ped.14048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 09/09/2019] [Accepted: 11/01/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND The increased and earlier use of prenatal ultrasound has facilitated the detection of congenital thoracic malformations (CTMs). Our Pediatric Pulmonology Institute follows an increasing number of patients with CTMs. Thus, we aimed to evaluate and describe prenatal sonographic findings of CTM, and to estimate changes in detection rates of CTMs over a period of 16 years. METHODS A retrospective, cross-section analysis of prenatal ultrasound (US) screening tests carried out in a large community-based clinic, comparing two periods: 2001-2007 and 2007-2017. RESULTS A total of 34 716 prenatal US were performed at a median gestational age of 15.4 weeks (range, 11.6-23.9) and 15.7 weeks (range, 12-33.6) in 2001-2007 and 2007-2017, respectively. In 2001-2007, 12 016 prenatal US tests detected 19 CTMs, compared to 30 CTMs in 22 700 tests in 2007-2017. Detection rates did not change (1.58/1,000 in 2001-2007 versus 1.32/1,000 in 2007-2017, P = 0.64). The most common abnormality was congenital pleural effusion (CPE) (17 cases, 34.7%), followed by congenital pulmonary airway malformation) and congenital diaphragmatic hernia; 13 cases each, 26.5%. Twenty CTMs, mainly congenital diaphragmatic hernia and CPE, were associated with other fetal lesions. CONCLUSIONS Congenital diaphragmatic hernia and CPE tend to appear with multiple lesions and warrant further attention. The incidence rates stayed stable when comparing the last decade to previous years. Thus, the increased referral of CTM can be attributed to an increase in the number of prenatal screening studies performed, rather than a true higher incidence.
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Affiliation(s)
- Mordechai Pollak
- Pediatric Pulmonary Institute, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Department of Pediatrics, Bnei Zion Medical Center, Haifa, Israel
| | - Michal Gur
- Pediatric Pulmonary Institute, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Moshe Bronshtein
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Ido Solt
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel
| | - Kamal Masarweh
- Pediatric Pulmonary Institute, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Lea Bentur
- Pediatric Pulmonary Institute, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Liu J, Ren XL, Li JJ. POC-LUS guiding pleural puncture drainage to treat neonatal pulmonary atelectasis caused by congenital massive effusion. J Matern Fetal Neonatal Med 2020; 33:174-176. [PMID: 30244617 DOI: 10.1080/14767058.2018.1526921] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Point of care lung ultrasound (POC-LUS) has played important roles in diagnosing neonatal lung diseases and assisting in their treatment. A newborn infant with severe respiratory distress diagnosed as pulmonary atelectasis caused by congenital massive pleural effusion, whose consolidated lung recruitment after pleural puncture drainage under POC-LUS guidance. Lung ultrasound can be performed easily and timely at bed-side with free of radiation exposure, thus it should be used extensively in the neonatal department.
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Affiliation(s)
- Jing Liu
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
| | - Xiao-Ling Ren
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
| | - Jian-Jun Li
- Department of Neonatology and NICU, Beijing Chaoyang District Maternal and Child Healthcare Hospital, Beijing, China
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Neonatal Chylothoraces: A 10-Year Experience in a Tertiary Neonatal Referral Centre. Case Rep Pediatr 2019; 2019:3903598. [PMID: 31001445 PMCID: PMC6436362 DOI: 10.1155/2019/3903598] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 02/27/2019] [Indexed: 01/31/2023] Open
Abstract
Background Neonatal chylothorax is a rare condition, but has a high mortality. Study Objectives To analyse the outcomes of a series of neonates with chylothorax and review the literature to determine best practice. Design A case series review and a literature review using electronic databases including the key words neonates and chylothorax. Results Six cases of neonatal chylothorax were identified during a ten-year period, two had congenital chylothoraces and four iatrogenic chylothoraces after thoracic surgery or chest instrumentation. The neonates were ventilated for a median of 30 (range 13–125) days with a median maximum daily pleural fluid output of 218 (range 86–310) ml/kg/day. All the neonates were given medium-chain triglyceride (MCT) feeds which stabilised pleural fluid output in four and reduced it in another. Octreotide was used in three neonates, but the dosage used had no significant effect on pleural output. Two neonates required surgical intervention. The literature review demonstrated MCT feeds can reduce or stabilise pleural fluid output, but highlighted variable use of octreotide and inconsistent dosing regimens and outcomes. No consensus regarding indications for surgical intervention was identified. Summary and Conclusion Neonatal chylothorax is uncommon, but affected neonates require high healthcare utilisation.
