Simplified Method
of Feeding Infants Born With Cleft Palate With or Without Cleft Lip Hermine M.
Pashayan, MD, Margaret McNab,
\s=b\ Most infants born with a cleft palate with or without cleft lip are undergrown and have histories of difficult feeding. For the past two years, all of the infants born with isolated cleft palate with or without cleft lip, referred to the Boston Floating Cleft Palate Clinic, were fed using a simplified method. A standard nipple that was cross cut and a standard glass baby bottle were used. The infants were fed in the sitting position and burped frequently. Data indicating that nutrition in these infants is adequate as judged by weight
gain was provided. (Am J Dis Child 133:145-147, 1979) first
at Cleft Palate
When Center, Floating pital, by private plastic seen
Boston
Hos¬
surgeons, most infants born with a cleft palate or
or without a cleft lip (CP ± CL) undergrown. Weight gain has often averaged less than 500 g month¬ ly during the first few months of life and histories of difficult feeding are
with are
From the Cleft Palate Clinic, Boston Floating and the Department of Pediatrics, Tufts-New England Medical Center Hospital, Boston. Reprints not available.
Hospital,
RN
the rule.1 The various elements of the feeding problems in these infants have pre¬ viously been outlined by Paradise and MacWilliams.1 One of the major causes of the difficulty in feeding is the inability to generate effective oral suck. This problem is due to the modi¬ fied intraoral anatomy created by the presence of the cleft palate which in turn leads to a direct communication between the oral and nasal cavities. By way of management, some authors-"7 have advocated the use of prosthetic feeding appliances that obturate the palatal cleft. Our experi¬ ence8 has shown that such appliances are not effective in promoting ade¬ quate weight gain and seem to provide a false sense of security to those who use them. Special nipples, such as the lamb's or winged, are also sometimes advised but parents have found them difficult to use or adjust to. Other devices that permit manual expression of milk into the infant's mouth are presently in use in many hospitals. One such device designed for individual feedings (up to 180 ml) is the Beniflex cleft lip/palate nurser and another is the modified Playtex
feeder. Data from the Pittsburgh Center where the modified Playtex feeder is used are not yet available. Our experience at the Boston Float¬ ing Hospital Cleft Palate Clinic has shown that parents are reluctant to use unusual appearing feeding devices to feed their infants in public or even in front of friends. We stress the fact that the infant born with an isolated CP ± CL is an otherwise normal infant born with an intact CNS, and has normal functions and normal potential for growth. Data showing that nutrition is adequate as judged by weight gain of six consecutive cases of isolated cleft lip palate and six cases of cleft palate alone are given in Tables 1 and 2, respectively. The weights are documented from the age of referral, which varies from 4 days to 4Vè weeks of age to the age when the patients had surgery on the lip and/or palate. The average time needed to feed an infant using this method, which includes burping the infant every 14 to 28 g of formula, is from 20 to 30 minutes. The total intake/feeding depended on the age of the infant as recommended by the Committee on Nutrition.
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Table 1 .—Infants Born With Isolated
Complete
Cleft
Lip and Palate Referred
to Clinic
Shortly
After Birth*
Case/Sex t-
*
_UU_2/M_3/M_4/M_5/F_6/F CLP
Diagnosist_bi CLP_uni CLP_uni CLP_bi CLP_uni CLP_uni Birth weight, 2,756(10-25) 3,908 (75)_2,966 (25)_2,614(3-10) g (percentile)_3,444 (50)_3,542 (50-75)
7 12 7 7 8 10 Age first seen in clinic, days 3.9 (50-75)_2.8 (10)_2.4 (5)_2.78 (25) Weight, kg (percentile)_3.48 (25)_3.75 (50-75) 2 wk 2 mo 5 wk 214 mo 2V2 mo 2 mo Age 4.8 (25)_3.6 (5)_2.84 (25) 5.68 (50)_4.75 (50-75) Weight, kg (percentile)_5.0 (25-50) 5 RJ 4 Rt 2 3 5t 5J Age, mo 5.06 (25)_4.34 (50) 6.9 (25-50)_7.83 (75)_6.85 (25-50) Weight, kg (percentile)_6.31 (25-50) 3% 6'/2 U 9§ 5t 9§ 9| Age, mo Weight, percentile_10-25_50_90_50_25-50_50 12 5Î 12 Lt 9§ 11§ Age, mo Weight, kg (percentile)_9.0(10-25)_10.8(50-75) _8.9 (25)_7.9 (25-50)_6.73 (50)
_
...
