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• Response to the article: Povidone-iodine pleurodesis for congenital chylothorax of the newborn
  Nadia kasdallah
  Published on: 22 March 2016
• Povidone-iodine pleurodesis for congenital chylothorax of the newborn (Resch et al.)
  Roland Hentschel
  Published on: 22 March 2016

• Published on: 22 March 2016

  Response to the article: Povidone-iodine pleurodesis for congenital chylothorax of the newborn

  • Nadia kasdallah, Doctor/Neonatologist

  To the editor: As part of a review of the literature regarding the use of Povidone iodine (PVI) to perform chemical pleurodesis in the management of congenital chylothorax (CCT), we read with great interest the case reported by Resch et al (1) and their following conclusion: "the risk-benefit assessment of PVI pleurodesis in the treatment of congenital chylothorax does not support its routine use as it may be associate...

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  To the editor: As part of a review of the literature regarding the use of Povidone iodine (PVI) to perform chemical pleurodesis in the management of congenital chylothorax (CCT), we read with great interest the case reported by Resch et al (1) and their following conclusion: "the risk-benefit assessment of PVI pleurodesis in the treatment of congenital chylothorax does not support its routine use as it may be associated with significant harm". We believe that the current data are certainly insufficient to draw definitive conclusions about the efficacy and safety of this procedure in the neonate. Randomized studies on large neonatal population are required to precise: the risks and benefits of this procedure, the timing and the modalities of its realization (duration of intervention, dilution and dosage of PVI) according to the patient's field (gestational age, weight and associated morbidity). However, we draw attention that significant harms after this procedure were reported in only specific situations. Brissaud O et al (2) reported the case of a newborn dead from end stage renal failure, oliguria, hydrops, and refractory hypotension after PVI pleurodesis. However, this patient had diffuse congenital lymphangectasia in the autopsy. This condition would favorite iodine absorption and could explain the worsening of oligoanuria and precipitation of renal failure in this patient. In another case of CCT reported by Mitanchez et al (3), lymphangiectasis was suspected and even chyle flow resolved within 24 hours, shock and acute renal failure occurred within 12 hours after instillation. Severe chronic failure was persist 6 months later. Mitanchez et al (3) have postulated that the pulmonary lymphangectasia would have favored the massive iodine absorption and thus intoxication in both cases. The case reported by Resch et al (1) combine tow risk factors for developing severe side effects of PVI. First, he has a pulmonary lymphangiectasia who already was jagged as a factor favoring systemic absorption and thus intoxication by the product. Second, he received a high concentration of PVI (10%) as the patient of Mitanchez et al (3). This could also explain the amplification of the risk of major adverse. Scottoni F et al (4) reported another hard situation of an extremely low birth weight and premature infant with extensive deep central veins thrombosis, abnormal renal function before treatment and who has developed multiple organ failure after the procedure. In our opinion, all these serious situations are likely to be either unresponsive to treatment or predictive of major side effects and should be excluded.

  References: 1 Resch B, Freidl T, Reiterer F. Povidone-iodine pleurodesis for congenital chylothorax of the newborn. Arch Dis Child Fetal Neonatal Ed Published Online First: 29 September 2015. doi:10.1136/archdischild-2015- 309184 2-Brissaud O, Desfrere L, Mohsen R, Fayon M, Demarquez J. Congenital idiopathic chylothorax in neonates: chemical pleurodesis with povidone- iodine (Betadine). Arch Dis Child Fetal and Neonatal Ed. 2003;88(6):F531- F533. 3-Mitanchez D, Walter-Nicolet E, Salomon R, Bavoux F, Hubert P. Congenital chylothorax: what is the best strategy? Arch Dis Child. Fetal Neonatal Ed. 2006;91(2):F153. 4-Scottoni F, Fusaro F, Conforti A, et al. Pleurodesis with povidone- iodine for refractory chylothorax in newborns: Personal experience and literature review. J Pediatr Surg Published Online First: 28 April 2015. doi:10.1016/j.jpedsurg.2015.03.069

  Conflict of Interest: None

  Conflict of Interest:

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  Conflict of Interest:
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• Published on: 22 March 2016

  Povidone-iodine pleurodesis for congenital chylothorax of the newborn (Resch et al.)

