Octreotide therapy for chylothorax in infants and children: A brief review

Should Newborns with Refractory Chylothorax Be Tried on Higher Dose of Octreotide?

Chylothorax is a rare but life-threatening condition in newborns, often requiring a prolonged hospital stay. To date, no unified guidance exists for best management approach. Octreotide, a somatostatin analogue, has been used to treat neonatal chylothorax due to its effect on the splanchnic circulation and lipid absorption. It is administered either subcutaneously or intravenously; for the latter, a dose range between 1 and 10 µg/kg/h is most commonly used. However, the optimal dose and way of administration remain unclear. Here, we report 2 newborn cases with large volume chylothorax (>500 mL/day), one with congenital chylothorax and one following a repair of a congenital diaphragmatic hernia (post-operative form). In both cases, a significant and sustained reduction in the volume of evacuated chyle was only seen once the dose of intravenous octreotide was increased to 20 µg/kg/h. We suggest that high-dose octreotide can be considered in seemingly refractory cases of neonatal chylothorax.

Congenital Chylothorax: Common and Uncommon Findings in an Infant with Chylous Effusions

Congenital chylothorax is defined as an abnormal accumulation of lymphatic fluid in the pleural space. It is a rare condition in the neonate that causes significant respiratory, nutritional, and immunologic problems resulting in a high mortality rate. Presented here is a case of congenital bilateral chylothorax in a preterm infant. Fetal ultrasound at 33 weeks' gestation showed polyhydramnios, bilateral pleural effusions, ascites, and subcutaneous edema. Fetal pleuracentesis was done on the right side with 118 mL of fluid aspirated. This article addresses the management of this difficult disease process, complications, and implications for research of controversial therapies.

ChyloBEST: Chylothorax in Infants and Nutrition with Low-Fat Breast Milk

Chylothorax occurs in 2.8-5% of infants after cardiac surgery and can increase morbidity and mortality. First-line conservative treatment consists of a chest tube drainage and a fat-free and medium-chain triglyceride (MCT)-enriched diet. This typically leads to a discontinuity of breast milk feeding due to high content of long-chain triglycerides within the breast milk. Modified breast milk with low fat content (LFBM) could provide numerous benefits like immunological properties of breast milk even for patients with chylothorax. This study was conducted at Herzzentrum Leipzig comparing clinical and growth outcomes between infants with chylothorax after surgery for congenital heart disease treated with LFBM (n = 13) versus MCT-Formula (n = 10). LFBM was prepared by centrifugation of native breast milk added with MCT-oil and fortifier. There were no differences in volume and duration of chest tube drainage between LFBM and MCT-formula treatment groups. Furthermore, no statistically significant differences with regard to weight and length gains could be observed between both feeding groups. LFBM is an efficient and unharmful treatment for chylothorax following cardiac surgery in young children.

Evaluating the Use of Octreotide for Acquired Chylothorax in Pediatric Critically Ill Patients Following Cardiac Surgery

OBJECTIVES

To evaluate the impact of octreotide on time to resolution of chylothorax compared with conventional therapy. Secondary outcomes include the following: time to reduction of chest tube output by 20%, additional surgeries for chylothorax, hospital length of stay, in-hospital mortality, and adverse drug reactions.

METHODS

We retrospectively evaluated the efficacy of octreotide vs conventional therapy for treatment postoperative chylothorax in pediatric patients in the cardiac ICU following surgery for congenital heart disease between October 2008 and June 2017.

RESULTS

Final analysis included 32 patients with chylothorax who met inclusion criteria. Patients who received octreotide had a longer duration of chest tube drainage than those who received conventional therapy (24 vs 9 days, p < 0.001). Resolution of chylothorax was achieved in 13 of 16 (81.3%) octreotide patients and 16 of 16 (100%) conventional patients (p = 0.178). There was a comparable time to reduction by 20% in drainage (6 vs 8 days, p = 0.337). There was no significant correlation between time after starting conventional management and reduction chylous output in either the octreotide or conventional therapy group (p = 0.809, p = 0.107, respectively). However, there was a significant and moderate correlation between octreotide and reduction in a chylous output following initiation of octreotide (R ² = 0.464, p = 0.021).

CONCLUSIONS

Octreotide is potentially a safe and effective therapy for treatment in pediatric patients with refractory chylothorax following surgery for congenital heart disease.

