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Cleft Lip and Palate

Summary

  • early feeding intervention and education from a Speech Pathologist and a Lactation Consultant fosters establishment of an effective feeding regimen
  • a dysfunctional feeding pattern may indicate other congenital anomalies
  • when breast feeding a baby with a soft palate cleft, unilateral or bilateral cleft, supplementary breast milk feeding is usually required
  • assisted feeding techniques are used with bottle feeding
  • oromotor development, adequate nutritional intake, positive caregiver/infant interaction and consistent carers are necessary for effective feeding

Introduction

Cleft lip and palate occurs in approximately 1 per 1000 births.

This may occur sporadically or in the setting of a family history.

Babies born with a cleft may present with a range of feeding difficulties according to the type and severity of the cleft, however, a direct relationship between cleft type and feeding problem does not seem to exist. Sucking efficiency varies but is reduced on both the bottle and breast.

The baby is at risk of failing to thrive as oral intake efficiency is reduced and the baby fatigues during lengthy feeds.

Diagnosis

Obvious in more severe cases. Careful examination with a bright light and a tongue depressor is required in the case of a posterior soft palate cleft or submucous cleft of the palate. Difficulties in feeding may lead to a later diagnosis.

Investigation

A small percentage of affected children have abnormalities elsewhere in the face or in other systems.

Management

Early

  • genetic counselling and information about the Cleft Pals Association who can arrange a parent visit if appropriate
  • feeding assessment by a Speech Pathologist within 24 hours of birth to discuss feeding options with the parents
  • referral to a Lactation Consultant to discuss breast feeding and/or expressing techniques
  • all mothers encouraged to put their baby to the breast for skin to skin contact, bonding and to maximise the opportunity to stimulate milk flow
  • parental education about infant feeding cues
    • Breast feeding

      A cleft palate can interfere with breast feeding as it precludes generation of suction during feeding. Milk extraction from the breast is inefficient and the required strong attachment to the breast is absent. The potential for a baby with a cleft palate to receive adequate nutrition from being exclusively breast fed in the traditional manner is limited. Mothers wishing to breast feed should consult a lactation consultant for support as breast feeding an infant with an unrepaired cleft is demanding.

      When breast feeding a baby with a soft palate cleft, unilateral or bilateral cleft compressing the breast to express the milk into the babies mouth will facilitate milk flow and the baby's suck swallow reflex. As the necessary negative intra oral pressure for sucking will rarely be produced for adequate volume intake, a "top up" with expressed breast milk via a supply line or bottle will be required.

      However, breast feeding a baby with an incomplete cleft lip can be achieved by pressing part of the breast into the cleft to obtain lip seal.

    • Bottle feeding

      Assisted breast milk feeding using squeezable bottles requires less support and intervention than using a rigid bottle, after initial instruction. A Haberman Feeder or Pigeon teat (cross cut) with a Cleft Pals or Soft Plas squeeze bottle are recommended. Before feeding, practice squeezing the bottle and compressing the teat to be familiar with rate of flow and pressure required.
      When feeding a baby with a cleft lip and palate, hold the baby in a semi upright position to minimise the nasal regurgitation of milk. Squeeze the bottle rhythmically only when the baby sucks (every two, three of five sucks). Burp the baby regularly as the cleft allows extra air to be ingested. The feed should be completed within 30-40 minutes.

  • Audiology
    • regular testing during childhood until risk of effusion/ otitis media subsides, removing need for ventilation tubes

  • Surgery (Plastic, ENT and Oral surgery)
    • lip repair early or up to 3 months
    • palate repair at approximately 6 months
    • bone graft to the cleft alveolus (gum) 9-11 years
    • ventilation tubes to ears at time of palate repair and subsequently
    • adjustments of lip and nose shape as required until fully grown
    • pharyngoplasty to improve speech age 5-6 years in 10-15% of patients with cleft palate

  • Dental, orthodontic and oral surgery
    • lifetime dental care
    • orthodontics before and after alveolar (gum) bone graft
    • jaw surgery to correct malocclusions in some teenagers

  • Speech therapy
    • supervision as speech develops, therapy as required

Areas of Uncertainty in Clinical Practice

  • There is little evidence that currently used feeding methods improve feeding efficiency and outcomes. Feeding difficulties are reported in the literature but opinions vary on appropriate feeding strategies
  • Palatal Obdurators
    The use of feeding plates is unsupported as they do not enable the infant to seal the oral cavity effectively and generate suction. However the firm palatal surface may assist the infant to stabilise and compress the nipple. The combined use of a palatal obdurator and lactation education may reduce feeding time, increase volume intake with increased flow rate but babies will still require supplementation.
  • Nasogastric Tubes
    Infants with airway difficulties may require combined oral and tube feeds. Airway stability must be determined prior to oral feeding and feeding coordination should be the focus not the volume of the oral feed.

References

Converse, Plastic & Reconstructive Surgery Vol.4, p. 1930 Saunders

Bannister P. Early Feeding Management. In:Watson ACH, Sell DA, Grunwell P (eds) .Management of Cleft Lip and Palate. London: Whurr; 2001 pp. 137-147.

Clarren, SK. Anderson, B. Wolf, LS. Feeding infants with cleft lip, cleft palate, or cleft lip and palate. Cleft Palate Journal 1987 Jul; 24(3): 244-249.

Glass RP, Wolf LS, Feeding Management of Infants with Cleft Lip and Palate and Micrognathia. Inf Young Children. 1999; 12(1): 70-81.

Shaw WC, Bannister RP, Roberts CT, Assisted feeding is more reliable for infants with clefts- a randomised controlled trial. Cleft Palate Craniofacial J. 1999; 36(3):262-8.

Web Links

CleftPALS QLD Inc

 

Last updated 30/05/2010

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