  • Roland Hentschel
  • Other Contributors:
    • Hans Fuchs and Daniel Klotz

  To the editor: We read with interest the case report on the use of polividon-iodine (PVI) to perform chemical pleurodesis in newborns and the short literature review on further 12 cases in 5 publications by Resch et al.[1]. We found another most recent publication from 2015 on a series of 5 young infants with a success rate of 80%[2]. We agree with Resch et al., who conclude that "the risk-benefit assessment of PVI pleur...

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  To the editor: We read with interest the case report on the use of polividon-iodine (PVI) to perform chemical pleurodesis in newborns and the short literature review on further 12 cases in 5 publications by Resch et al.[1]. We found another most recent publication from 2015 on a series of 5 young infants with a success rate of 80%[2]. We agree with Resch et al., who conclude that "the risk-benefit assessment of PVI pleurodesis in the treatment of congenital chylothorax does not support its routine use as it may be associated with significant harm". However, we miss in their brief report a distinct warning of the danger of disturbed thyroid function after administration of PVI, in particular in newborns. PVI is indicated for skin disinfection. At a concentration of > 5 mg/l free iodine is microbicidal. Standard 7.5%- or 10%-PVI solutions have a concentration of free iodine between 10 and 22 mg/l[3]; assuming total enteral nutrition a 1.5 kg-infant gets 15 - 25mcg of iodine per day from mother's milk or formula, but a further 50 - 110 mcg, if 5 ml PVI is instilled in the pleura[1]. Assuming an equal or even better absorption rate through the pleura this may result in a reduction in thyroid hormone levels (Wolff-Chaikoff effect) in a population of newborns and preterm infants, which is particularly vulnerable to hypothyroidism. Contrary to what one might expect dilution of PVI solutions leads to increase of free iodine, which is dissolved out of the molecule complex: a 50-fold dilution in saline increases the free iodine to about 1-2 g/l, which is a 100-fold increase of the original substance[3]. At least 10 of the 17 patients mentioned above were treated with diluted solutions. Parravicini et al. drew attention to this issue already in 1996. They analyzed free iodine in urine of VLBW infants exposed by the use of PVI for vascular or lumbar puncture, or by administration of iodinated contrast media. They observed iodine urine levels, which were up to 1.000 times higher than in control infants. One third of their patients had hypothyroidism, and more than 20% had TSH levels above 20 microU/ml, with SGA infants being in particular prone to hyperthyrotropenemia[4]. A literature research in PubMed with the key words "chemical pleurodesis newborn" yields 6 hits, 5 of them dealing with PVI. This creates the impression, that only PVI is effective for pleurodesis. However, in adults pleurodesis can be performed with a variety of agents, and even more of them have been studied successfully in animals: erythromycin, bleomycin, tetracycline, a slurry of talc, silver nitrate, polidocanol, ethanol, OK- 432, and even autologous blood has been studied. In summary it seems prudent to recommend close observation of infants and young children treated with PVI with respect to pending hypothyroidism. PVI solutions should never be diluted, because free iodine increases with decreasing concentration. There is a need for controlled studies on chemical pleurodesis in newborns with agents other than PVI.

  References: 1 Resch B, Freidl T, Reiterer F. Povidone-iodine pleurodesis for congenital chylothorax of the newborn. Arch Dis Child Fetal Neonatal Ed Published Online First: 29 September 2015. doi:10.1136/archdischild-2015- 309184 2 Scottoni F, Fusaro F, Conforti A, et al. Pleurodesis with povidone- iodine for refractory chylothorax in newborns: Personal experience and literature review. J Pediatr Surg Published Online First: 28 April 2015. doi:10.1016/j.jpedsurg.2015.03.069 3 Atemnkeng MA, Plaizier-Vercammen J, Schuermans A. Comparison of free and bound iodine and iodide species as a function of the dilution of three commercial povidone-iodine formulations and their microbicidal activity. Int J Pharm 2006;317:161-6. doi:10.1016/j.ijpharm.2006.03.013 4 Parravicini E, Fontana C, Paterlini GL, et al. Iodine, thyroid function, and very low birth weight infants. Pediatrics 1996;98:730-4.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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