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Sloan P, Johng S, Daniel JM, Rhee CJ, Mahmood B, Gravari E, Marshall S, Downey AG, Braski K, Gowda SH, Fernandes CJ, Dariya V, Haberman BE, Seabrook R, Makkar A, Gray BW, Cookson MW, Najaf T, Rintoul N, Hedrick HL, DiGeronimo R, Weems MF, Ades A, Chapman R, Grover TR, Keene S. A clinical consensus guideline for nutrition in infants with congenital diaphragmatic hernia from birth through discharge. J Perinatol 2024; 44:694-701. [PMID: 38627594 DOI: 10.1038/s41372-024-01965-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 03/28/2024] [Accepted: 04/08/2024] [Indexed: 05/15/2024]
Abstract
OBJECTIVE To develop a consensus guideline to meet nutritional challenges faced by infants with congenital diaphragmatic hernia (CDH). STUDY DESIGN The CDH Focus Group utilized a modified Delphi method to develop these clinical consensus guidelines (CCG). Topic leaders drafted recommendations after literature review and group discussion. Each recommendation was sent to focus group members via a REDCap survey tool, and members scored on a Likert scale of 0-100. A score of > 85 with no more than 25% outliers was designated a priori as demonstrating consensus among the group. RESULTS In the first survey 24/25 recommendations received a median score > 90 and after discussion and second round of surveys all 25 recommendations received a median score of 100. CONCLUSIONS We present a consensus evidence-based framework for managing parenteral and enteral nutrition, somatic growth, gastroesophageal reflux disease, chylothorax, and long-term follow-up of infants with CDH.
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Affiliation(s)
- Patrick Sloan
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8116, St. Louis, MO, 63110-1093, USA.
| | - Sandy Johng
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - John M Daniel
- Department of Pediatrics, Division of Neonatology, University of Missouri Kansas School of Medicine, Kansas City, MO, USA
| | - Christopher J Rhee
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Burhan Mahmood
- Department of Pediatrics, Division of Newborn Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Evangelia Gravari
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | | | - Ann G Downey
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Katie Braski
- Department of Pediatrics, Division of Neonatology, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sharada H Gowda
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Caraciolo J Fernandes
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Vedanta Dariya
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Beth E Haberman
- Department of Pediatrics, Division of Neonatology, University of Cincinnati College of Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Ruth Seabrook
- Department of Pediatrics, Division of Neonatology, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Abhishek Makkar
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Brian W Gray
- Department of Surgery, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Michael W Cookson
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Tasnim Najaf
- Department of Pediatrics, Division of Newborn Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8116, St. Louis, MO, 63110-1093, USA
| | - Natalie Rintoul
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Holly L Hedrick
- Department of Pediatric General Thoracic and Fetal Surgery Children's Hospital of Philadelphia Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle Children's Hospital, Seattle, WA, USA
| | - Mark F Weems
- Division of Neonatology and Le Bonheur Children's Hospital, Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Anne Ades
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Rachel Chapman
- Department of Pediatrics, USC Keck School of Medicine, Fetal & Neonatal Institute, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Theresa R Grover
- Department of Pediatrics, Section of Neonatology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Sarah Keene
- Division of Neonatal-Perinatal Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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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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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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Abstract
Background and Objective Octreotide is a somatostatin analogue and has been used off-label for a variety of conditions. There are no specific guidelines for the use of octreotide in neonates and its safety and efficacy have not been systematically evaluated. The objective of this study is to present our experience of using octreotide therapy in neonates. Methods This is a retrospective study of neonates who received octreotide therapy during their hospital stay over a 15 years period (2003–2017) in a tertiary neonatal centre. The demographic details and indications of octreotide therapy including time of initiation, route, dose, duration and adverse effects of therapy were noted. The clinical course following octreotide administration was also analysed. Results Eleven neonates received octreotide therapy during the study period, of which nine had chylothorax and two had chylous ascites. Resolution of the chylous effusion with octreotide therapy was achieved in 4 out of 11 (36.3%) of the cases. The median duration of octreotide therapy in cases with successful resolution was 17.5 days. With the exception of minor side effects such as hyperglycaemia, none of the patients had any significant side effects that required discontinuation of therapy. Conclusion Octreotide was used safely as an adjunctive therapy for the treatment of chylothorax and chylous ascites in neonates. However, larger prospective controlled trials are required to establish the optimal dose, time of initiation, duration and efficacy of octreotide therapy in neonates.
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Affiliation(s)
- Syed Ahmed Zaki
- Monash Newborn, Monash Children's Hospital, Clayton, VIC, Australia
| | | | - Atul Malhotra
- Monash Newborn, Monash Children's Hospital, & Department of Paediatrics, Monash University, 246 Clayton Road, Clayton, VIC, Australia.
