Indian Pediatr 2014;51: 146-148
Skimmed Milk Preparation in Management of
V Gupta, *NV Mahendri, P Tete and Sridhar Santhanam
From the Department of Neonatology and *Dietetics,
Christian Medical College, Vellore, Tamil Nadu, India.
Correspondence to: Dr. Sridhar Santhanam, Professor,
Department of Neonatology, Christian Medical College, Vellore,
Tamil Nadu, India.
Received: July 8, 2013;
Initial review: August 22, 2013;
Accepted: December 05, 2013.
Background: Treatment for congenital chylothorax is based on
adequate drainage of the pleural fluid and total parenteral nutrition
followed by re-establishment of feeds using medium-chain-triglycerides
based milk formulas which are expensive and not easily available.
Case characteristics: Two newborns (one term and one preterm) with
congenital chylothorax. Intervention: Skimmed milk preparation
for enteral nutrition to provide high protein and low fat diet.
Outcome: Successful resolution of chylothorax. Message:
Skimmed milk preparation may be used for enteral nutrition of babies
with congenital chylothorax where other feeding alternatives or
commercial formulas are either not successful or are not available.
Keywords: Chylothorax, Neonate, Octreotide,
Skimmed milk preparation
with predominance of mononuclear cells along with high triglyceride
mmol/L or 106.2 mg/dL) . Medical management includes pleural
drainage, cessation of oral feeds with total parenteral nutrition (TPN),
diet modification with milk low in fat content, and octreotide. We
report the successful use of skimmed milk preparation for enteral
nutrition in congenital chylothorax.
Chylothorax is a collection of
lymphatic fluid within the pleural space, and is relatively uncommon
. Case fatality rate of congenital chylothorax, when complic2ated
with hydrops, can reach upto 98% . The diagnosis of chylothorax is
made in the presence of white cell count of greater than 1,000 cell/mm
Case 1: A female weighing 2030g was born at 33
weeks of gestation to a 29-year-old mother by elective caesarean section
done in view of antenatally detected hydrops with increasing bilateral
pleural effusion. There was history of two previous intrauterine deaths
with fetal hydrops. This baby was depressed at birth with APGAR scores
of 6 and 9 at 1 and 5 minutes, respectively. She had respiratory
distress soon after birth, and was intubated and ventilated. X-ray
showed bilateral pleural effusion; pleural tap done soon after birth
drained 40 mL straw coloured fluid from right hemithorax, the analysis
of which was suggestive of chylothorax (WBC count 4100/mm3
with 98% lymphocytes, triglycerides 393 mg/dL, chylomicrons 400 mg/dL
and protein 2.8 g/dL).
Chest tube was inserted on day 2 of life for
progressively increasing fluid collection. She was started on gavage
feeds with expressed breast milk (EBM) from day 3 of life, reaching 66
mL/kg/day by day 8 of life. In view of persistent pleural drainage,
feeds were stopped and parenteral nutrition was started. She was also
started on octreotide infusion starting at 1 µg/kg/hr from day 9 of life
reaching 9 µg/kg/hr by day 14
of life. Trial of feeding with medium-chain triglyceride-
based milk was unsuccessful. The dose of octreotide was kept almost
constant i.e., 9 µg/kg/hr until day 40 of life. Finally, skimmed
milk preparation (prepared from skimmed milk powder (10g), table sugar
(10g), coconut oil (2g) and water to make total volume 100 mL) was used
for enteral nutrition in addition to intravenous octreotide from 32nd
day of life. Pleural drainage started declining and finally ceased by
34th day of life. Baby was discharged on skimmed milk preparation along
with fat soluble vitamin supplements on 42nd day of life. At 4 months,
baby had reached a weight of 4000 g, and started on weaning foods. Her
growth and development was appropriate for her corrected age on
Case 2: A male baby weighing 3220 g was
delivered at term to a 22-year-old mother by normal vaginal delivery.
There was antenatal detection of a left sided pleural effusion. Baby was
depressed at birth with APGAR scores of 6 and 9 at 1 and 5 minutes,
respectively. Baby had mild respiratory distress soon after birth. Left
sided chylothorax was diagnosed on biochemichal analysis (WBC 6200/mm3,
protein 3.4 g/dL, glucose 83 mg/dL, triglyceride 147 mg/dL, chylomicrons
102 mg/dL) of pleural fluid. He was started on gavage feeds using EBM
soon after birth and graded up until 120 mL/kg/day by day 6 of life.
Chest drain was inserted on day 6 of life in view of gradually
increasing pleural fluid; feeds were stopped. He was started on TPN and
kept nil-by-mouth from day 7 to day 16 of life. Skimmed milk preparation
was started from day 16 of life. Feeds were graded up to 150 mL/kg/day
by day 21 of life, and chest drain was removed on day 22 of life when
there was no pleural drainage for preceding 5 days. He was discharged on
skimmed milk preparation with no further re-accumulation of pleural
Congenital chylothorax may present with bilateral
pleural effusions and respiratory insufūciency [2,4]. Hydrops may
develop due to impaired venous return by cardiac and vena caval
compression, and/or loss of protein into pleural space leading to
generalized hypoproteinemia and edema . Octreotide, a somatostatin
analogue, has been used in various cases of congenital and postoperative
chylothorax [5-7]. We unsuccessfully used octreotide infusion in the
first baby. Special milk formulas  are not freely available in India
in view of a stringent infant food act, and are far too expensive to
use. Use of fat-free human milk was reported beneficial by Chan, et
al. . We, therefore, tried the formula prepared from skimmed milk
powder which led to resolution of effusion in both babies. Adequate
weight gain was documented during hospital stay, and after discharge, in
both the children.
The use of pleural drain, TPN and octreotide is
recommended in the initial management of congenital chylothorax. On
resolution of the effusion, enteral feeds need to be started using low
fat or fat-free milk formulas which are costly and are not freely
available. Skimmed milk preparation with coconut oil (rich in
medium-chain- triglyceride) could be a cheap and effective alternative
to provide low fat and high protein calories in patients with congenital
chylothorax where other feeding options have failed or commercial
formulas are not accessible.
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