Plastic Bronchitis in an AIDS Patient with Pulmonary Kaposi Sarcoma

Plastic bronchitis is the expectoration of bronchial casts in the mold of the tracheobronchial tree. It is a rare occurrence of unknown etiology that has been primarily described in children with congenital heart disease. In this case report, we present the first reported case of plastic bronchitis in a patient with pulmonary Kaposi sarcoma and underlying HIV infection.

Octreotide for congenital and acquired chylothorax in newborns: A systematic review

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.

Effects of somatostatin/octreotide treatment in neonates with congenital chylothorax

The influence of somatostatin/octreotide treatment on outcomes of neonates with congenital chylothorax remains controversial. We retrospectively reviewed our experience with somatostatin/octreotide therapy in neonates with this very rare disease.Fourteen neonates with congenital chylothorax who were treated with somatostatin (3.5-7 μg/kg/h, before 2016) or octreotide (1-6 μg/kg/h, after January 2016), along with traditional management between 2013 and 2016, were retrospectively reviewed in this observational study. Their daily volumes of pleural drainage and parameters of respiratory support were recorded, and the potential side effects of somatostatin/octreotide were screened.Four patients (28.6%) had a unilateral presentation of pleural effusion, whereas 10 patients (71.4%) had a bilateral presentation. Twelve patients (85.7%) survived until discharge without later recurrence or death, whereas 2 patients (14.3%) died within the first 3 days after birth. Somatostatin/octreotide treatment was maintained for a median period of 6 days (range 1-16 days). The chest tube was removed after a median duration of 14 days (range 2-51 days), and no patient needed pleurodesis or thoracic duct ligation surgery. The average daily drain output within 3 days post-treatment (median 62 mL, range 10-651 mL) was significantly lower than that before treatment (median 133 mL, range 70-620 mL) (P = .002). The need for ventilation support was reduced in most patients (85.7%) after the initiation of somatostatin/octreotide therapy. No serious side effects were identified.Somatostatin/octreotide treatment reduced pleural drainage and respiratory support without significant side effects. Further randomized controlled studies with more patients are necessary to ascertain the benefits of somatostatin/octreotide in neonates with congenital chylothorax.

Treatment of chylothorax developed after congenital heart disease surgery: a case report

Chylothorax is defined as the accumulation of lymphatic fluid or chyle in the pleural space. Chylothorax treatment is composed of conservative; pleural drainage, termination of enteral feeding, total parenteral nutrition and supplementation with medium- chain triglycerides and surgical therapies; ductus thoracicus ligation, pleuroperitoneal shunts or pleuredesis. Nowadays, for cases among which conservative therapies fail, treatment with octreotide has been reported to be beneficial with promising results. A neonate who developed chylothorax after surgery performed for congenital heart disease was treated successfully with octreotide.

Congenital chylothorax: a prospective nationwide epidemiological study in Germany

BACKGROUND

Congenital chylothorax (CCT) is a rare disease of unknown aetiology. Treatment approaches vary; none has been evaluated prospectively.

OBJECTIVE

To prospectively determine incidence, treatment and outcome of infants with CCT born in Germany in 2012.

DESIGN

CCT was defined as non-traumatic chylous pleural effusion within 28 days after birth. As part of the Surveillance Unit for Rare Pediatric Conditions in Germany (Erhebungseinheit für seltene pädiatrische Erkrankungen in Deutschland), all paediatric departments (n=432) received monthly reporting cards to notify the study centre of CCT cases, which were analysed based on anonymised questionnaires and discharge summaries. Data are shown as median (range) or n/N.

RESULTS

Of 37 cases reported, 28 met inclusion criteria. Questionnaires and/or discharge summaries were available for 27/28. Assuming complete reporting, the incidence of CCT was 1:24 000. Nine infants suffered from proven or suspected syndromal anomalies, most frequently Noonan syndrome (5/9). Postnatally, 23 required mechanical ventilation, 3 continuous positive airway pressure; only 1 had no respiratory support. 17 infants were treated with inotropes/vasopressors, 25 required pleural drainage for 11 (1-36) days. In 13 infants, enteral feeds were withheld initially; 25 received medium-chain triglyceride diet at some time, 9 were treated with octreotide or somatostatin. 18 infants survived without, 6 with sequelae attributable to the underlying disorder; 3 infants died (median age at death 37 (2-144) days). Duration of hospital stay in survivors was 51 (20-127) days. Infants treated with octreotide or somatostatin had similar outcomes compared with those not treated.

