Dietary treatment of congenital chylothorax with skimmed breast milk.

BACKGROUND: Congenital chylothorax (CC) is a rare but potentially life-threatening condition in newborns. It is defined as an accumulation of chyle in the pleural cavity. The few publications regarding medical management and therapeutic dietary intervention motivated us to share our experience. METHODS: Neonates diagnosed with congenital chylothorax and treated at Innsbruck Medical University Hospital between 2013 and 2020 (n = 6, gestational age: 36 3/7, 32 5/7, 36 4/7, 35 0/7, 35 4/7, 37 3/7 weeks) were eligible for this report. The cornerstones of treatment for chylothorax conventionally consist of chest tube drainage (CTD), respiratory support, dietary restriction of long-chain triglycerides (LCT) or total parenteral nutrition (TPN). In further course the introduction of a medium-chain triglyceride (MCT)-based formula followed by an overlapping switch to a formula with low LCT and high MCT, containing the essential long-chain fatty acids (LCFA), is attempted. In three patients we used fat-modified (skimmed) breast milk to provide a high protein and low fat diet and to avoid the discontinuation of breast milk. RESULTS: The outcome of an early introduction of LCFA in the form of skimmed breast milk after resolution of chylothorax diverse. One patient had a favourable outcome, meaning no recurrence of pleural effusion, adequate weight gain and a content mother, while another patient had a relapse of pleural effusion after the administration of skimmed milk and was therefore transitioned back to Basic F® . The CC of patient 5 was difficult due to Noonan syndrome. Two weeks after the introduction of skimmed breast milk the mother wanted to stop to express breast milk, so nutrition was changed to Basic F®. CONCLUSION: The first-line therapy of chylothorax is a combination of respiratory stabilization and dietary modification. The use of skimmed breast milk is advisable in CC and feasible by means of a simple milk defatting procedure. It offers benefits to mothers who wish to resume breast feeding after resolution of chylothorax and has proven positive effects, above all in preterm infants as optimal nutrition with protective components superior to formula feeding. However, the nutritional analysis of the skimmed milk and the correlation to a re-accumulation of pleural fluid remains a question to be answered.

Leche materna descremada en recién nacidos con quilotórax: opciones con una unidad de nutrición personalizada / Skimmed breast milk in newborns with chylothorax: Options with a personalised nutrition unit

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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.

The Practicality of Feeding Defatted Human Milk in the Treatment of Congenital Chylothorax.

Introduction: Congenital chylothorax (CC) is a rare and life-threating condition. Since its treatment is founded on the elimination of long-chain fatty acids from the diet, breastfeeding has been traditionally contraindicated. However, breast milk could be very beneficial due to its immunological and nutritional benefits. Only limited research has been published about the usage of modified-fat breast milk (MBM) in chylothorax treatment. Methods and Results: Systematic review methods were used by two independent reviewers. Only a few case report studies (quality assessment on the domains of the GRADE approach), two small controlled studies, a retrospective study, and some test-tube-based laboratory research met the inclusion criteria. Despite this, we have observed a widespread clinical adoption of this novel treatment in health institutions. Data suggest that modified-fat breast milk does facilitate the resolution of chylothoraces. Refrigerated centrifuge (2°C, 3,000 rpm for 15 minutes) and syringe fat removal methods were the most efficient options in terms of fat reduction. Conclusions: Feeding of human milk is advisable in CC and feasible by means of a simple milk defatting procedure. Open questions remain, related to length and degree of fat restriction and need for individualized fortification of defatted breast milk.

Congenital Chylothorax in a Neonate with Cornelia de Lange Syndrome: A Rare Complication Managed with a Novel Indigenously Prepared Milk Formulation.

Congenital chylothorax is a relatively uncommon condition seen in newborn period. Treatment comprises of adequate pleural fluid drainage, octreotide infusion, total parenteral nutrition followed by medium chain triglyceride (MCT) based low fat milk preparations. The authors present a case of Cornelia de Lange syndrome with a rare presentation of antenatally diagnosed chlyothorax presenting at birth with respiratory distress. The baby was managed with skimmed milk formulation fortified with coconut oil providing low fat and high proteins.

[Assessment of Fat-free Diet for Postoperative Chylothorax].

