An international survey of the nutrition management of chylothorax: a time for change

Marino, Luise V.; Bell, K.; Woodgate, J; Doolan, Annabel

doi:10.1017/s1047951119001525

Cited by 13 publications

(13 citation statements)

References 36 publications

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“…In a previous study we conducted at our institution, infants with post-surgical chylothorax fed MFBM for a minimum of 6 weeks (n ¼ 8) demonstrated both clinically relevant and statistically significant declines in weight-and length-for-age zscores whereas infants treated with MCT formula (n ¼ 8) did not [6]. As reported in a recent international survey, both feeding management practices and duration of treatment for chylothorax vary widely [27]. While this, and small sample sizes, may account for differences in growth across institutions and individual studies, data from the present study suggest proactive enteral feeding guidelines seem to be a prudent approach to improving growth of infants being treated for post-surgical chylothorax.…”

Section: Discussionmentioning

confidence: 72%

Growth of cardiac infants with post-surgical chylothorax can be supported using modified fat breast milk with proactive nutrient-enrichment and advancement feeding protocols; an open-label trial

DiLauro

Russell

McCrindle

et al. 2020

Clinical Nutrition ESPEN

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Background & aim: Previously we showed that modified fat breast milk (MFBM) facilitated resolution of post-surgical chylothorax in cardiac infants, but their weight-forage and length-forage z-scores declined over the !6-week treatment duration. Our aim was to evaluate the growth of infants diagnosed with post-surgical chylothorax and fed according to one of two proactive feeding protocols using MFBM or a high medium triglyceride (MCT)-containing formula (standard of care). Methods: In this open-label trial, infants who were receiving >50% of their enteral feeds as breast milk prior to chylothorax diagnosis were randomized to receive their enteral feeds according to one of two proactive MFBM protocols: Target Fortification (n ¼ 8), where the protein concentration of defatted breast milk was measured weekly and multi-and single-nutrient modulars were added to provide 3.5 g/kg/day of protein; or Higher Initial Concentration (n ¼ 8), where defatted breast milk was initially fortified to an energy and nutrient level higher than that of unmodified breast milk (80kcal/100 ml; 2.2 g/100 ml protein). A third nonrandomized group of infants (n ¼ 8) received high MCT formula (68kcal/100 ml; 2.3 g/100 ml protein). The intervention lasted for a minimum of 6-weeks after chest tube removal and continued after discharge. Weekly weight, length and head circumference (HC) measurements were completed. Results: At enrolment, there was no statistically significant differences in mean (±SD) weight-forage (À1.6 ± 0.9, n ¼ 24), length-forage (À1.3 ± 0.8), or HC-forage (À0.9 ± 1.0) z-scores among groups. Changes in mean weight-(À0.3 ± 0.9, n ¼ 23), length-(0.1 ± 0.6) and HC-forage (0.2 ± 0.6) z-scores did not differ among groups over the treatment period. There was no difference in duration or volume of chest tube drainage across groups. Conclusion: Use of proactive MFBM feeding protocols both resolve chylothorax and support growth in infants following cardiothoracic surgery. Trial registration: ClinicalTrials.gov (NCT02577419).

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Section: Discussionmentioning

confidence: 72%

Growth of cardiac infants with post-surgical chylothorax can be supported using modified fat breast milk with proactive nutrient-enrichment and advancement feeding protocols; an open-label trial

DiLauro

Russell

McCrindle

et al. 2020

Clinical Nutrition ESPEN

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“…Given the variable incidence of chylothorax across centers it is also plausible that the etiology may also vary and thus high CTO may not be an early manifestation at other centers. [1,3,4,7,8,11,14,21,28,32,33] However, our external validation results suggest the model is generalizable.…”

Section: Commentmentioning

confidence: 77%

“…The complications associated with chylothorax following pediatric cardiac surgery include increased mortality, length of stay (LOS), cost, malnutrition, central line dependence, thrombosis, and infections. [1][2][3][4][5][6][7][8][9][10][11][12] These adverse associations are exacerbated by increased chylothorax duration.…”

