Why do children with cleft palate have difficulty with feeding and swallowing?

Infants with cleft lip and/or cleft palate can have difficulty feeding. These babies usually benefit from modified feeding techniques to make feeding successful and enjoyable.

Goals for feeding all babies are to:

• Provide optimal nutrition for growth
• Choose a safe and supportive feeding method and supplies
• Establish and maintain a nurturing parent-infant bond

Infants with cleft lip and/or palate have decreased or loss of oral suction (air leak). This decrease is caused by the opening in the lip or palate that does not allow the infant to build pressure to create suction. Because of this, these babies need a nipple with a specialized valve or a modified feeding bottle. Without modifications, the liquid these infants get during feeding may be limited. That can increase the amount of time required for an infant to feed, resulting in not enough nutrition and tiring the infant.

Feeding Needs

Early feeding intervention is critical for these infants. If possible, seek out experts to help educate you before your baby is born, so you know what to expect and have the resources you need when you deliver. At the Cleft and Craniofacial Center at Cincinnati Children’s, we provide prenatal education for families whose babies have been diagnosed during pregnancy with a cleft lip and/or palate.

Infants normally lose weight right after birth. Typically, full-term infants return to or are above their birth weight on or before the 10th day of life. For any infant, poor weight gain can be a sign of a feeding issue. With the right interventions, infants with cleft lip and/or palate are able to meet standard feeding and growth goals. Your primary care provider and your craniofacial care team will watch your baby’s weight closely to ensure his or her feeding needs are being met.

Breastfeeding and Bottle Feeding

It is our goal to help parents be successful in feeding their infant, whether you choose to bottle feed or breastfeed. We understand that families recognize the benefits of breastfeeding.

Whether breastfed or bottle fed, babies with cleft lip and/or palate can have difficulty latching on or maintaining an adequate strength of compression and suction. With breastfeeding, this can impact the amount of milk the mother will make (if pumping is not completed) and can limit the amount of milk the infant gets at the breast.

In a very small percentage of cases where the baby can maintain a good latch, they may be successful in feeding at the breast. Even a tiny cleft can result in poor intake and it may be difficult to establish full breastfeeding. Babies with a cleft palate typically have additional challenges to breastfeeding due to decreased suction. Your care team will work with you through these challenges. We recognize how difficult it can be as you work to help your baby feed successfully. We’ll work with you to develop an individualized feeding plan to meet your infant’s feeding needs.

Common Feeding Challenges

Some common challenges for parents when feeding an infant with a cleft are:

• Lengthy feeding times
• More frequent feedings
• Small volumes with feeding that do not meet nutritional needs

Infants should not feed for longer than 30 minutes at a time. Feeding is like exercise for a newborn, and they should be fed at least eight times a day. When the baby feeds for more than 30 minutes, more calories will be burned. Over time, this can result in poor growth and limited weight gain. A member of your care team will provide support to identify how to feed your baby.

Parent-Child Interaction and Feeding

Feeding is a strong reinforcement for bonding and interaction between you and your infant. It is a frequent activity (initially occurring eight to 10 times each day) that allows parent and child to interact.

During feeding, infants express how they are feeling. We call these “infant cues.” Infant cues include babies’ sounds, facial expressions and body movements that signal they are hungry, need a break, etc. For example, infants cry and place their hands to their mouth to show they are hungry. They often become fussy or pull away from the bottle when they need a break. They may turn away from the bottle when they are finished. It is important for caregivers to understand these cues and respond to reinforce the infant’s needs.

Bottle Feeding Supplies

Your care team can help you choose a feeding method to best meet your baby’s needs. There are several nipple / bottle systems that can be used with infants with cleft lip and palate. It is important that the bottle used with your baby provides sufficient volume in an appropriate feeding time. Selecting the correct feeder for your baby and you is an individualized process. Some systems may work better than others.

Because feedings happen so frequently and need to become a consistent routine for an infant’s best learning and overall efficiency, it is recommended that you continue with the same feeding system once your infant has established a functional feeding routine. Infants learn best when they are fed in a consistent way. Altering systems, nipples, flow rates, etc., can be confusing for infants and can create additional challenges. If you feel the need to transition to a different bottle, contact your craniofacial care team member for additional assistance.

Holding Your Infant

Like all other aspects of feeding infants, positioning infants for successful feeding is important. It can take some practice to find the position that works best for your baby.

In general, it works well to hold infants with a cleft in an upright or semi-upright position for feedings. This will help direct the flow of milk and decrease the amount of liquid that either spills out of the mouth or enters the nose through the cleft. Many younger newborns might benefit from a side-lying position that provides good body support and helps to regulate the flow of liquid during the feeding.

It is important to position your baby so you can see each other’s faces during the feeding. This allows you both to interact and respond to each other throughout the feeding, and to observe how your baby is tolerating the feeding.

Your care team will work with you to help you find the holding position that works best for your child.

Special Techniques for Bottle Feeding

We will work with you individually to help you become successful at bottle feeding your infant. We have special instructions for and demonstrate each type of bottle.

Some of the techniques you’ll hear about when you learn to bottle feed your child include:

• “Pulse squeezing”: This is a common feeding technique used with the Mead Johnson and the Medela (Haberman) feeders. To do this, gently squeeze the bottle (Mead Johnson) or the nipple (Medela) to help milk flow into the mouth. A brief squeeze once every two or three sucks allows for a limited amount of milk to flow into your infant’s mouth. Only use these intermittent squeezes when your infant is actively feeding (compressing the nipple and swallowing). It is important to not provide a squeeze while an infant is not actively compressing the nipple. Infants rest and catch up their breathing during the feeding with these breaks; providing a squeeze during this break can cause choking.
• Filling and placing the nipple: For the Medela Feeder and Dr. Brown Specialty Feeding System, you’ll need to know how to correctly fill and place the nipple. The easiest way to do this is to squeeze the nipple to release the air, then turn the bottle upside down (nipple facing down) and release the squeeze. This will allow milk to flow through the valve into the nipple. You can do this one to three times to allow milk to fill the nipple.
• Gagging / choking: If your infant gags or chokes during feeding, it is possible that helping regulate the speed of flow can help. To do this, provide brief periodic breaks during the feeding, and offer less frequent or less strength of a squeeze.
• Burping your baby: Burp your baby often to offset swallowing air. A common rule is to burp about every ounce or when infants show long pauses with agitation during feeding.
• Signs to stop feeding: We will work with you so you can learn signs (“cues”) to watch for that indicate you should stop feeding your baby. You’ll be looking at how much your baby has been fed, how much your baby has been spitting up, and how often you’ve burped your baby.

If you ever have a question about the feeding supplies, call your care team.

Transitioning to Spoon Feeding / Cup Drinking

A cleft lip is typically repaired with surgery around 3 months of age. Cleft palate repair is commonly performed at about 9-12 months of age, depending on other health and developmental issues.

Prior to cleft palate repair, our surgeon preference is to transition your child from a bottle to an open cup. Beginning at the six-month visit, we assist you in preparing for your child to have cleft palate surgery. During this visit, we demonstrate spoon feeding and cup drinking. You will receive detailed instructions and support from our team. We will begin offering spoon and cup drinking in small amounts each day. Over the next two to three months, you will increase how much your infant accepts from the cup and gradually discontinue using the bottle. This will simplify feeding and minimize the time required in the hospital after surgery. We will provide additional feeding therapy support if your child is having difficulty with this transition prior to surgery.

When to Call the Doctor

If your baby is not gaining weight, or if problems with the feeding persist, call your child’s doctor and your Cleft and Craniofacial Center caregivers. Your baby may need other devices and methods to help with feeding.

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