"1976 National Center for Health Statistics growth curves were used. tbi CLP indicates bilateral cleft lip palate, uni CLP, unilateral cleft lip palate. JWeight at time of lip palate (L, left; R, right). §Weight at time of palate closure.
Table 2.-lnfants Born With Isolated Cleft Palate Referred to Clinic
Shortly After Birth*
Case/Sex 1/F Birth
weight, g
2/F
3/F
(percentile)_2,278 (3)_3,262 (50)_3,635(50-75)
4/M
2,924(10-25) 4 days
5/F
6/M
3,542(50)_3,290 (25-50)
4 wk 11 days 4 days 8 days 4Vi wk Age first seen in clinic Weight, kg (percentile)_2.8 (3)_3.6 (50)_3.7 (50)_2.9(10-25)_3.7 (25-50)_3.15 (25) 3 mo 6 wk 7 wk 5 wk 8 wk 6 wk Age 5.45 (75)_3.8 (25)_4.95 (25)_4.3 (25) Weight, kg (percentile)_3.4 (5)_4.05 (25-50) 7 5 8 5 4Vi 4 Age, mo Weight, kg (percentile)_5.68 (25)_6.2 (50)_7.8 (90)_8.8 (50)_8.4 (50-75)_6.46 (25) 10 10* 9 10* 8s 9* Age, mot 9.0 7.95 (25-50) 8.9(25) 9.36(50-75) Weight, kg (percentile)_8.1 (25-50) (50)_10.1(50-75)
*1976 NCHS growth charts were used. tWeight at time of palate closure.
Fig 1 .—Standard nipple with surgical blade inserted to widen cut.
Fig 2.—Infant with cleft palate being fed by mother.
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METHOD We recommend the use of standard equipment, ie, standard nipple that has been crosscut (Fig 1). The center of the cross being the central hole already present on the standard nipple. The enlarged cut provides adequate ejection of milk into the infant's mouth with the minimum effort or pressure which the infant with an altered palatal anatomy is able to provide. Our recommendations on the feeding of these infants is as follows: First, use a standard nipple that has been crosscut in the following way (Fig 1): (1) To crosscut the nipple, use a surgical blade or a clean cuticle removing pair of scissors with sharp thin blades. The central point of the cross¬ cut is the preexisting hole on the nipple. (2) The size of the crosscut is between 0.5 to 1 cm. If milk dribbles from the sides of the nipple or through the nostrils during feed¬ ing, the cut is too wide. If feeding takes longer than 30 minutes without nasal régurgitation and oral dribbling, the cut is too small. (3) Do not use a preemie nipple to feed a full-term infant. Preemie nipples are too soft and will collapse easily, preventing rapid filling of the nipple. Their use will prolong feeding time as the infant works harder to feed, and will lead to excessive swallowing of air and a false feeling of fullness. After preparing the nipple, feed the infant in a sitting position on the mother's lap (Fig 2). Then, hold the bottle in a slightly upward tilted position to avoid sucking in of more air during feed¬ ing. Burp the infant every 14 to 28 g of formula. While in the crib, keep the infant in the prone position. This allows oral or nasal régurgitation of formula to trickle forward and reduces the chances of aspira¬ tion. Cereal, when added, is added to the formula in the bottle. Introduce the infant to the use of a cup prior to admission for lip and/or palate surgery (ie, at approximate-
ly 4 months of age for lip and 8 months for palate repair). The choice of formula is up to the pediatrician providing the infant's primary care. It is imperative, however, that the parent be shown how to crosscut the nipple and how to position the infant during feeding (Fig 2). Our experience has shown that unless the mother is asked to actually feed the infant in front of us, it is difficult for her to follow written instructions and the method is not as effective. It is also imperative to bear in mind that this meth¬ od is contraindicated in infants born with the Robin anomalad (in which cleft palate is accompanied by micrognathia and glossoptosis) because of the position of the infant during feeding. It is not as effective in producing normal weight gain in cases of infants born with a CP ± CL associated with multiple congenital abnormalities, such as in infants with trisomy 13 or 18 syndrome or those with CNS damage.