CONCLUSIONS

Based on this small observational study, CCT seems to have a favourable prognosis if not associated with genetic disorders.

Chylothorax and chylous ascites: management and pitfalls

Leakage of lymph from the lymphatic ducts causes chylothorax (CT) or chylous ascitis (CA). This may happen for unknown reasons during fetal life or after birth and may also be caused by trauma after thoracic surgery or by other conditions. Fetal CT and CA may be lethal particularly in cases with fetal hydrops that sometimes benefit of intra-uterine instrumentation. After birth, symptoms are related to the amount of accumulated fluid. Sometimes, severe cardio-respiratory compromise prompts active therapy. Most patients with CT or CA benefit from observation, rest, and supportive measures alone. Drainage of the fluid may be necessary, but then loss of protein, fat, and lymphoid cells introduce new risks and require careful replacement. Low-fat diets with MCT and parenteral nutrition decrease fluid production while allowing adequate nutritional input. If lymph leakage does not stop, secretion inhibitors like somatostatin or octreotide are prescribed, although there is only weak evidence of their benefits. Imaging of the lymphatic system is indicated when the leaks persist, but this is technically demanding in children. Shunting of the lymph from one body space to another by means of valved catheters, embolization of the thoracic duct, and/or ligation of the major lymphatics may occasionally be indicated in cases refractory to all other treatments.

Chylothorax development in infants and children in the UK

AIM

To describe the incidence, patient profile, management strategies and outcome for infants and children who developed a chylothorax in the UK.

METHODS

A prospective study of infants and children ≥24 weeks' gestation - ≤16 years, who developed a chylothorax in the UK and were reported through the British Paediatric Surveillance Unit (BPSU). Clinicians completed a questionnaire on the presentation, diagnosis, management and outcome of these children. Three further data sources were accessed to confirm these data.

RESULTS

The incidence in children in the UK was 0.0014% (1.4 per 100,000) and 3.2% (3200 per 100,000) for those developing a chylothorax following a cardiac surgical procedure. The incidence was highest in infants ≤12 months at 16 per 100,000 (0.016%). A total of 219 questionnaires were returned with 172 cases meeting the eligibility criteria. Development of a chylothorax was most commonly associated with cardiac surgical procedure (65.1%) and was most frequently confirmed by laboratory verification of triglyceride content of the pleural fluid ≥1.1 mmol/L (66%). Although a variety of management strategies were employed, treatment with an intercostal pleural catheter (86.5%) and a medium chain triglyceride (MCT) diet (89%) was most commonly reported. The majority of the children had a prolonged hospital stay with a reported mortality of 12.2%.

CONCLUSIONS

Development of a chylothorax in infants and children in the UK was not common. The primary association was with a cardiac surgical procedure. The child's hospital stay was lengthy and therefore the impact on the child, family and hospital resources were significant. Common management strategies existed but national guidance is required to optimise practice. This study allows for better information relating to this serious complication to be given to patients and families and provides the basis for future research and practice development.

Chylothorax in infants and children

Chylothorax, the accumulation of chyle in the pleural space, is a relatively rare cause of pleural effusion in children. It can cause significant respiratory morbidity, as well as lead to malnutrition and immunodeficiency. Thus, a chylothorax requires timely diagnosis and treatment. This review will first discuss the anatomy and physiology of the lymphatic system and discuss various causes that can lead to development of a chylothorax in infants and children. Then, methods of diagnosis and treatment will be reviewed. Finally, complications of chylothorax will be reviewed.

The role for tunneled indwelling pleural catheters in patients with persistent benign chylothorax

BACKGROUND

Utilization of tunneled indwelling pleural catheters (TIPCs) for persistent pleural effusions is increasingly more common; however, the presence of chylothorax is generally considered a contraindication for utilization of a TIPC due to concerns regarding potential nutritional, immunologic and hemodynamic complications. Therefore, in this study, a cohort of patients with persistent benign chylothorax managed with TIPCs is described.

METHODS

A retrospective analysis of patients with persistent benign chylothorax managed with a TIPC at the study center between January 1, 2008, and March 1, 2012, was completed. Extracted data included patient characteristics, chylothorax etiologies, prior interventions, outcomes and complications.

