Persistent Low-Output Neonatal Chylothorax: How Long Are We Justified to Wait for Pleurodesis in Partial Responders?

The aim of our study was to review our experience regarding the management of neonatal chylothorax, with particular focus on outcomes of partial responders.

We conducted a retrospective analysis of neonatal chylothorax cases between January 2015 and December 2023. First-line management included drainage, fasting, parenteral nutrition, and octreotide. Good responders had a drainage output of <2 ml/kg/day after 1 week; partial responders had 2-10 ml/kg/day, and non-responders had >10 ml/kg/day or >100 ml/day for 5 days with complications. Partial responders continued conservative management, while non-responders received second-line treatment with bedside iodopovidone chemical pleurodesis.

Thirty-five newborns (15 females, 20 males) were diagnosed with chylothorax, 11 congenital and 24 acquired (18 CDH, 5 esophageal atresia, 1 caval thrombosis). After first-line treatment, 7 (20%) were good responders, 19 (54%) were partial responders, and 9 (26%) were non-responders. Non-responders received iodopovidone pleurodesis, which resolved the condition in all cases (median time to resolution was 4 days). Complications during hospitalization included 8 cases of sepsis (1 fatal), 5 of atelectasis (4 related to pleurodesis), and 4 venous thromboses. Partial responders had significantly more sepsis (p = 0.029) but less atelectasis (p = 0.025) compared to non-responders, with similar resolution times and hospital stays. After a median follow-up of 3 years, there were no recurrences or thyroid dysfunction in the iodopovidone group.

First-line conservative management, although initially appropriate, can lead to serious morbidity if prolonged. Timely second-line treatment for partial responders with low-output chylothorax can minimize morbidity and mortality. Bedside chemical pleurodesis with iodopovidone is a safe and effective second-line treatment for refractory neonatal chylothorax.