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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: 51] [Impact Index Per Article: 8.5] [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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Czobor NR, Roth G, Prodán Z, Lex DJ, Sápi E, Ablonczy L, Gergely M, Székely EA, Gál J, Székely A. Chylothorax after pediatric cardiac surgery complicates short-term but not long-term outcomes-a propensity matched analysis. J Thorac Dis 2017; 9:2466-2475. [PMID: 28932552 DOI: 10.21037/jtd.2017.07.88] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND The occurrence of postoperative chylothorax in children with congenital heart disease is a rare and serious complication in cardiac intensive care units (ICUs). The aim of our study was to identify the perioperative characteristics, treatment options, resource utilization and long term complications of patients having chylothorax after a pediatric cardiac surgery. METHODS Patients were retrospectively assessed for the presence of chylothorax between January 2002 and December 2012 in a tertiary national cardiac center. Occurrence, treatment options and long term outcomes were analyzed. Chylothorax patients less than 2 years of age were analyzed using propensity-matched statistical analysis in regard to postoperative complications after discharge. RESULTS During the 10-year period, 48 patients had chylothorax after pediatric cardiac surgery. The highest incidence was observed on the second postoperative day (7 patients, 14.6%). Seven patients (14.6% of the chylothorax population) died. During the follow up period, 5 patients had additional thromboembolic complications (2 had confirmed thrombophilia). Eleven patients had a genetic abnormality (3 had Down's syndrome, 3 had Di-Giorge's syndrome, 1 had an IgA deficiency and 4 had other disorders). During the reoperations (49 cases), no chylothorax occurred. After propensity matching, the occurrence of pulmonary failure (P=0.001) was significantly higher in the chylothorax group, and they required prolonged mechanical ventilation (P=0.002) and longer hospitalization times (P=0.01). After discharge, mortality and neurologic and thromboembolic events did not differ in the matched groups. CONCLUSIONS Chylothorax is an uncommon complication after pediatric cardiac surgery and is associated with higher resource utilization. Chylothorax did not reoccur during reoperations and was not associated with higher mortality or long-term complications in a propensity matched analysis.
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Affiliation(s)
| | - György Roth
- School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Zsolt Prodán
- Department of Pediatric Cardiac Surgery, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - Daniel J Lex
- School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Erzsébet Sápi
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - László Ablonczy
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - Mihály Gergely
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - Edgar A Székely
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | - János Gál
- Department of Anesthesiology and Intensive Care, Semmelweis University, Budapest, Hungary
| | - Andrea Székely
- Department of Anesthesiology and Pediatric Intensive Care, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary.,Department of Anesthesiology and Intensive Care, Semmelweis University, Budapest, Hungary
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Church JT, Antunez AG, Dean A, Matusko N, Deatrick KB, Attar MA, Gadepalli SK. Evidence-based management of chylothorax in infants. J Pediatr Surg 2017; 52:907-912. [PMID: 28342580 DOI: 10.1016/j.jpedsurg.2017.03.010] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/09/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Management guidelines for infants with chylothorax lack substantial evidence. We sought to identify variables that impact outcomes in these patients in order to develop an evidence-based management algorithm. METHODS We retrospectively reviewed the medical records of all infants diagnosed with chylothorax from June 2005 to December 2014 at our institution. Data collected included demographics, chest tube output (CTO), medical and dietary interventions, surgical procedures, and absolute lymphocyte count (ALC). Outcomes analyzed included death, sepsis, necrotizing enterocolitis (NEC), requiring surgery, and success of therapy, defined as CTO decrease by >50% within 7days. RESULTS Of 178 neonates with chylothorax, initial therapy was high medium chain triglyceride (MCT) feedings in 106 patients, nothing by mouth (NPO), total parenteral nutrition (TPN) in 21, and NPO/TPN plus octreotide in 45. Octreotide use in addition to NPO/TPN revealed no significant differences in any outcome including success (47% vs. 43%, p=0.77). Initial CTO and ALC correlated with needing surgery (p=0.002 and p=0.006, respectively), and with death (p=0.028 and p=0.043, respectively). ALC also correlated with sepsis (p<0.001). CONCLUSIONS Octreotide has no advantage over NPO/TPN alone in infants with chylothorax. CTO and ALC predict requiring surgery. We propose a management guideline based on CTO and ALC without a role for octreotide. TYPE OF STUDY Retrospective case-control study. LEVEL OF EVIDENCE 3.
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Affiliation(s)
- Joseph T Church
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA.
| | - Alexis G Antunez
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Ashley Dean
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Niki Matusko
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Kristopher B Deatrick
- Section of Pediatric Cardiovascular Surgery, Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - Mohammad A Attar
- Section of Neonatology, Department of Pediatrics, University of Michigan Health System, Ann Arbor, MI, USA
| | - Samir K Gadepalli
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, MI, USA
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Letendre JA, Boysen S. Cranial vena cava syndrome secondary to cryptococcal mediastinal granuloma in a cat. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2015; 56:365-369. [PMID: 25829555 PMCID: PMC4357908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The successful management of cranial vena cava syndrome with suspected secondary chylothorax due to mediastinal cryptococcal granuloma in a 4-year-old male domestic shorthair cat is described. Treatment included long-term antifungal medication, short-term corticosteroids, intermittent thoracocentesis, rutin, octreotide, and enalapril.
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Affiliation(s)
| | - Søren Boysen
- Address all correspondence to Dr. Søren Boysen; e-mail:
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