RESULTS

Eleven patients (14 hemithoraces) had persistent benign chylothorax treated with placement of a TIPC during the inclusion time frame. Etiology of the chylothorax was nontraumatic in 8 of the 11 patients, with the remaining 3 secondary to thoracic surgery. Pleurodesis was achieved in 9 of the 14 hemithoraces, with a median time to pleurodesis of 176 days. All procedures were well tolerated, and no immediate periprocedural complications were reported. One serious complication was encountered in the form of a postoperative pulmonary embolism after replacement of an occluded TIPC, resulting in the patient's death. Two patients had transient occlusions of their TIPCs successfully treated with intracatheter thrombolytic therapy. No significant adverse nutritional, hemodynamic or immunologic outcomes were reported during follow-up for any included patient.

CONCLUSIONS

Utilization of a TIPC for the management of persistent benign chylothorax should be considered early because pleurodesis may be frequently and safely achieved in this patient population.

Octreotide for chylous effusions in congenital diaphragmatic hernia

BACKGROUND/PURPOSE

Chylothorax is a frequent complication in congenital diaphragmatic hernia (CDH) infants and is associated with significant morbidity. The optimal treatment strategy remains unclear. We hypothesize that octreotide decreases chylous effusions in infants with CDH.

METHODS

This is a retrospective study of all infants with CDH admitted to our institution from October 2006 to October 2011.

RESULTS

Eleven (12%) infants developed a chylothorax. Five infants were managed conservatively with thoracostomy and total parenteral nutrition. Six infants were started on octreotide therapy. None of the infants required surgical intervention to stop the effusion. There was no significant difference in survival to discharge, length of stay, or average daily chest tube output between groups. There appeared to be a temporally associated drop in chest tube output upon initiation of octreotide in two infants; however, the overall rate of decline in chest tube drainage was unchanged. In addition, there were infants in the conservative group who demonstrated a similar drop in daily chest tube output despite the absence of octreotide.

CONCLUSIONS

Our data suggest that the majority of chylous effusions in CDH infants resolve with conservative therapy alone.

Transabdominal ligation of the thoracic duct with pericardial-peritoneal shunting in a case of primary idiopathic chylous pericardial effusion

Primary chylous pericardial effusion is a rare entity with few cases reported so far. We report a case of idiopathic etiology in a previously healthy 16-year-old boy. The patient presented with intermittent chest pain and dizziness caused by a chronic pericardial effusion. An echocardiogram revealing a pericardial effusion and open pericardiocentesis with a drainage of approximately of 500 ml of chylous fluid established the diagnosis. Patient had no history of trauma, cardiac surgery, central insertion of subclavian catheters or blunt injury. Computed tomography ruled out malignancies in the abdomen and chest. Clinical, laboratory and radiological investigations for the possible underlying cause of the condition were not determined. Management with a dietary regimen consisting of a medium-chain triglyceride-rich diet, octreotide pharmacological treatment and initial subxiphoid resection with pericardial tube drainage was unsuccessful. Surgical approach was required consisting of pericardio-peritoneal window with trans-abdominal ligation (clipping) of the thoracic duct above the diaphragm. Postoperative outcome was uneventful and there was a rapid recovery after surgical management.

Octreotide as therapeutic option for congenital idiopathic chylothorax: a case series

BACKGROUND

Octreotide, a somatostatin analogue, is used for the management of patients with refractory chylothorax although its safety and efficacy in neonates have not been evaluated in controlled clinical trials. We present one of the largest case series about the use of octreotide in congenital idiopathic chylothorax.

METHODS

Six cases of congenital chylothorax (CC) were prospectively collected, who were managed with same unit protocol for octreotide. Mean (SD) gestation was 34.5 (±2.2) weeks, and birthweight was 3410 (±840.4) g. All infants required chest drains from day 1 of life, and the mean (SD) duration of insertion was 36.1 (±8.5) days. Octreotide was commenced at a median age of 13.5 days (range 8-22), given for a median duration of 20 days (range 12-27). The starting dose was 0.5-1 μg/kg/h with an increment of 1-2 μg/kg/day to a maximum of 10 μg/kg/day. Resolution of chylothorax was achieved in five patients, being resistant to treatment in the sixth patient. None had adverse effects from octreotide. Full enteral feeds were reached at a mean age of 44 days.

