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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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LETTERS TO THE EDITOR
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 153-154
 

Skim milk preparation for the management of chylothorax developing after congenital diaphragmatic hernia repair


1 Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Pediatrics, Division of Neonatology, All India Institute of Medical Sciences, New Delhi, India

Date of Web Publication1-Mar-2019

Correspondence Address:
Dr. Vishesh Jain
Department of Pediatric Surgery, All India Institute of Medical Sciences, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_174_18

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How to cite this article:
Anand S, Jain V, Agarwala S, Priyadarshi M, Sankar M J. Skim milk preparation for the management of chylothorax developing after congenital diaphragmatic hernia repair. J Indian Assoc Pediatr Surg 2019;24:153-4

How to cite this URL:
Anand S, Jain V, Agarwala S, Priyadarshi M, Sankar M J. Skim milk preparation for the management of chylothorax developing after congenital diaphragmatic hernia repair. J Indian Assoc Pediatr Surg [serial online] 2019 [cited 2019 Jul 24];24:153-4. Available from: http://www.jiaps.com/text.asp?2019/24/2/153/253334




Sir,

A full-term male newborn, antenatally diagnosed as a left-sided diaphragmatic hernia, underwent laparotomy and repair of the diaphragmatic hernia at the 2nd day of birth. Intraoperatively, a large defect with a sac containing spleen, left lobe of liver, colon, and stomach was evident. On initiation of enteral feeds (breast milk) by orogastric route on postoperative day 6 (POD 6), there was an increase in the intercostal drain (ICD) output with milky white-appearing pleural fluid. Pleural fluid examination (total cell count of 600/mm3 [70% lymphocytes], triglycerides = 797 mg/dl, and pleural fluid cholesterol-to-serum cholesterol ratio of <1) confirmed the diagnosis of chylothorax.[1] We tried Simyl-medium chain triglycerides (MCT) formula for 2 days, but there were no changes in the effusion patterns. Moreover, the ICD output increased to around 1.5 times in that period. Thus, the decision to introduce fortified skim milk was taken on POD 11. There was a significant decline in the ICD output within 72 h of introduction of fortified skim milk with subsequent resolution of the chylothorax completely. The ICD was removed on POD 17, and the baby was transitioned to breastfeeds before discharge.

Chylothorax is the most common form of pleural effusion in neonates. Its exact etiopathogenesis following congenital diaphragmatic hernia (CDH) repair remains unclear. However, possible mechanisms contributing to its occurrence include injury to the diaphragmatic lymphatics, disruption of the lymphatics on the hernia sac, extrinsic compression of the mediastinal lymphatics, and congenital lymphatic malformation associated with CDH.[2] Prenatal diagnosis, diaphragmatic patch repair, and extracorporeal membrane oxygenation use have been independently associated with the development of chylothorax in newborns with CDH.

In the index case, the baby developed a moderate chylous output from the ICD on POD 6 subsequent to initiation of breastfeeds. The ICD output was neither high (≤100 ml/kg body weight) nor persistent (≤2 weeks) to opt for a surgical remedy.[3] Numerous studies have shown variable degrees of success with different nonsurgical methods of treating postoperative chylothorax. While Mills et al. have shown a 40% success rate by adopting total parenteral nutrition, a study by Hanekamp et al. have shown resolution of chylothorax in all children by instituting enteral formula rich in MCT.[2],[4] An alternative to these formulas is either a skim milk or expressed breast milk.[5] Here, we had initiated feeds with skim milk at 40 ml every 2 hourly. Feeds were gradually upgraded to 150 ml/kg/day. The calorie content in skim milk is low (33 Kcal/100 ml), and its fortification can be done with 2-g cornflower (8 Kcal) and 2 ml of MCT oil (16.8 Kcal) for every 100 ml of milk (as done in the index case). Furthermore, the addition of linoleic acid is advised to prevent essential fatty acid deficiency. In the index case, a significant decline in the chylous effusion was evident within 72 h of introducing feeds with fortified skim milk. Thus, fortified skim milk can be a cheap and potent alternative to the MCT enteral formulas in the refractory cases.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for images and other clinical information of the patient to be reported in the journal. The patient's parents understand that name and initials of the patient will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Maldonado F, Hawkins FJ, Daniels CE, Doerr CH, Decker PA, Ryu JH, et al. Pleural fluid characteristics of chylothorax. Mayo Clin Proc 2009;84:129-33.  Back to cited text no. 1
    
2.
Mills J, Safavi A, Skarsgard ED; Canadian Pediatric Surgery Network (CAPSNet). Chylothorax after congenital diaphragmatic hernia repair: A population-based study. J Pediatr Surg 2012;47:842-6.  Back to cited text no. 2
    
3.
Tutor JD. Chylothorax in infants and children. Pediatrics 2014;133:722-33.  Back to cited text no. 3
    
4.
Hanekamp MN, Tjin A Djie GC, van Hoek-Ottenkamp WG, Hazebroek FW, Tibboel D, Postema RR, et al. Does V-A ECMO increase the likelihood of chylothorax after congenital diaphragmatic hernia repair? J Pediatr Surg 2003;38:971-4.  Back to cited text no. 4
    
5.
Gupta V, Mahendri NV, Tete P, Santhanam S. Skimmed milk preparation in management of congenital chylothorax. Indian Pediatr 2014;51:146-8.  Back to cited text no. 5
    




 

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