feeding
and by placing the infant in the prone position while in the crib. Adequate intake and weight gain is achieved by the first month after referral. Finally, visits to the Cleft Palate Clinic for demonstration of feedings are reduced to a minimum (two visits, six weeks apart). To assure normal progress, telephone contact between the mother and the clinic nurse at first weekly and then once every two to three weeks is main¬ tained. None of the mothers has had a problem learning the technique. A copy of the pamphlet outlining the care of the child born with a cleft palate with or without cleft lip at the Boston Floating Hospital Cleft Palate Clinic is available on request. Correspond¬ ing measurements for height and head circum¬ ference of cases given in Tables 1 and 2 are available on request.
COMMENT
References
The advantages of our method are as follows: It costs the same as feeding an infant without a cleft palate. The equipment used is standard, easily available, and not unusual in appear¬ ance. It provides the infant with the daily recommended intake without undue effort on the part of mother or infant. The infant's oral gratification and emotional needs are not impaired since the infant is allowed to suck and the mother can cuddle the infant during feeding. Nasal régurgitation is controlled by varying the size of the cut and reduced by positioning of the infant. Aspiration between feedings is reduced by burping the infant frequently during and after each
1. Paradise JL, MacWilliams BJ: Simplified feeder for infants with cleft palate, Pediatrics 53:566-568, 1974. 2. Zickefoose M: Feeding problems of children with cleft palate. Children 4:225-227, 1957. 3. Drillien CM, Ingram TTS, Wilkinson EM: The Causes and Natural History of Cleft Lip and Palate. Baltimore, Williams & Wilkins, 1966. 4. Lifton JC: Methods of feeding infants with cleft palates. J Am Dent Assoc 53:22-31, 1956. 5. Burston WR: The early orthodontic treatment of cleft palate conditions. Dent Pract 9:41\x=req-\ 52, 1958. 6. Williams AC, Rothman BM, Seidman IH: Management of a feeding problem in an infant with cleft palate. Am Dent Assoc 77:81-83, 1968. 7. Molson TS: Prosthesis for the newborn. Prosth Dent 21:384-387, 1969. 8. Pashayan HM, Lichtenstein GA: Growth patterns of infants with isolated cleft of the palate with or without cleft lip treated with presurgical orthopedics. Presented at 33rd annual meeting of the American Cleft Palate Association, New Orleans, February 1975. J
J
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of Feeding Infants Born With Cleft Palate With or Without Cleft Lip Hermine M.
Pashayan, MD, Margaret McNab,
\s=b\ Most infants born with a cleft palate with or without cleft lip are undergrown and have histories of difficult feeding. For the past two years, all of the infants born with isolated cleft palate with or without cleft lip, referred to the Boston Floating Cleft Palate Clinic, were fed using a simplified method. A standard nipple that was cross cut and a standard glass baby bottle were used. The infants were fed in the sitting position and burped frequently. Data indicating that nutrition in these infants is adequate as judged by weight
gain was provided. (Am J Dis Child 133:145-147, 1979) first
at Cleft Palate
When Center, Floating pital, by private plastic seen
Boston
Hos¬
surgeons, most infants born with a cleft palate or
or without a cleft lip (CP ± CL) undergrown. Weight gain has often averaged less than 500 g month¬ ly during the first few months of life and histories of difficult feeding are
with are
From the Cleft Palate Clinic, Boston Floating and the Department of Pediatrics, Tufts-New England Medical Center Hospital, Boston. Reprints not available.