CONCLUSION

Early commencement of octreotide is recommended although further reports to evaluate the safety and efficacy would add to the profile of this medication in the treatment of CC.

Successful treatment of neonatal chylothorax with octreotide

Chylothorax is a relatively uncommon, but a common form of pleural effusion in the neonates. It may be either congenital or acquired. The efficacy of octreotide therapy for chylothorax is controversial. Herein the authors report successful suppression of chylothorax by octreotide in a newborn who had undergone thoracostomy tube.

Congenital chylothorax in a late preterm infant and successful treatment with octreotide

Chylothorax is defined as abnormal accumulation of lymphatic fluid in the pleural space and is a rare condition in neonates. Chylothorax causes respiratory and nutritional problems and a significant mortality rate. Octreotide is a long-acting somatostatin analog that can reduce lymphatic fluid production and has been used as a new strategy in the treatment of chylothorax. Here, we report a premature baby with severe bilateral pleural effusion diagnosed by prenatal ultrasound and subsequently confirmed to be congenital chylothorax after birth. This newborn baby was initially treated with bilateral chest tube insertion to relieve severe respiratory distress. However, the chylothorax recurred after a medium-chain-triglyceride-enriched formula was initiated. The accumulation of chylothorax diminished after the administration of octreotide. Therefore, octreotide may allow the patient to avoid invasive procedures, such as reinsertion of chest tubes or surgery.

Pleural effusion in a neonate

A premature neonate who developed respiratory distress in the first few days of life was found to have a pleural effusion, which reaccumulated following drainage. The effusion was demonstrated to be a chylothorax. He required multiple chest drains and was started on a medium chain triglyceride formula feed. This brought about a full resolution of the effusions and he made a complete recovery.

Pleural effusions in children undergoing cardiac surgery

Persistent pleural effusions are a source of significant morbidity and mortality following surgery in congenital heart disease. In this review, we discuss the etiology, pathophysiology, and management of this common complication.

Tension chylothorax complicating acute malignant airway obstruction

Acute upper airway obstruction represents one of the most challenging emergencies in pediatric practice. In particular, a tension chylothorax complicating a malignant airway obstruction is a rare and life-threatening complication. We report a rapidly progressing tension chylothorax associated with a cervical mass in a 10-month-old male infant. To our knowledge, the extension of a cervical mass to the supraclavear region resulting in a compressive chylothorax represents an exceptional event in pediatrics. Early recognition and prompt treatment resulted to be essential to relieve the compression and to avoid end-stage hemodynamic and respiratory function derangement.

Congenital primary hydrothorax: effect of thoracoamniotic shunting on neonatal clinical outcome

BACKGROUND

Spontaneous regression in the foetal period has been described for congenital hydrothorax. Hydrothorax may become larger and bilateral with hydrops and pulmonary hypoplasia. Prenatal thoracentesis and thoracoamniotic shunting of massive hydrothorax are indicated to decrease perinatal morbidity. In the neonatal period, persistent hydrothorax may require intensive care.

OBJECTIVE

To investigate neonatal outcome after thoracoamniotic shunting for congenital primary hydrothorax with hydrops/ polydramnios.

METHODS

Retrospective study on the postnatal management of a cohort of 28 congenital primary hydrothorax cases after thoracoamniotic shunting (January 2000-August 2005).

RESULTS

Congenital hydrotorax without major structural anomalies complicated by polidramnios and/or hydrops<34 weeks' gestation were the criteria accepted for thoracoamniotic shunting. There were neither pregnancy terminations nor utero deaths. Although 64% of cases were complicated by severe neonatal respiratory insufficiency, neonatal mortality rate was low (21.4%) if compared with literature. Univariate analysis identified 'birth at gestational age (GA)<35 weeks' and 'time between prenatal shunting and birth' as predictive factors for needing of ventilation. Multivariate analysis identified 'birth at GA<35 weeks' as the only independent predictor for needing ventilation. (OR=0.08, CI 95%=0.01-0.96, p=0.046). No risk factors for death or adverse neurological outcomes were reported.

CONCLUSIONS

Congenital hydrothorax although corrected by thoracoamniotic shunting is complicated by severe respiratory distress. The neonatal outcome may be improved limiting degree of prematurity; the presence of thoracoamniotic shunt is not per se an indication of premature birth, at least until GA>35 weeks and adequate pulmonary maturity is reached.

