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| CASE REPORT |
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| Year : 2020 | Volume
: 9
| Issue : 4 | Page : 289-291 |
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Use of high-dose octreotide in the treatment of congenital chylothorax
Mohammad Abdulaziz Alhasoon
Department of Pediatrics, Unaizah College of Medicine and Medical Sciences, Qassim University, Buraydah, Kingdom of Saudi Arabia
| Date of Submission | 11-Apr-2020 |
| Date of Decision | 12-Apr-2020 |
| Date of Acceptance | 25-Aug-2020 |
| Date of Web Publication | 01-Oct-2020 |
Correspondence Address:
Dr. Mohammad Abdulaziz Alhasoon
Department of Pediatrics, Unaizah College of Medicine and Medical Sciences, Qassim University, Buraydah
Kingdom of Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcn.JCN_38_20
The report provides a critical examination of the use of octreotide at a dosage of 20 μg/kg/h in the treatment of congenital chylothorax. The case analysis recounts a recent application of high-dosage octreotide in the treatment of a neonatal patient who failed to respond to a lower dosage of octreotide. In this case, the patient responded effectively to octreotide at 20 μg/kg/h and was subsequently discharged without any side effects. This case is compared with similar cases published in recent literature to advance the clinical analysis of a potential application of high-dose octreotide in the treatment of congenital chylothorax when lower dosages fail to produce results.
Keywords: Congenital chylothorax, high dosage, neonatal, octreotide
How to cite this article:
Alhasoon MA. Use of high-dose octreotide in the treatment of congenital chylothorax. J Clin Neonatol 2020;9:289-91 |
| Introduction | |  |
Neonatal congenital chylothorax is a rare condition with an incidence of 1 in 27,244[1] and Up to 50% of neonates with neonatal chylothorax can be associated with genetic syndromes.[2] The disorder causes an accumulation of lymphatic fluid within the pleural cavity, and it is the most commonly reported cause of pleural effusion in newborn patients.[1] Currently, there are no uniform standards for the treatment of chylothorax, and a number of treatment strategies have been suggested by researchers in recent years. To improve the outcome of chylothorax treatment, new medicinal approaches have been attempted. One potential method of treatment is the utilization of high-dosage octreotide.
| Case Report | | |
A male infant was born through an emergency cesarean section at the gestational age of 37 weeks with a birth weight of 3.03 kg to a 35-year-old mother. Antenatal ultrasound and fetal ECHO were unremarkable as well as serology markers for the mother. He was born in poor condition and required resuscitation at birth with positive pressure ventilation and endotracheal intubation in the delivery room before transfer to the neonatal intensive care unit (NICU).
He was initially ventilated on conventional ventilation which was switched to high-frequency oscillatory ventilation at 1 h of age in view of worsening respiratory acidosis. The initial chest radiograph obtained following admission to NICU showed massive pleural effusion on the right side with significant mediastinal shift, shortly afterward, a chest tube was inserted on the right hemithorax and 200 ml of fluid was drained within the first 30 min following insertion [Figure 1]. The total chest drain output over the first 24 h was 600 ml. Pleural fluid sent for cytology and chemical analysis and the diagnosis of chylothorax was confirmed by the predominance of lymphocytes and high triglycerides (white blood cell count 2790/cells/μL, with 90% lymphocyte, and milky colored appearance).
On day 5, he was commenced on medium-chain triglyceride (MCT) based formula and octreotide therapy at 3 μg/kg/h. The octreotide dosage was progressively increased until day 12 at which point the dosage was recorded at 10 μg/kg/h. On day 15, high-drainage level continued to be recorded; therefore, octreotide dosage was increased to 12 μg/kg/h.
The high-drainage level was subsequently recorded on day 19, therefore he was commenced on a high dose of octreotide therapy at 20 μg/kg/h after obtaining parental consent. The patient responded to the increased dosage, with a total cessation of the chest drain output by day 25. He was successfully extubated on day 27, followed by the slow reduction of octreotide on day 28. Successful chest tube removal was achieved by day 30, followed by discontinuation of the octreotide on day 32. The MCT formula was gradually discontinued and replaced with standard formula without reaccumulation of chylothorax [Figure 2]. The patient was finally discharged on day 40. | Figure 2: The chest radiograph upon discharge from the hospital after removal of the chest tube and starting regular formula
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[Figure 3], [Figure 4], [Figure 5] shows the progress of the chest drain output and the octreotide dosages during the course of hospital stay. | Figure 5: The response of effusion amount to increasing dose of octreotide
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| Discussion | | |
We report a case history of chylothorax in a term infant who only responded to high-dose octreotide at 20 μg/kg/h. Indeed, our patient was initially treated with standard doses of octreotide therapy with no response in the chylous fluid output. Our patient did not develop significant side effects with the high-dose octreotide therapy. Multiple side effects have been reported in neonates treated with octreotide, including hyperglycemia, necrotizing enterocolitis, transient mild cholestasis, transient hypothyroidism, pulmonary hypertension, and severe hypotension.[3]
The introduction of high-dose octreotide proved to be effective in a case with severe effusion. Our patient did not respond effectively to the typical maximum octreotide dosage of 10–12 μg/kg/h.
