a rare condition in newborns called congenital chylothorax ( cc ) occurs when lymphatic fluid accumulates within the pleural cavity .
here is a presentation of a birth traumatic case with bilateral pleural effusion successfully treated by octreotide .
a 3100-g - term male newborn delivered vaginally from a 33-year - old mother was admitted to the neonatal intensive care unit with respiratory distress signs . early chest x - ray ( cxr ) showed bilateral pleural effusion .
the thoracentesis pleural fluid had been drained with these characteristics : glucose : 1.9425 mmol / l , protein : 11
g / l , cholesterol : 1.295 mmol / l , and triglycerides : 3.39 mmol / l . counts of red blood cells and white blood cells were 10,000 and 2500 per cu / mm , respectively ; so , congenital chylothorax was diagnosed and total parenteral nutrition ( tpn ) were initiated .
therefore , we started feeding with a medium chain triglyceride ( mct ) , but plural effusion was seen once again and we had to restart tpn .
finally , the cxr and ultrasound did not show any pleural effusion in both sides and the ultrasound done in the third month showed no pleural effusion either .
octreotide therapy as one of the conservative managements for cc can be considered before surgical methods .
this treatment method also had some effects on the feeding initiation time and helped us to start feeding sooner
. however , more studies like clinical trials are still necessary to investigate all aspects of octreotide treatment to determine the amount of its dose , initiation time , treatment duration , etc .
a rare condition in newborns called congenital chylothorax ( cc ) occurs when lymphatic fluid accumulates within the pleural cavity ( 1 ) .
diagnosis of cc is confirmed when analysis of pleural fluid shows a triglyceride content equal to or more than 1.13
mmol / l with a cell count equal to or more than 1000 cells/l ( 80% or more lymphocytes ) ( 2 ) . in the post natal period ,
supportive methods like ventilator care , immediate drainage of effusion , and total parenteral nutrition ( tpn ) must be considered as first line treatment .
recently , using different doses of octreotide with different treatment responses was reported in some case reports ( 2 , 3 ) . surgical methods can be useful as a final option when using those managements could not help ( 4 ) . here is a presentation of a birth traumatic case with bilateral ( right prominent ) pleural effusion successfully treated by supportive care and low dose of octreotide .
this newborn male , weighing 3100 g , was delivered at 38th week of gestation from a 33-year - old mother through normal vaginal delivery .the score of apgar was 6 in 5 minutes .
there were acrocyanosis , subcostal , and intercostal retractions , and the acceleratory muscles were used for breathing that showed respiratory distress .
therefore , the infant was ventilated with ambo bag ( o2 sat was about 75% - 80% ) admitted to the neonatal intensive care unit ( nicu ) and finally connected to a ventilator at baqiyatallah hospital in tehran , iran . an early chest x - ray ( cxr ) showed bilateral ( right more than left ) pleural effusion with left - sided heart shift ( figure 1 ) .
kidney , urinary tract , and bladder also were reported normal in ultrasound but the report confirmed bilateral pleural effusion ( right prominent ) .
insertion of intercostal tubes ( icd ) was performed and about 60 cc of pleural fluid was drained ( first its color was light red and then gradually changed to white ) .
biochemistry analysis of pleural fluid showed following characteristics : glucose : 1.9425 mmol / l , protein : 11g / l , cholesterol : 1.295 mmol / l and triglycerides : 3.39 mmol / l . counts of rbc and wbc were 10,000 and 2500 per cu / mm .
after two weeks of begging tpn , accumulation of plural fluid was approximately stopped ; therefore , we started feeding with a medium chain triglyceride ( mct ) .
here we decided to start octreotide subcutaneously ( 1 g / kg / day ) .
with initiation of octreotide , bilateral pleural effusion was decreased , and respiratory status improved .
ultrasound was performed daily and showed a decrease of pleural effusion in the right side .
moreover , there was no evidence of pleural fluid in the left side ( figure 2 ) .
after 20 days of using octreotide , the cxr and ultrasound did not show any pleural effusion accumulation in the both sides , and the patient was discharged .
follow - up physical examination and ultrasound done during 3 months showed no pleural effusion .
as mentioned above chylothorax means accumulation of chyle within the pleural cavity , and it is based on the etiology . it is usually categorized in several forms like traumatic , spontaneous , and congenital ( 1 ) .
here we presented a case of cc in a newborn male with trauma birth that was successfully treated by continuous administration of low dose of octreotide .
the patient had a low apgar score and was in respiratory distress status ; so , he was shifted to the nicu and connected to a ventilator .
