A preterm extremely low birth weight (ELBW) infant developed recurrent apneas and bilateral pleural effusions secondary to umbilical venous catherization. The infant was managed by prompt drainage of the pleural fluid, supportive care and removal of the umbilical catheter. Although pericardial effusion and unilateral pleural effusion as complication of umbilical venous lines were previously reported [1-4], bilateral pleural effusion without pericardial effusion is not reported in newborns.

A preterm ELBW infant was born to a Gravida 3 mother at 28 weeks of gestation by emergency lower cesarean section secondary to doppler compromise and antepartum hemorrhage. Apgars at 1 and 5 minutes were 8 and 9, respectively. Antenatal period was complicated with maternal hypothyroidism and mother was diagnosed with autoimmune thyroiditis. The infant was admitted to NICU at 30 minutes of life and was started on nasal prong oxygen in view of mild respiratory distress. Chest radiograph at admission was normal. An umbilical venous line was inserted at 3 hours of life for partial parenteral nutrition. Position and tip of the line was confirmed with chest radiograph and 2D echocardiogram. On the second day of life, the infant was started on total parenteral nutrition with a protein of 3g/kg/day and lipid of 2gm/kg/day.

Chronology of events, drainage of chylous fluid from the pleural cavities, no recurrence of pleural collection after removal of umbilical venous line, high triglycerides in the pleural fluid support an association of umbilical vein catheter with bilateral pleural effusions in our index infant on parenteral nutrition. Two possible explanations for umbilical line induced pleural effusions are, line migration and hyperosmolar endothelial damage. Migration of catheter tip may occur because of movement of head and extremities and flushing of umbilical venous catheter by nursing staff. The umbilical vein catheter could perforate the pericardial sac to the mediastinum and cause bilateral pleural effusions. In the index case there was no evidence of catheter perforation of vessel wall or migration of catheter tip. Increased osmolality of the parenteral fluid causing endothelial damage may be the most plausible explanation for pleural effusions in this infant. Although, congenital hypothyroidism is rarely associated with chylothorax [5], the rapidity of improvement and the chronology of events make this association unlikely in the index case.

Sridhar, et al. [1] reported left pleural effusion in a 31 week preterm infant due to peripherally inserted central catheter migration 24 hours after insertion. They confirmed the line position with contrast X-ray which showed the tip in the left pulmonary artery and dye in the left lung field. The effusion resolved with removal of catheter. Pabalan, et al. [2] reported right sided pleural effusion in a 28 week preterm infant following umbilical venous catheterization. The complication occurred nearly 40 hours after the line placement. Chest X ray revealed normal tip position of the catheter. Drainage and catheter removal helped in complete resolution of the pleural effusion. Hong, et al. [3] reported umbilical venous line related pleural and pericardial effusion in a 34 week preterm infant [3]. In their case, the newborn was started on parenteral nutrition on day 2 of life, developed pleural effusion 5 days and pericardial effusion 8 days after insertion of umbilical venous catheter. The symptoms cleared only after removal of catheter on day 13 of life. The catheter position and tip was always appropriate and there was no evidence of line migration. Madhavi, et al. [4] reported right pleural effusion in a 26 week extremely preterm infant secondary to migration of a central venous catheter into pulmonary vasculature. They confirmed the catheter tip in right pulmonary artery by radiographic contrast examination. The baby improved after aspiration of pleural fluid and removal of central venous catheter. Similar cases of pericardial and unilateral pleural effusions [6] related to umbilical venous catheter or peripherally inserted central catheter placements have been well reported. However, bilateral pleural effusions without pericardial fluid complicating umbilical line placements are rare and not reported previously in newborns.

1. Sridhar S, Thomas N, Kumar ST, Jana AK. Neonatal hydrothorax following migration of a central venous catheter. Indian J Pediatr. 2005;72:795-6.

2. Pabalan MJ, Wynn RJ, Reynolds AM, Ryan RM, Youssfi M, Manja V, et al. Pleural effusion with parenteral nutrition solution: an unusual complication of an "appropriately" placed umbilical venous catheter. Am J Perinatol. 2007;24:581-5.

3. Hong EJ, Lee KA, Bae H, Kim MJ, Han HS. Umbilical venous Line related pleural and pericardial effusion causing cardiac tamponade in premature neonate. Korean J Pediatr. 2006;49:686-9.

4. Madhavi P, Jameson R, Robinson MJ. Unilateral pleural effusion complicating central venous catheterisation. Arch Dis Child Fetal Neonatal Ed. 2000;82:F248-249.

5. Noseda C, Putet G. [Congenital chylothorax and hypothyroidism: a case report and a review of the literature]. Arch Pediatr. 2009;16:1470-3.