Failure to respond to the typical maximum dosage of octreotide has been reported in a recent study that also examined the effective use of high-dose octreotide.[4] In that study, three patients who did not respond to octreotide at a dose range of 2–12 μg/kg/h.,[4] did respond favorably to an octreotide dose of 20 μg/kg/h with the eventual resolution of chylothorax and no significant side-effects.
Indeed, others have shown a response to octreotide therapy in the standard dose range of 7.5 μg/kg/h–12 μg/kg/h.[3],[5]
In another case report, an infant was successfully treated and improved with low-dose octreotide 2 μg/kg/h.[6] In this particular study, the patient required no intubation and experienced no side-effects.[6]
On the contrary, a systematic review in which the efficacy of octreotide, was assessed did not recommend its use in the treatment of neonatal chylothorax.[7]
On the other hand, there is a case series published the last year 2019.[1] showed that six cases of neonatal chylothorax were identified during a 10-year period, two had congenital chylothoraces, and four iatrogenic; octreotide was used in three neonates, but the dosage used had no significant effect on pleural output (doses were 1–2 μg/kg/h, 1–4 μg/kg/h, and 2–8 μg/kg/h).
Although the number of studies that specifically examine the usage of high-dose octreotide in neonatal patients is limited, recent results have shown promise. Therefore, it is necessary to expand research in this area in order to determine whether or not high-dose octreotide may be adopted as a standard treatment in those instances where a low-dose treatment regimen is ineffective. Some potential factors to be considered in future research include the combination of alternative feeding programs such as the use of skim milk,[8] as well as the potential long-term impact of high-dose octreotide within the digestive system.[9]
This strategy was recently applied in the treatment of a neonatal patient with congenital chylothorax. The treatment was reported as effective, with the patient discharged in a relatively short timeframe after receiving treatment. As a result, this treatment may be further explored as a standard strategy when low-dose octreotide fails to produce desired results.
The successful application of octreotide in a neonatal patient at a dosage of 20 μg/kg/h provides a potential step toward great improvements in treatment strategies. The high rate of infant mortality associated with chylothorax suggests that a new approach must be adopted. As stated in the introduction to this report, there is no formal standardization of chylothorax treatment, therefore medical professionals have been open to experimentation. Multiple cases showing the effective employment of high-dose octreotide in the treatment of chylothorax without significant side effects may provide the impetus for wider adoption of this treatment strategy. If further successes are recorded, it may be possible to recommend a new standard of treatment utilizing high-dose octreotide.
| Conclusion | | |
The case that has been described within this report is highly significant because it provides evidence of a new approach to treatment that may possibly be adopted in the event that low-doses of octreotide prove ineffective.
We recommend that the high dose of octreotide in congenital chylothorax can be safely augmented to a highest of 20 μg/kg/h.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials 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 | | |
| 1. | White MK, Bhat R, Greenough A. Neonatal chylothoraces: A 10-year experience in a tertiary neonatal referral centre. Case Rep Pediatr 2019;2019:3903598. Published 2019 Mar 13. doi:10.1155/2019/3903598.  |
| 2. | Downie L, Sasi A, Malhotra A. Congenital chylothorax: Associations and neonatal outcomes. J Paediatr Child Health 2014;50:234-8. |
| 3. | Bellini C, De Angelis LC, Bellini T. Octreotide treatment for neonatal chylothorax. World J Pediatr 2018;14:623. |
| 4. | Saito M, Kamoda T, Kajikawa D, Miyazono Y, Kanai Y, et al. High Dose Octreotide for the Treatment of Chylothorax in Three Neonates. J Neonatal Biol 2016;5:218. doi:10.4172/2167-0897.1000218. |
| 5. | Yin R, Zhang R, Wang J, Yuan L, Hu L, Jiang S, et al. Effects of somatostatin/octreotide treatment in neonates with congenital chylothorax. Medicine 2015;96:e7594. |
| 6. | Saeidi R, Nourizadeh S. Octreotide for the management of chylothorax in newborns, case report. Iran J Neonatol 2015;5:37-9. |
| 7. | Das A, Shah PS. Octreotide for the treatment of chylothorax in neonates. Cochrane Database Syst Rev 2010;(9):CD006388. |
| 8. | Sahoo T, Mangla MK, Sethi A, Thukral A. Successful treatment of congenital chylothorax with skimmed milk and long course octreotide. BMJ Case Rep 2018;11:bcr2018226347. Published 2018 Dec 3. doi:10.1136/bcr-2018-226347. |
| 9. | Lamberts SWJ, Hofland LJ. Anniversary review: Octreotide, 40 years later. Eur J Endocrinol 2019;181:R173-83. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
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