BACKGROUND: Chylothorax after lung cancer surgery is relatively rare but must be considered as a complication of thoracic surgery. METHOD: Between January 2012 and June 2017, 818 patients underwent lung cancer surgery at our hospital. Among them, 14 (1.7%) patients with chylothorax were retrospectively reviewed. Three patients were treated with oral intake cessation except water and total parental nutrition( TPN)[TPN group], 11 patients were treated with a fat-free diet( fat-free diet group). RESULTS: The drainage period was similar in both group [group TPN;13 (12~14) days and group fat-free diet;15.7 (6~42) days]. In the TPN group, 3 patients underwent pleurodesis and no patient needed surgical intervention. In the fat-free diet group, 5 patients improved only with diet management. Pleurodesis was necessary in 5 of which 3 underwent surgical intervention. CONCLUSIONS: A fat-free diet is useful in treating chylothorax after lung cancer surgery.

Successful treatment of congenital chylothorax with skimmed milk and long course octreotide.

Congenital chylothorax (CC) is a rare entity in neonatal period requiring multimodal management strategies. Despite optimum treatment, some cases remain refractory posing significant challenge to the treating physician. We here describe a 33-week preterm neonate presenting with refractory congenital chylothorax who needed treatment with combination of skimmed milk, high dose and prolonged duration octreotide for resolution. This case highlighted that octreotide has a good safety profile in newborn infants with congenital chylothorax and locally available skimmed milk fortified with medium chain triglyceride (MCT) oil is a cheap and safe alternative.

Immunoglobulin A and Protein Content of Low-Fat Human Milk Prepared for the Treatment of Chylothorax.

BACKGROUND: Several case studies report successful recovery from chylothorax while infants were fed low-fat human milk. The reported growth rates were inadequate despite milk supplementation with added medium-chain triglycerides (MCTs). The objective was to determine the effect that various human milk fat separating methods, refrigerated centrifuge, room temperature centrifuge, and refrigeration have on the loss of immunoglobulin A (IgA) and protein in the preparation of low-fat human milk. METHODS: Protein and IgA were measured in 31 samples of reduced-fat human milk. Reduced-fat breastmilk samples were prepared by separating the fat using 3 methods (refrigerated centrifuge, room temperature centrifuge, and a refrigeration method), followed by lower fat milk extraction by syringe. RESULTS: The refrigeration method decreased IgA concentration by 17% (P = .035) while centrifugation and fat removal from the human milk samples led to a 38% decline in IgA concentration in both the nonrefrigerated and refrigerated centrifuge samples (P < .0001 for both). Protein declined by 11% with refrigeration and fat removal (P < .0001) while centrifugation and fat removal decreased protein concentration by 31% (P < .0001) in both nonrefrigerated centrifuge and refrigerated centrifuge samples. CONCLUSIONS: Preparing low-fat human milk for patients with chylothorax decreased the IgA and protein contents. As well as fat (in the form of MCTs), protein likely needs to be supplemented for infants fed low-fat human milk to support adequate growth.

Dieta enteral fonte em triglicerídeo de cadeia média como coadjuvante terapêutico em um caso de quilotórax bilateral secundário à linfoma folicular / Entera diet supply in medium chain triglycerid as a therapeutic coadjuvant in a case of bilateral quilotórax secondary to follicular lymphoma

