Megan Brey

CD730: Research Paper

November 24, 2014
Feeding Intervention for the Infant with Unrepaired Cleft
Cleft lip (CL) and/or palate (CL/P) are the most common congenital defects of
the face and the fourth most common birth defect (Miller & Willging, 2013, p. 355). A
cleft may occur in isolation or in association with other anomalies (i.e., syndromes,
sequences, or associations). Feeding difficulties associated with CL/P were first
reported by Fabricus of Aquapendente in 1619 (Jones, 1988). He noted that these
infants were unable to suck and as a result, often died from malnutrition. In a study by
Reid, Reilly, & Kilpatrick (2006), feeding difficulties were the most frequently cited
problems mentioned by parents of infants with CL/P, with roughly one-third of infants
with CL/P having early feeding difficulties (Reid, 2006). Therefore, it is the purpose of
this paper to review the current feeding interventions available to infants with CL/P and
their caregivers.
It is commonly accepted that the feeding methods and problems vary as a result
of the type and severity of the infants cleft (Clarren, Anderson, & Wolf, 1987; Mizuno,
Ueda, Kani, & Kawamura, 2002; Oliver & Jones, 1997). The feeding problems of infants
with CL/P may be caused by insufficient oral suction, reduced food intake, ulceration of
the nasal mucosa, poor bolus organization, excessive air intake, and/or disruption of
swallow initiation (Amstalden-Mendes, Magna, & Gil-da-Silva-Lopes, 2007; Habel, Sell
& Mars, 1996; Miller & Willging, 2013; Reid, 2006). As a result, these infants may
present with poor feeding skills, lengthy feeding times, milk regurgitation through the
nasal cavity, laryngeal penetration, and inadequate volume of oral intake (Habel et al.,

1996; Miller & Willging, 2013; Reid, 2006). All of these factors influence the infants
ability to gain weight and affect their nutritional status, both critical to determining when
the infant is able to undergo surgical closure of the cleft (Riski, 2007).
Maintaining nutrition and determining feeding techniques that allow as normal of
feeding as possible must be of the highest priority when working with infants with CL/P
(Clarren et al., 1987). Infants will vary in their ability to feed and compensate for the cleft
defect. Parents will need counseling and advice at the earliest time possible, including
nutritional guidelines and support, and diet modification, if needed (Turner et al., 2001).
Feeding interventions that do not consider the individuality of the infant and their
caregiver lack a complete understanding of the complexity of feeding.
Compensatory techniques and intervention should be determined after
assessment of the type and severity of cleft, the infants oral motor skills, and
observation of the infant feeding (Miller & Willging, 2013). It is of equal importance to
take into consideration the individuality of the infant and context of parental nurturing.
(Dailey, 2013; Ross, 2008). In 1987, Clarren et al. were able to identify an effective
feeding technique for infants with CL/P within one to two days after initial assessment.
They recommended that one should think of the infants feeding abilities in terms of two
basic tasks: sucking (i.e., action which draws milk into the mouth) and swallowing (i.e.,
transfer of milk from oropharynx to stomach). However, in order for a professional to be
able to make such rapid recommendations, one first must be knowledgeable of all
available compensatory feeding techniques and/or interventions.
Compensatory feeding techniques and interventions generally fall into one of the
following categories: breastfeeding modifications, modifications of nipple and bottle

types, cup feeding, positioning alterations, oral facilitation techniques, and feeding
obturators/prostheses (Miller & Willging, 2013). Before reviewing each of these
techniques or interventions, it is important to note that recent literature reviews have
noted a lack of empirical evidence to support a variety of these compensatory strategies
and interventions, as most of the supporting evidence has been based on expert
opinion and clinical experience only (Masarei et al., 2007; Reid, 2006; Reid et al., 2006;
Riski 2007).
There is growing body of literature pertaining to breastfeeding in infants with
CL/P. Various studies have noted that the type, location, and severity of cleft are the
main determining factors in breastfeeding success (Dailey, 2013; Garcez & Giugiliani,
2005; Reid, 2006). In order to improve the infants ability to latch and seal on the breast,
external lip and cheek support may be recommended. Certain feeding positions,
depending on the size and location of cleft, can also foster the expression of milk. Such
modifications may include instruction on occlusion of the cleft lip by the caregivers
thumb, directing the nipple towards the opposite side of the cleft, and use of a semierect positioning of the child to prevent milk from entering the nasal cavity (Garcez &
Giugiliani, 2005). Supporters of breastfeeding cite that breastfeeding encourages
normal, physiologic muscular involvement of the mouth and face and has protective
functions including reduction of otitis media and prevention of nasal mucous
inflammation (Garcez & Giugiliani, 2005). Infants with an isolated cleft lip have been
shown to have the greatest success with breastfeeding, followed by infants with small
soft palate clefts or submucous clefts (Garcez & Giugiliani, 2005). Infants with larger
clefts appear to have the least success with breast feeding caused by an inability to