Hospital,
RN
the rule.1 The various elements of the feeding problems in these infants have pre¬ viously been outlined by Paradise and MacWilliams.1 One of the major causes of the difficulty in feeding is the inability to generate effective oral suck. This problem is due to the modi¬ fied intraoral anatomy created by the presence of the cleft palate which in turn leads to a direct communication between the oral and nasal cavities. By way of management, some authors-"7 have advocated the use of prosthetic feeding appliances that obturate the palatal cleft. Our experi¬ ence8 has shown that such appliances are not effective in promoting ade¬ quate weight gain and seem to provide a false sense of security to those who use them. Special nipples, such as the lamb's or winged, are also sometimes advised but parents have found them difficult to use or adjust to. Other devices that permit manual expression of milk into the infant's mouth are presently in use in many hospitals. One such device designed for individual feedings (up to 180 ml) is the Beniflex cleft lip/palate nurser and another is the modified Playtex
feeder. Data from the Pittsburgh Center where the modified Playtex feeder is used are not yet available. Our experience at the Boston Float¬ ing Hospital Cleft Palate Clinic has shown that parents are reluctant to use unusual appearing feeding devices to feed their infants in public or even in front of friends. We stress the fact that the infant born with an isolated CP ± CL is an otherwise normal infant born with an intact CNS, and has normal functions and normal potential for growth. Data showing that nutrition is adequate as judged by weight gain of six consecutive cases of isolated cleft lip palate and six cases of cleft palate alone are given in Tables 1 and 2, respectively. The weights are documented from the age of referral, which varies from 4 days to 4Vè weeks of age to the age when the patients had surgery on the lip and/or palate. The average time needed to feed an infant using this method, which includes burping the infant every 14 to 28 g of formula, is from 20 to 30 minutes. The total intake/feeding depended on the age of the infant as recommended by the Committee on Nutrition.
Downloaded From: http://archpedi.jamanetwork.com/ by a DALHOUSIE UNIVERSITY-DAL-11762 User on 05/19/2015
Table 1 .—Infants Born With Isolated
Complete
Cleft
Lip and Palate Referred
to Clinic
Shortly
After Birth*
Case/Sex t-
*
_UU_2/M_3/M_4/M_5/F_6/F CLP
Diagnosist_bi CLP_uni CLP_uni CLP_bi CLP_uni CLP_uni Birth weight, 2,756(10-25) 3,908 (75)_2,966 (25)_2,614(3-10) g (percentile)_3,444 (50)_3,542 (50-75)
7 12 7 7 8 10 Age first seen in clinic, days 3.9 (50-75)_2.8 (10)_2.4 (5)_2.78 (25) Weight, kg (percentile)_3.48 (25)_3.75 (50-75) 2 wk 2 mo 5 wk 214 mo 2V2 mo 2 mo Age 4.8 (25)_3.6 (5)_2.84 (25) 5.68 (50)_4.75 (50-75) Weight, kg (percentile)_5.0 (25-50) 5 RJ 4 Rt 2 3 5t 5J Age, mo 5.06 (25)_4.34 (50) 6.9 (25-50)_7.83 (75)_6.85 (25-50) Weight, kg (percentile)_6.31 (25-50) 3% 6'/2 U 9§ 5t 9§ 9| Age, mo Weight, percentile_10-25_50_90_50_25-50_50 12 5Î 12 Lt 9§ 11§ Age, mo Weight, kg (percentile)_9.0(10-25)_10.8(50-75) _8.9 (25)_7.9 (25-50)_6.73 (50)
_
...