Introução: O quilotórax é uma condição patológica, onde em muitos casos compromete o estado nutricional devido à perda contínua do quilo com consequente prejuízo imunológico. O objetivo deste estudo foi descrever os resultados clínicos e nutricionais observados após intervenção nutricional precoce via terapia enteral com oferta de fórmula caseira à base de caseína, maltodextrina, triglicerídeo de cadeia média (TCM) e oligoelementos. Método: Trata-se de um estudo relato de caso do tipo observacional descritivo, de uma paciente diagnosticada com quilotórax secundário a linfoma folicular não Hodgkin. Resultados: A instituição da terapia nutricional precoce concomitante ao tratamento conservador pareceram inferir numa diminuição discreta do débito quiloso, entretanto só houve melhora significativa do quadro clínico, após o diagnóstico de linfoma e início do tratamento da doença base, nesse caso a quimioterapia. Quanto ao aspecto nutricional houve perda nutricional discreta desde a admissão até a alta, portanto a terapia precoce apesar de não ser eficaz em reverter estado nutricional, esta preservou-o e manteve sua capacidade funcional. Discussão: O diagnóstico etiológico e tratamento precoces são imprescindíveis no desfecho clínico favorável. Há duas opções terapêuticas nutricionais, entretanto não há consenso entre qual mais eficaz na reversão do quadro patológico, apesar de já ser bem estabelecido que a oferta de triglicerídeo de cadeia média (TCM) via enteral ou parenteral em conjunto ao repouso gastrintestinal são coadjuvantes eficazes na diminuição do débito quiloso. Conclusão: O suporte enteral precoce com oferta de TCM via nasoenteral se comportou como coadjuvante no tratamento do quilotórax, apesar de não restaurar estado nutricional é capaz de mantê-lo. A terapia conservadora só mostrou resultados significativos a partir do início do tratamento da doença base, neste caso o câncer, reforçando a importância de um diagnostico clinico rápido

Introduction: Chylothorax is a pathological condition, where in many cases it compromises the nutritional status due to the continuous loss of the kilo with consequent immunological damage. The objective of this study was to describe the clinical and nutritional results observed after early nutritional intervention through enteral therapy with a homemade formula based on casein, maltodextrin, medium chain triglyceride (MCT) and trace elements. Method: This is a descriptive observational case report of a patient diagnosed with chylothorax secondary to follicular non-Hodgkin lymphoma. Results: The institution of early nutritional therapy concomitant with conservative treatment seemed to infer a slight decrease in chylousdebit, however, there was only a significant improvement of the clinical condition, after the diagnosis of lymphoma and the beginning of treatment of the base disease, in this case, chemotherapy. Regarding the nutritional aspect, there was a discreet nutritional loss from admission to discharge, so early therapy, although not effective in reversing nutritional status, preserved it and maintained its functional capacity. Discussion: Etiologic diagnosis and early treatment are essential in the favorable clinical outcome. There are two nutritional therapeutic options, although there is no consensus among which is more effective in reversing the pathological condition, although it is already well established that the supply of medium chain triglyceride (MCT) via enteral or parenteral together with gastrointestinal rest are effective adjuvants in decreased chylous flow rate. Conclusion: The early enteral support with nasoenteral TCM supply behaved as a coadjuvant in the treatment of chylothorax, although not restoring nutritional status is able to maintain it. Conservative therapy only showed significant results from the beginning of treatment of the underlying disease, in this case cancer, reinforcing the importance of a rapid clinical diagnosis

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Rare case of massive bilateral chylothorax.

We present a case of a 48-year-old woman who was referred from an outside hospital. There, she had initially underwent hysterectomy and left salpingo-oophorectomy for tubo-ovarian abscess. She later developed a colovaginal fistula and perforation of sigmoid colon and underwent Hartmann's procedure along with drainage of a left subphrenic abscess. Subsequently, she had to be intubated for acute respiratory failure and was transferred to our hospital. At our hospital, she was found to have massive bilateral pleural effusions. Bilateral small-bore chest tubes were inserted that drained milky fluid. Pleural fluid analysis was consistent with bilateral chylothorax. Thereafter, patient's respiratory status improved and she was extubated. The mechanism of chylothorax was thought be either secondary to the multiple abdominal procedures or alternatively as a complication of the right subclavian catheter that was placed at the outside hospital. Her chest tubes were removed eventually, and she had a slow but definite recovery.

Mediastinal chyloma after lung cancer surgery: case report.

BACKGROUND: Chylothorax is a relatively rare but well-known complication of thoracic surgery. CASE PRESENTATION: A 70-year-old man underwent right upper and middle bilobectomy and systematic lymph node dissection through a posterolateral thoracotomy for lung cancer. On the second postoperative day, he developed chylothorax that was treated with dietary management and pleurodesis. The discharge diminished and his chest tube was removed on the ninth postoperative day. On the 14(th) postoperative day, the patient complained of dyspnea and dysphagia, and imaging studies revealed mediastinal chyloma. Thoracoscopic surgical drainage was performed and the site of chyle leakage was sutured. CONCLUSIONS: This report presents an unexpected complication of chemical pleurodesis and reviews the indications for surgical intervention in cases of postoperative chylothorax.

