Sir: Chylothorax in a premature infant is a relatively rare complication; however, the disease may cause significant breathing difficulty and may even necessitate the use of ventilatory support [2]. Patients may suffer from massive lymph drainage causing significant losses of fluid, protein and lymphocytes. We report a case of chylothorax which occurred suddenly on the 98th day after birth and was treated successfully with continuous intravenous infusion of octreotide.

The female infant was delivered vaginally at 24 weeks and 3 days of gestation. The birth weight was 690 g and the Apgar score was 3 at 1 min and 5 at 5 min. She was intubated immediately after birth and admitted to the neonatal intensive care unit. During the 1st hour of life, exogenous surfactant was instilled and an umbilical artery catheter was placed. The infant was managed using a mechanical ventilator for the next 17 days and then nasal CPAP was continued for the following 3 weeks. On the 15th day after birth, the surgical closure of a patent ductus arteriosus was performed. The oxygen requirement tended to decrease and on the 47th day after birth, the infant became oxygen-independent. Since the 70th day of life, the infant had been fed exclusively with breast milk and gained weight regularly. At 98 days of age, an increase in respiratory effort was observed and infant required 30% supplementary oxygen. A chest X-ray film revealed a white pleural effusion in the left thoracic cavity (Fig. 1). Within the next 24 h, breathing difficulty arose and the infant was intubated. We decided to evacuate the pleural space by tube thoracostomy and obtained 65 ml of a milky fluid. Cytological analysis of the chest fluid showed lymphocytes (97%), macrophages (0.5%) and tissue cells (2.5%). Chemical analysis of the fluid demonstrated total protein (29 g/l), high-density lipoprotein (0.29 mmol/l), low-density lipoprotein (above the upper limits of measurable range), triglycerides (4.67 mmol/l) and glucose (4.3 mmol/l). Chest fluid culture was negative. We changed the breast milk feeding to medium-chain triglyceride-formula and observed that the pleural effusion was no longer milky. Nevertheless, the flow remained abundant (50 ml/24 h) and the infant still required ventilatory support and supplementary oxygen at the level of 25%–30%. On the 5th day after the diagnosis of chylothorax was made and since the clinical condition of the infant remained unchanged, we decided to use octreotide. A continuous intravenous infusion of octreotide (0.3 µg/kg per h) was introduced after obtaining informed parental consent. After the first 24 h of octreotide therapy, the chest drainage stopped and infant was extubated. On the 3rd day of treatment, the chest tube was removed and breast milk feeding re-introduced. The infusion of octreotide was continued for a total 4 days. No side-effects such as hyperglycaemia or hypotension were observed during the whole period of treatment. The chest X-ray film obtained on the 7th day after the octreotide infusion was completed, demonstrated no pleural effusion in the left thoracic cavity (Fig. 2). The infant was discharged on the 127th day of life.

Fig. 1
figure 1

The pleural effusion in the left thoracic cavity

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Fig. 2
figure 2

A chest X-ray film shows no accumulation of fluid on the 7th day after completing octreotide therapy

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Conservative therapy of chylothorax currently includes the use of a diet with medium-chain triglycerides or discontinuing enteral feeding and replacing it with parenteral nutrition [1, 3,5]. The lack of oral intake stops stimulation of gastrointestinal tract secretion and absorption of food. It causes less volume offered for absorption and flow into the thoracic duct. However, depriving a premature infant of enteral nutrition may increase the risk of necrotising enterocolitis. The mechanism of somatostatin action seems to be dependent on its inhibitory effects on hepatic, splanchnic and portal blood flow [3, 4,6]. Somatostatin also inhibits pancreatic secretion, decreases gallbladder contractility and intestinal transit time. It reduces absorption of glucose, amino acids as well as gastrointestinal tract peptide hormones release. According to our knowledge, there is no previous report describing the use of somatostatin in the treatment of thoracic duct injury, spontaneously occurring in a premature infant in the 4th month of life. The introduction of somatostatin, immediately and significantly reduced chyle production, without any adverse clinical side-effects.