Chylothorax and Breastfeeding
by Anne Eglash MD, IBCLC, FABM
Chylothorax is a condition where lymphatic fluid collects in the chest cavity, between the lung and the chest wall. Infants are rarely born with this, and others develop this after surgery due to disruption of the lymphatic system that is supposed to haul away this fluid. The fluid contains proteins, fats and different elements from the immune system such as antibodies and infection-fighting cells. Because this nutritious fluid ends up in the chest wall, the infant can develop malnutrition, dehydration and infections.
According to the authors of this week’s CQW, the primary management for chylothorax is dietary, which involves using medium-chain triglycerides as the fat source, rather than long chain fatty acids found in breastmilk, in order to bypass the lymphatic system. Medium chain fatty acids do not transfer into the lymph tissue like long chain fatty acids do. Over time, the infant’s body heals its lymphatic system. Historically mothers were instructed to not breastfeed infants with chylothorax.
As our readers know, breastmilk has a myriad of bioactive factors that help fight infection and strengthen the infant’s immune system. So the question is, can infants with chylothorax receive breastmilk? The long-chain fatty acids in breastmilk would need to be removed in order to avoid increasing the chyle volume.
The authors performed a systematic review of published literature on this topic. Admittedly, the research is scant, with only a retrospective case series, a few case reports, and 2 small case studies meeting criteria for this review.
- It is generally recommended to fortify skimmed breastmilk with medium chain triglycerides, fat-soluble vitamins, essential fatty acids, and protein.
- Using a centrifuge to separate the fat from breastmilk has been shown to be effective.
- Many human milk banks have the equipment and knowledge to skim breastmilk.
- Continuing dietary fat restriction for the infant for 2-6 weeks after lymphatic fluid is gone would be reasonable.
- Skimmed breastmilk contains ½ the calories of regular breastmilk.
- Allowing milk to separate in the refrigerator, and then using a syringe or spoon to remove the fat layer, is as effective as centrifuging the milk to remove the fat layer.
See the Answer
Congenital chylothorax (CC) is a rare and life-threating condition. Since its treatment is founded on the elimination of long-chain fatty acids from the diet, breastfeeding has been traditionally contraindicated. However, breast milk could be very beneficial due to its immunological and nutritional benefits. Only limited research has been published about the usage of modified-fat breast milk (MBM) in chylothorax treatment.
Methods and Results
Systematic review methods were used by two independent reviewers. Only a few case report studies (quality assessment on the domains of the GRADE approach), two small controlled studies, a retrospective study, and some test-tube-based laboratory research met the inclusion criteria. Despite this, we have observed a widespread clinical adoption of this novel treatment in health institutions. Data suggest that modified-fat breast milk does facilitate the resolution of chylothoraces. Refrigerated centrifuge (2C, 3,000 rpm for 15 minutes) and syringe fat removal methods were the most efficient options in terms of fat reduction.
Feeding of human milk is advisable in CC and feasible by means of a simple milk defatting procedure. Open questions remain, related to length and degree of fat restriction and need for individualized fortification of defatted breast milk.
We don’t have much information in the literature regarding the use of skimmed breastmilk for chylothorax, and the studies included in this review include different methods of skimming, depending on whether it is done in the hospital, at home, or at a milk bank. Centrifuging the milk appears to be more effective at removing fat than removing the fat with a syringe or spoon, after the milk has separated in the refrigerator. One case study involved an infant whose family use a top loading washing machine to centrifuge the milk for skimming.
The bottom line is that the fat removal procedure is not complicated. Involvement of a nutritionist to determine proper fortification of the skimmed milk is important, as is close monitoring of infant growth. In short, there does not appear to be a good reason to withhold fortified skimmed breastmilk from infants with chylothorax.