Uso de fórmula nutricional semielemental con alto contenido de TCM en pacientes con diagnóstico de quilotórax congénito o adquirido / Use of semielemental nutritional formula with high TCM content in patients with congenital or acquired chylothorax diagnosis

INTRODUCCIÓN: Antecedentes: El presente informe expone la evaluación del producto nutricional Fórmula semielemental con alto contecnido de TCM (triglicéridos de cadena media) respecto a su uso en pacientes con diagnóstico de quilotóraz congénito o adquirido. Aspectos Generales: El quilotóraz es la acumulación de quilo o fluído alcalino en la cavidad pleural que resulta de fugas provenientes de los vasos linfáticos por malformaciones o lesiones del conducto torácio. Esta enfermedad puede ocurrir en pacientes de cualquier edad, incluyendo neonatos e infantes.Tecnología Sanitaria de Interés: Las fórmulas con alto contenido de triglicéridos de cadena media (TCM) son fórmulas semielementares, ya que los nutrientes que las componen se encuentran higrolizados en moléculas pequeñas. Estas fórmulas están clasificadas como "fórmulas con modificaciones del cuerpo graso", y están compuestas por RCM (70-90% de los lípidos) y pequeñas cantidades de triglicéridos de cadena larga (TCL), añadidos para cubrir los requerimientos de ácidos grasos de los infantes que las consumen. METODOLOGÍA: Estrategia de Búsqueda: Se realizó una búsqueda de literatura científica en relación al uso de fórmulas semielementales con alto contenido de triglicéridos de cadena media (TCM) en neonatos o lactantes con quilotóraz congénito o adquirido. Se dio preferencia a guías de práctica clínica, revisiones sistemáticas con o sin meta-analísis y ensayos clínicos aleatorizados. RESULTADOS: Se realizó la búsqueda bibliográfica y de evidencia que sustente el uso de una formula semielemental con alto contenido de triglicéridos de cadena media (TCM) en pacientes con diagnóstico de quilotórax congénito o adquirido.Luego de revisar un total de 261 referencias resultados de la búsqueda bibliográfica, logramos filtar 38 estudios relevantes. Sinopsis de la Evidencia: Existe evidencia sobre el uso de dietas con alto contenido de triglicéridos de cadena média (TCM) como tratamiento de quilotórax en infantes, niños, adolescentes y adultos lo cual constituye evidencia indirecta para la evaluación del presente Dictamen. CONCLUSIONES: En la presente evaluación de tecnologia sanitaria se presenta la evidencia recabada sobre el beneficio de las fórmulas semielementales con alto contenido de triglicéridos de cadena media (TCM). La evidencia encontrada que compara el uso de una fórmula con alto contenido de TCM con el uso de nutrición parenteral (NPT) es escaza. Se ha identificado evidencia proveniente de un único estudio observacional que compara el uso de fórmulas con alto contenido de TCM con el uso de NPT en infantes con quilotórax post-quirúrgico. El Instituto de Evaluación de Tecnologías en Salud e Investigación-IETSI, aprueba el uso de la fórmula semielemental con alto contenido de TCM en neoantos o infantes con diagnóstico de quilotórax congénito o adquirido. El present Dictamen Preliminar tiene una vigencia de dos años a partir de la fecha de publicación.

Is bilateral chylothorax possible after simple cough? Yes.

Chylothorax is accumulation of chylous fluid in the pleural space due to impaired integrity of the thoracic duct or its branches. In childhood, the causes differ from those in adults because children less frequently develop malignancies and are more resistant to trauma. Commonly, chylothorax occurs as a complication of tumoral invasion or cardiopulmonary surgery. Treatment of chylothorax is essentially medical. In the event of medical treatment failure or a massive effusion, surgery is needed. We describe the case of a 65-year-old woman who developed bilateral chylothorax after a simple cough. She was treated with a medium-chain triglyceride diet and thoracentesis.

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.

Skimmed milk preparation in management of congenital chylothorax.