( triglyceride content  1.13 mmol / l with a cell count  1000 cells/l ( 80% or more lymphocytes ) ) ( 2 ) all options of therapeutic approaches for management of cc usually begin with supportive and conservative methods .
ligation of thoracic duct , pleural absorption , and pleurodesis as the surgery methods can be useful when all medical and conservative methods fail to reduce the pleural effusion and treatment of cc ( 4 ) , conservative methods include long hospitalization , thoracentesis and insertion of chest tube , total parenteral nutrition , and introduction of a mct diet ( 1 , 4 ) . also , octreotide is another option of conservative management that has been used in some cases for treatment of chylothorax .
it is a peptide that mimics the effect of somatostatin pharmacological and results in the reduction of gastrointestinal secretions , intrahepatic venous flow , amount of triglyceride , and chyle output of pleural effusion ( 1 , 5 , 6 ) .
intravenous infusion is necessary for somatostatin while octreotide can be used subcutaneously or intravenously ( 1 ) .
table 1 shows the studies that have previously used octreotide for the treatment of cc ( 2 - 4 , 7 - 16 ) .
based on this table , octreotide has been successfully used for the treatment of cc in some studies ; however , it should be taken into account that this treatment method can not be applied in all cases of cc . in the majority of these studies ,
octreotide usually starts initially 0.5 to 1 g / kg / h then gradually increases to 10 g / kg / h ( for 5 to 28 days ) .
mildly distended abdomen in two cases and pulmonary hypertension in 4 patients were side effects of the octreotide therapy reported in these studies . in our case ,
low dose of octreotide ( 1 g / kg / day ) was given subcutaneously and after 20 days there was no pleural effusion .
one of the advantages of using octreotide in our case was related to the feeding initiation time .
after one week of using octreotide , we could start feeding with mct without re - accumulation of fluid in the plural cavity .
adverse effects are rare but diarrhea or constipation , nausea , vomiting and hyperglycemia , or hypoglycemia have been reported in some cases ( 1 , 5 ) . in our case , we did not see any side effects of octreotide even with 20 days of the octreotide therapy .
ongenital chylothorax even as a rare etiology of pleural effusion should be considered in neonate with plural effusion and in respiratory distress .
also , based con the table 1 , it can be concluded that octreotide can be considered as a good option for conservative management of cc .
more studies like clinical trials are still necessary to investigate all aspects of octreotide treatment to determine the amount of its dose , time of initiation and duration of treatment , its treatment effect together with other conservative treatment and etc .
 introduction : a rare condition in newborns called congenital chylothorax ( cc ) occurs when lymphatic fluid accumulates within the pleural cavity . here is a presentation of a birth traumatic case with bilateral pleural effusion successfully treated by octreotide.case presentation : a 3100-g - term male newborn delivered vaginally from a 33-year - old mother was admitted to the neonatal intensive care unit with respiratory distress signs . 
 early chest x - ray ( cxr ) showed bilateral pleural effusion . the thoracentesis pleural 
 fluid had been drained with these characteristics : glucose : 1.9425 mmol / l , protein : 11 
 g / l , cholesterol : 1.295 mmol / l , and triglycerides : 3.39 mmol / l . counts of red blood cells and white blood cells were 10,000 and 2500 per cu / mm , respectively ; so , congenital chylothorax was diagnosed and total parenteral nutrition ( tpn ) were initiated . 
 accumulation of plural fluid was approximately stopped after begging tpn for two weeks . 
 therefore , we started feeding with a medium chain triglyceride ( mct ) , but plural effusion was seen once again and we had to restart tpn . 
 we decided to start octreotide subcutaneously ( 1 g / kg / day ) . 
 finally , the cxr and ultrasound did not show any pleural effusion in both sides and the ultrasound done in the third month showed no pleural effusion either.conclusions:octreotide therapy as one of the conservative managements for cc can be considered before surgical methods . 
 this treatment method also had some effects on the feeding initiation time and helped us to start feeding sooner 
 . however , more studies like clinical trials are still necessary to investigate all aspects of octreotide treatment to determine the amount of its dose , initiation time , treatment duration , etc . 