A case of spontaneous chylothorax in an adolescent

We discuss an male adolescent who presented to the emergency department with fever and respiratory distress. He was subsequently diagnosed with spontaneous chylothorax. We review his clinical presentation and diagnostic and therapeutic interventions and provide a discussion of the subject.

Octreotide for the treatment of chylothorax in neonates

BACKGROUND

Routine care for chylothorax in neonate includes either conservative or surgical approaches. Octreotide, a somatostatin analogue, has been used for the management of patients with refractory chylothorax not responding to conservative management.

OBJECTIVES

To assess the efficacy and safety of octreotide in the treatment of chylothorax in neonates.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE and EMBASE (to March 7, 2010). We assessed the reference lists of identified trials and abstracts from the annual meetings of the Pediatric Academic Societies published in Pediatric Research (2002 to 2009) without language restrictions.

SELECTION CRITERIA

We planned to include randomised or quasi-randomised controlled trials of octreotide in the treatment of congenital or acquired chylothorax in term or preterm neonates, with any dose, duration or route of administration.

DATA COLLECTION AND ANALYSIS

Data on primary (amount of fluid drainage, respiratory support, mortality) and secondary outcomes (side effects) were planned to be collected and analysed using mean difference, relative risk and risk difference with 95% confidence intervals.

MAIN RESULTS

No randomised controlled trials were identified. Nineteen case reports of 20 neonates with chylothorax in whom octreotide was used either subcutaneously or intravenously were identified. Fourteen case reports described successful use (resolution of chylothorax), four reported failure (no resolution) and one reported equivocal results following use of octreotide. The timing of initiation, dose, duration and frequency of doses varied markedly. Gastrointestinal intolerance and clinical presentations suggestive of necrotizing enterocolitis and transient hypothyroidism were reported as side effects.

AUTHORS' CONCLUSIONS

No practice recommendation can be made based on the evidence identified in this review. A prospective registry of chylothorax patients and a subsequent multicenter randomised controlled trial are needed to assess the safety and efficacy of octreotide in the treatment of chylothorax in neonates.

Chylothorax in congenital diaphragmatic hernia

PURPOSE

Following surgical repair of congenital diaphragmatic hernia (CDH), chylothorax can be present in 7-28% of the cases. It has been associated with prenatal diagnosis, the use of ECMO and prosthetic patches during reparatory surgery. The objective is to present a neonatal unit experience in handling this complication and the search for predictive factors for its appearance in our patients.

METHODS

A retrospective study was carried out between 2003 and 2009.

RESULTS

We found 65 patients with CDH, of which 7 (10.8%) developed a chylothorax, 5 responded to drainage and diet restriction. Octreotide (OCT) was used in two cases that did not respond to the usual treatment. OCT was successful with one patient, while surgical resolution of the chylothorax was necessary in the other. Two patients died, none of them during treatment of chylothorax. We did not find a significant association between chylothorax and the variables studied in these patients.

CONCLUSIONS

Chylothorax is a common complication following CDH repair. We have a low rate of this complication in our institution. Conservative management is an appropriate approach for all patients; OCT could be an alternative to avoid surgery. We did not find any predictive factors for chylothorax in our series.

Necrotizing enterocolitis in neonates receiving octreotide for the management of congenital hyperinsulinism

The somatostatin analog octreotide was used for the first time in the treatment of an infant with congenital hyperinsulinism in 1986. Since then, it is commonly used in the management of congenital hyperinsulinemic hypoglycemias. Despite a wide variety of potential adverse reactions, octreotide is generally well tolerated. It has been extensively demonstrated that octreotide reduces the splanchnic blood flow in a dose-dependent manner, affecting the entire gastrointestinal tract, and some concern has been recently raised regarding the potential implications of this effect in the development of necrotizing enterocolitis in neonates receiving octreotide for the management of congenital hyperinsulinism. The aim of this report is to present a series of patients treated at our institution in which we observed this association, and review the current related literature.