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Bellini C, Cabano R, De Angelis LC, Bellini T, Calevo MG, Gandullia P, Ramenghi LA. Octreotide for congenital and acquired chylothorax in newborns: A systematic review. J Paediatr Child Health 2018; 54:840-847. [PMID: 29602276 DOI: 10.1111/jpc.13889] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 01/16/2018] [Accepted: 02/12/2018] [Indexed: 12/26/2022]
Abstract
AIM Chylothorax is a rare but life-threatening condition in newborns. Octreotide, a somatostatin analogue, is widely used as a therapeutic option in neonates with congenital and acquired chylothorax, but its therapeutic role has not been clarified yet. METHODS We performed a systematic review to assess the efficacy and safety of octreotide in the treatment of congenital and acquired chylothorax in newborns. Comprehensive research, updated till 31 October 2017, was performed by searching in PubMed, MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL) databases using the MeSH terms 'octreotide' and 'chylothorax'. Both term and preterm newborns with congenital or acquired chylothorax treated with octreotide within the 30th day of life were included. Octreotide treatment was considered effective if a progressive reduction/ceasing in drained chylous effusion occurred. RESULTS A total of 39 articles were included. Octreotide was effective in 47% of patients, with a slight but not significant difference between congenital (30/57; 53.3%) and acquired (9/27; 33.3%) chylothorax (P = 0.10). Marked variation in octreotide regimen was observed. The most common therapeutic scheme was intravenous infusion at a starting dose of 1 μg/kg/h, gradually increasing to 10 μg/kg/h according to the therapeutic response. Side effects were reported in 12 of 84 patients (14.3%). Only case reports were included in this review due to the lack of randomised controlled trials. CONCLUSION Octreotide is a relatively effective and safe treatment option in neonates with chylothorax, especially for the congenital forms.
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Affiliation(s)
- Carlo Bellini
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
| | - Rita Cabano
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
| | - Laura C De Angelis
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
| | - Tommaso Bellini
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
| | - Maria G Calevo
- Epidemiology, Biostatistics and Committees Unit, Gaslini Children's Hospital, Genoa, Italy
| | - Paolo Gandullia
- Gastroenterology and Digestive Endoscopy Unit, Gaslini Children's Hospital, Genoa, Italy
| | - Luca A Ramenghi
- Neonatal Intensive Care Unit, Neonatal Emergency Transport Service, Department of Mother and Child, Gaslini Children's Hospital, Genoa, Italy
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Bentur L, Gur M, Pollak M, Masarweh K, Solt I, Bronshtein M. Early prenatal ultrasound diagnosis of congenital thoracic malformations. J Matern Fetal Neonatal Med 2018; 32:3531-3536. [PMID: 29720002 DOI: 10.1080/14767058.2018.1465920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Objectives: To evaluate and describe the spectrum and rate of congenital thoracic malformations (CTMs) diagnosed by early prenatal sonography (gestational age (GA) less than 16 weeks). Methods: A retrospective, cross-sectional analysis of prenatal ultrasound screening tests in a community-based clinic. Results: In 2001-2017, 31 261 prenatal ultrasound tests detected 31 CTMs at a gestational age of 15.2 (range, 11.6-16.0) weeks. The most common malformation was congenital pleural effusion (CPE) (15 fetuses, 0.48/1000), followed by congenital diaphragmatic hernia (CDH) (10 fetuses, 0.32/1000). Pulmonary hypoplasia (PH), congenital pulmonary airway malformation and broncho-pulmonary sequestration appeared in much smaller proportions (three, two and one fetuses, respectively). Most CTMs were associated with additional fetal lesions (15 fetuses, 48%). All early CDH (10 fetuses) and PH (three fetuses) and 6/15 with CPE had termination of pregnancy or missed abortions. Conclusions: Prenatal ultrasound before 16 GA was able to detect CTMs in 0.99/1000 of screening ultrasound (US) performed. Most CTMs tended to appear with multiple lesions and were associated with unfavorable outcomes. Earlier prenatal diagnosis may enable early termination of pregnancy in fetuses with lethal malformations.
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Affiliation(s)
- Lea Bentur
- a Pediatric Pulmonary Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus , Haifa , Israel.,b Rappaport Faculty of Medicine , Technion - Israel Institute of Technology , Haifa , Israel
| | - Michal Gur
- a Pediatric Pulmonary Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus , Haifa , Israel
| | - Mordechai Pollak
- a Pediatric Pulmonary Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus , Haifa , Israel.,c Department of Pediatrics , Bnai Zion Medical Center , Haifa , Israel
| | - Kamal Masarweh
- a Pediatric Pulmonary Institute, Ruth Rappaport Children's Hospital, Rambam Health Care Campus , Haifa , Israel
| | - Ido Solt
- b Rappaport Faculty of Medicine , Technion - Israel Institute of Technology , Haifa , Israel.,d Department of Obstetrics and Gynecology , Rambam Health Care Campus , Haifa , Israel
| | - Moshe Bronshtein
- b Rappaport Faculty of Medicine , Technion - Israel Institute of Technology , Haifa , Israel.,d Department of Obstetrics and Gynecology , Rambam Health Care Campus , Haifa , Israel
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