generate negative intraoral pressure and a lack of separation between the nasal and
oral cavities (Miller, 2011).
The use of modified nipples and bottle types has shown to be beneficial for a
wide range of cleft severity, type and location (Riski, 2007). The Cleft Palate Foundation
provides videos and a booklet of information regarding various nipple and bottle
modifications for parents to consider as well as instructions for assembly. There are a
variety of nipple modifications available including the Special Needs Feeder, Pigeon
nipple and bottle, and the Enfamil Cleft Palate Nurser (Feeding Your Baby, 2014;
Miller & Willging, 2013). As with breastfeeding, the determination of the type of nipple is
based on the severity of the cleft and the infants oral/motor feeding skills. For instance,
the use of a soft nipple with an enlarged cross-cut hole is recommended for infants with
an isolated cleft palate, because this enables tongue movements to express a greater
quantity of milk (Clarren et al., 1987) .The correct nipple should allow for adequate
contact between the nipple and the tongue in order to allow for successful compression
of the nipple and tongue movement (Miller & Willging; 2013). Proper determination of
nipple size and type is crucial as this determines the fluid flow rate. The most common
size and types of nipples are single hole, cross-cut, and Y shape nipples. In a 2002
study by Mizuno et al., a new nipple type, type P nipple, was shown to help create a
higher expression/compression pressure in infants with CL/P who have significant
sucking difficulties. Another nipple modification includes the use of a valving
component, which helps prevent rapid flow of fluids.
Many times the use of a bottle modification is used in conjunction with nipple
modifications to further assist with feeding. The option of a soft, squeezable bottle that

the feeder compresses in sync with the infants tongue and jaw sucking motions is one
such modification (Dailey, 2013, p. 64). This allows for the caregiver to have control
over the fluid flow rate and decreases the need for the infant to create negative intraoral
pressure (Mizuno et al., 2002; Riski, 2007). Squeezable bottles have been reported by
caregivers as easier to use, less likely to require modification than the rigid bottle, and
resulted in fewer reported feeding difficulties (Reid, 2006; Riski, 2007; Shaw, Bannister,
& Roberts, 1999).
Similar to the modification of a nipple and/or bottle, the use of cup feeding has
also been used as a compensatory feeding technique. This modification is especially
useful if the infant is unable to generate a suck, as it eliminates the need for one. Cup
feeding also allows for better swallowing control, as the infant is able to swallow only
when they are ready, which also allows for easier control of respiration (Lang, Lawrence
& Orme, 1994). This method enables the infant to feed directly from a cup, which allows
the mother more time to try to establish breast feeding if so desired. This method may
also be a valuable alternative for mothers who wish to breastfeed but require another
complementary feeding method until surgical correction is performed or when mothers
cannot or do not want to breastfeed (Amstalden-Mendes, Magna & Gil-da-Silva-Lopes;
2007). Other benefits include the fostering of early positive body and eye contact
between parents and their infant and involvement of both parents (Lang et al., 1994, p.
368)
Positioning alterations can be beneficial for a wide variety of infants with clefts
both with and without cleft lip. General recommendations include holding the infant in a
more upright or slightly reclined position to decrease the occurrence of breast milk or

formula from entering the nasal cavity and/or eustachian tubes during feeding and to
allow gravity to encourage posterior flow of the fluid (Dailey, 2013; Miller, & Willging,
2013). Positioning the infant in a side-lying or supine position has also been
recommended, as this facilitates anterior positioning of the tongue and therefore
prevents upper airway obstruction during feeding (Miller, & Willging, 2013). Frequent
burping during feeding is also recommended as this addresses the infants problems
with increased air ingestion.
Oral facilitation techniques may be used exclusively or in addition to positioning
alterations or other compensatory and/or intervention techniques. They may include
support and/or stabilization of the infants lips, jaw, and/or cheeks, including proper
placement of the feeders thumb to occlude the cleft during breastfeeding, which was
previously mentioned. Proper lip closure may be facilitated by placement of the feeders
index finger and thumb on either size of the infants cheeks. Stabilization of the infants
jaw through placement of the feeders middle finger under the infants chin, and the
index finger between the chin and lower lip, helps to give the infant a stable location for
movement of the tongue, lips, and cheeks (Miller & Willging, 2013). These techniques
should always first be taught and demonstrated by a professional, such as a speechlanguage pathologist, and practiced by the caregiver/feeder under their guidance before
implementation into the infants everyday feeding routine.
The final compensatory feeding technique/intervention category, feeding
obturators/prosthesis, has been hotly debated and researched. A palatal obturator
creates the crucial separation of the oral and nasal cavities, thus providing a surface for
the infant to oppose the nipple to during suckling. The use of a palatal obturator or plate,

has been used to facilitate direct breast feeding for infants with CL/P. Proponents of this
method argue that the use of a plate facilitates feeding by allowing compression of the
nipple, facilitating intraoral pressure, reducing feeding times, promoting weight gain,
allowing breast feeding, and preventing aspiration (Riski, 2007; Turner et al., 2001).
However, in a study by Shaw et al. (1999), no benefits for the palatal obturator were
found in regards to feeding frequency, food intake level, or velocity of food intake in the
first 24 weeks of life. This was substantiated by Choi, Kleinheinz, Joos & Komposchs
(1991) findings which stated that the presence of a plate failed to make a difference in
the ability of the infant with CL/P to generate negative intraoral pressure. Furthermore,
multiple studies have shown that the presence of a plate alters the oral flora and in turn
increases the presence of dental caries (Riski, 2007; Shaw et al., 1999). Other
disadvantages associated with the use of a palatal obturator include cost and difficulty
in consistent everyday use (Miller & Willging, 2013).
Every infant presents with a different cleft and situation. Therefore, a technique
that was successful for one family may be found to be unsuccessful for another. In order
to determine what compensatory feeding techniques and interventions will best meet
the needs of the infant and the caregivers, the speech-language pathologist will need to
be knowledgeable of all available options and their efficacy. When determining the
intervention, one must always keep in mind that the goal of feeding intervention is to
facilitate a normal feeding pattern, promote growth and development, and reduce
stress experienced by both the infant and the family (Reid, 2004, p. 277).

Works Cited
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