Section: Introductionmentioning

confidence: 99%

Prediction Model with External Validation for Early Detection of Postoperative Pediatric Chylothorax

et al. 2023

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Background: Earlier diagnosis of chylothorax following pediatric cardiac surgery is associated with decreased duration of chylothorax. Pleural uid testing is used to diagnosis chylothorax which may delay detection in patients who are not enterally fed at time of chylothorax onset. Our aim was to develop and externally validate a prediction model to detect chylothorax earlier than pleural uid testing in pediatric patients following cardiac surgery.Methods: A Multivariable logistic regression model was developed to detect chylothorax using a stepwise approach. The model was developed using data from patients <18 years following cardiac surgery from Primary Children's Hospital, a tertiary-care academic center, between 2017 and 2020. External validation used a contemporary cohort (n=171) from Lucille Packard Children's Hospital.Results: A total of 763 encounters (735 patients) were analyzed, of which 72 had chylothorax. The nal variables selected were chest tube output (CTO) the day after sternal closure (dichotomized at 15.6 mL/kg/day, and as a continuous variable) and delayed sternal closure. The highest odds of chylothorax was associated with CTO on post sternal closure day 1 >15.6mL/kg/day (odds ratio 11.3, 95% CI 6,3, 21.3). The c-statistic for the internal and external validation datasets using the dichotomized CTO variable were 0.78 (95% CI:0.73, 0.82) and 0.84 (95% CI, 0.78, 0.9) and performance improved when using CTO as a continuous variable (OR 0.84, CI: 95% CI 0.80, 0.87) Conclusions: Using the models described, chylothorax after pediatric cardiac surgery may be detected earlier and without reliance on enteral feeds.

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“…Common practice includes trial of an medium-chain triglyceride-based infant formula or defatted human milk for 2-7 days and monitoring total chest tube drainage before considering parenteral nutrition. 9 Formulas commercially available for infants with chylothorax, specifically those with feeding intolerance or documented milk protein allergies, are limited. Often, off label use of toddler and adolescent formulas are required but should be done with close nutritional guidance to avoid nutrient deficiency.…”

Section: Neonates and Infant Diet Managementmentioning

confidence: 99%

“…Medium-chain triglyceride-rich diets where >85% of the fat source is medium-chain triglycerides used for the treatment of chylothorax may not provide adequate amounts essential fatty acids. 9 Essential fatty acid deficiency results when there is insufficient dietary intake of linoleic acid and alpha-linolenic acid from a limitation of dietary fat or altered absorption of fat. 35 The human body is unable to synthesise linoleic acid (18:2 Δ 9,12 ) and alpha-linolenic acid (18:3 Δ 9,12, 15 ) due to the lack of enzymes that can introduce double bonds beyond the Δ 9 site, therefore making them essential from the diet.…”

Section: Essential Fatty Acid Deficiencymentioning

confidence: 99%

Nutritional management of postoperative chylothorax in children with CHD

et al. 2022

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Introduction: Chylothorax after congenital cardiac surgery is associated with increased risk of malnutrition. Nutritional management following chylothorax diagnosis varies across sites and patient populations, and a standardised approach has not been disseminated. The aim of this review article is to provide contemporary recommendations related to nutritional management of chylothorax to minimise risk of malnutrition. Methods: The management guidelines were developed by consensus across four dietitians, one nurse practitioner, and two physicians with a cumulative 52 years of experience caring for children with CHD. A PubMed database search for relevant literature included the terms chylothorax, paediatric, postoperative, CHD, chylothorax management, growth failure, and malnutrition. Results: Fat-modified diets and nil per os therapies for all paediatric patients (<18 years of age) following cardiac surgery are highlighted in this review. Specific emphasis on strategies for treatment, duration of therapies, optimisation of nutrition including nutrition-focused lab monitoring, and supplementation strategies are provided. Conclusions: Our deliverable is a clinically useful guide for the nutritional management of chylothorax following paediatric cardiac surgery.

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An international survey of the nutrition management of chylothorax: a time for change

Cited by 13 publications

References 36 publications

Growth of cardiac infants with post-surgical chylothorax can be supported using modified fat breast milk with proactive nutrient-enrichment and advancement feeding protocols; an open-label trial

Growth of cardiac infants with post-surgical chylothorax can be supported using modified fat breast milk with proactive nutrient-enrichment and advancement feeding protocols; an open-label trial

Prediction Model with External Validation for Early Detection of Postoperative Pediatric Chylothorax

Nutritional management of postoperative chylothorax in children with CHD

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