BACKGROUND: Treatment for congenital chylothorax is based on adequate drainage of the pleural fluid and total parenteral nutrition followed by re-establishment of feeds using medium-chain-triglycerides based milk formulas which are expensive and not easily available. CASE CHARACTERISTICS: Two newborns (one term and one preterm) with congenital chylothorax. INTERVENTION: Skimmed milk preparation for enteral nutrition to provide high protein and low fat diet. OUTCOME: Successful resolution of chylothorax. MESSAGE: Skimmed milk preparation may be used for enteral nutrition of babies with congenital chylothorax where other feeding alternatives or commercial formulas are either not successful or are not available.

Evaluation of fat separation and removal methods to prepare low-fat breast milk for fat-intolerant neonates with chylothorax.

BACKGROUND: The purpose of this study was to compare 2 methods (syringe and spoon methods) of removing the fat from the low-fat milk portion and compare 3 methods (refrigerated centrifuge, nonrefrigerated centrifuge, and refrigeration method) of separating breast milk into the fat and low-fat milk components. METHODS: Human milk was divided into 24 aliquots using the 3 separating methods, and 2 methods (syringe, spoon) were compared to extract the low-fat milk. Thirty-one human milk samples were separated into fatty and low-fat milk layers using 3 methods: 24-hour refrigerator storage (2°C), centrifuged at 3000 rpm for 15 minutes at room temperature, and spun in the refrigerated-centrifuge at 3000 rpm for 15 minutes at 2°C. After 24 hours of refrigeration, a syringe was used to remove the low-fat milk. Triglycerides were analyzed before and after separation and removal methods. RESULTS: For fat removal, the syringe method (1.2 g/dl, 95% confidence interval [CI], 1.1-1.4, fat content) left 34% less residual fat compared to the spoon method (1.9 g/dl, 95% CI, 1.5-2.3); this difference did not reach statistical significance (P = .065). For fat separation, the centrifuge methods (mean: 1.0 g/dl, 95% CI, 0.8-1.1) left significantly less residual fat than the refrigerator method (3.4 g/dl, 95% CI, 3.0-3.7; P < .0001). CONCLUSION: Using the syringe vs a spoon at removing the milk from the fat, although not statistically significant, was likely of clinical importance. A centrifuge was more effective at separating the fat in human milk.

Low-fat diet management strategy for chylothorax after pulmonary resection and lymph node dissection for primary lung cancer.

OBJECTIVE: We reviewed our experience of iatrogenic chylothorax after pulmonary resection for primary lung cancer to evaluate a low-fat diet management strategy. METHODS: From October 2003 to March 2010, 1580 patients underwent lobectomy or greater resection and systematic mediastinal lymph node dissection for primary lung cancer at our institution. Chylothorax was diagnosed on the basis of chylous leakage from the chest tube and was confirmed by presence of triglycerides (>110 mg/dL) in the drainage fluid. We initially treated the patients with chylothorax conservatively with a low-fat diet (fat intake <10 g/day). If chest tube drainage produced >500 mL of chylous fluid during the first 24 hours after the initiation of the low-fat diet, surgical intervention was performed. If chest tube drainage produced >300 mL/day of chylous fluid after 3 days of a low-fat diet, we performed pleurodesis by injecting a preparation of OK-432, a penicillin-treated lyophilized preparation of a Streptococcus strain into the thoracic cavity through a chest tube. RESULTS: Postoperative chylothorax developed in 37 patients (2.3%), 33 men and 4 women, with a median age of 69 years (range, 44-84). The initial procedures were pneumonectomy in 1 patient and lobectomy in 36 patients. In 23 patients (62%), their condition resolved with the low-fat diet only. A total of 10 patients underwent OK-432 pleurodesis, and 8 of these were cured with continuation of the low-fat diet. These 31 patients who responded to conservative treatment (84%) resumed a normal diet at a median of 10 days (range, 5-27) after the chylothorax diagnosis. The remaining 6 patients (16%) underwent reoperation and were discharged at a median of 18 days (range, 14-33) after the initial surgery. CONCLUSIONS: A low-fat diet and OK-432 pleurodesis achieved positive results in >80% of patients with chylothorax after pulmonary resection with systematic mediastinal lymph node dissection within 4 weeks after the initial surgery. More than 500 mL of chylous fluid during the first 24 hours after the initiation of the low-fat diet was valid as an indication of the need for surgical intervention.