Chylothorax: diagnosis and management in children

Chylothorax is the accumulation of chyle in the pleural space, as a result of damage to the thoracic duct. Chyle is milky fluid enriched with fat secreted from the intestinal cells and lymphatic fluid. Chylothorax in children, is most commonly seen as a complication of cardiothoracic surgery but may occur in newborns or conditions associated with abnormal lymphatics. The diagnosis is based on biochemical analysis of the pleural fluid, which contains chylomicrons, high levels of triglycerides and lymphocytes. Investigations to outline the lymphatic channels can prove helpful in some cases. Initial treatment consists of drainage, dietary modifications, total parenteral nutrition and time for the thoracic duct to heal. Somatostatin and its analogue octreotide may be useful in some cases. Surgery should be considered for patients who fail these initial steps, or in whom complications such as electrolyte and fluid imbalance, malnutrition or immunodeficiency persist. Surgical intervention may be attempted thoracoscopically with repair or ligation of the thoracic duct.

Diagnosis and management of lymphatic vascular disease

The lymphatic vasculature is comprised of a network of vessels that is essential both to fluid homeostasis and to the mediation of regional immune responses. In health, the lymphatic vasculature possesses the requisite transport capacity to accommodate the fluid load placed upon it. The most readily recognizable attribute of lymphatic vascular incompetence is the presence of the characteristic swelling of tissues, called lymphedema, which arises as a consequence of insufficient lymph transport. The diagnosis of lymphatic vascular disease relies heavily upon the physical examination. If the diagnosis remains in question, the presence of lymphatic vascular insufficiency can be ascertained through imaging, including indirect radionuclide lymphoscintigraphy. Beyond lymphoscintigraphy, clinically-relevant imaging modalities include magnetic resonance imaging and computerized axial tomography. The state-of-the-art therapeutic approach to lymphatic edema relies upon physiotherapeutic techniques. Complex decongestive physiotherapy is an empirically-derived, effective, multicomponent technique designed to reduce limb volume and maintain the health of the skin and supporting structures. The application of pharmacological therapies has been notably absent from the management strategies for lymphatic vascular insufficiency states. In general, drug-based approaches have been controversial at best. Surgical approaches to improve lymphatic flow through vascular reanastomosis have been, in large part, unsuccessful, but controlled liposuction affords lasting benefit in selected patients. In the future, specifically engineered molecular therapeutics may be designed to facilitate the controlled regrowth of damaged, dysfunctional, or obliterated lymphatic vasculature in order to circumvent or mitigate the vascular insufficiency that leads to edema and tissue destruction.

Pleural effusions in the neonate

PURPOSE OF REVIEW

This review highlights the pathophysiological mechanisms, incidence, clinical features, as well as the diagnosis and treatment of pleural effusions in the neonate.

RECENT FINDINGS

Pleural effusions are rare except in hydropic neonates. Elevated pleural fluid/serum immunoglobulin G ratio may be a diagnostic marker for congenital chylothorax in utero. Chylothorax may be congenital or acquired. Hydrothoraces may appear at any time during the neonatal period and are related to infectious and noninfectious aetiologies. Haemothorax is defined as the presence of blood in the pleural space. Parenteral nutrition leakage may occur in a newborn with a venous central catheter leading to an effusion that looks like a chylothorax. The value of elevated pleural fluid N-terminal pro-brain natriuretic peptide levels as a marker of congestive heart failure is not yet established in neonates. More recently, in cases of chylothorax that did not resolve with drainage and bowel rest, the use of somatostatin or its analogue octreotide has been described with success. If conservative management fails after 5 weeks, surgical intervention is indicated.

SUMMARY

Clinicians must be aware of the wide range of disorders causing pleural effusions, the different types and clinical presentations, differential diagnosis, and how to treat each specific case.

Tension chylothorax in two pediatric patients

Although the accumulation of gas is the most common cause of an expanding interpleural space, the presence of other structures or substances (hydrothorax, gastrothorax, hemothorax, urohemothorax, pyothorax, and chylothorax) under pressure may be sufficient to cause hemodynamic and respiratory compromise. We present two pediatric patients that developed hemodynamic and respiratory effects secondary to a chylothorax. The first patient presented in respiratory distress and cardiovascular collapse 4 weeks after a Fontan procedure. Placement of a chest tube resulted in the release of chyle under pressure and prompt resolution of hemodynamic and respiratory symptoms. The second patient was a 2100 g neonate who developed a chylothorax during an episode of sepsis following gastroschisis repair. On two separate occasions, the development of the chylothorax was associated with tachycardia, oliguria, and increased requirements during mechanical ventilation. Chest tube placement resulted in the release of chyle under pressure and resolution of the symptoms. These two cases demonstrate that chylothorax like pneumothorax can have deleterious effects on hemodynamic and respiratory function.