"1976 National Center for Health Statistics growth curves were used. tbi CLP indicates bilateral cleft lip palate, uni CLP, unilateral cleft lip palate. JWeight at time of lip palate (L, left; R, right). §Weight at time of palate closure.
Table 2.-lnfants Born With Isolated Cleft Palate Referred to Clinic
Shortly After Birth*
Case/Sex 1/F Birth
weight, g
2/F
3/F
(percentile)_2,278 (3)_3,262 (50)_3,635(50-75)
4/M
2,924(10-25) 4 days
5/F
6/M
3,542(50)_3,290 (25-50)
4 wk 11 days 4 days 8 days 4Vi wk Age first seen in clinic Weight, kg (percentile)_2.8 (3)_3.6 (50)_3.7 (50)_2.9(10-25)_3.7 (25-50)_3.15 (25) 3 mo 6 wk 7 wk 5 wk 8 wk 6 wk Age 5.45 (75)_3.8 (25)_4.95 (25)_4.3 (25) Weight, kg (percentile)_3.4 (5)_4.05 (25-50) 7 5 8 5 4Vi 4 Age, mo Weight, kg (percentile)_5.68 (25)_6.2 (50)_7.8 (90)_8.8 (50)_8.4 (50-75)_6.46 (25) 10 10* 9 10* 8s 9* Age, mot 9.0 7.95 (25-50) 8.9(25) 9.36(50-75) Weight, kg (percentile)_8.1 (25-50) (50)_10.1(50-75)
*1976 NCHS growth charts were used. tWeight at time of palate closure.
Fig 1 .—Standard nipple with surgical blade inserted to widen cut.
Fig 2.—Infant with cleft palate being fed by mother.
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METHOD We recommend the use of standard equipment, ie, standard nipple that has been crosscut (Fig 1). The center of the cross being the central hole already present on the standard nipple. The enlarged cut provides adequate ejection of milk into the infant's mouth with the minimum effort or pressure which the infant with an altered palatal anatomy is able to provide. Our recommendations on the feeding of these infants is as follows: First, use a standard nipple that has been crosscut in the following way (Fig 1): (1) To crosscut the nipple, use a surgical blade or a clean cuticle removing pair of scissors with sharp thin blades. The central point of the cross¬ cut is the preexisting hole on the nipple. (2) The size of the crosscut is between 0.5 to 1 cm. If milk dribbles from the sides of the nipple or through the nostrils during feed¬ ing, the cut is too wide. If feeding takes longer than 30 minutes without nasal régurgitation and oral dribbling, the cut is too small. (3) Do not use a preemie nipple to feed a full-term infant. Preemie nipples are too soft and will collapse easily, preventing rapid filling of the nipple. Their use will prolong feeding time as the infant works harder to feed, and will lead to excessive swallowing of air and a false feeling of fullness. After preparing the nipple, feed the infant in a sitting position on the mother's lap (Fig 2). Then, hold the bottle in a slightly upward tilted position to avoid sucking in of more air during feed¬ ing. Burp the infant every 14 to 28 g of formula. While in the crib, keep the infant in the prone position. This allows oral or nasal régurgitation of formula to trickle forward and reduces the chances of aspira¬ tion. Cereal, when added, is added to the formula in the bottle. Introduce the infant to the use of a cup prior to admission for lip and/or palate surgery (ie, at approximate-
ly 4 months of age for lip and 8 months for palate repair). The choice of formula is up to the pediatrician providing the infant's primary care. It is imperative, however, that the parent be shown how to crosscut the nipple and how to position the infant during feeding (Fig 2). Our experience has shown that unless the mother is asked to actually feed the infant in front of us, it is difficult for her to follow written instructions and the method is not as effective. It is also imperative to bear in mind that this meth¬ od is contraindicated in infants born with the Robin anomalad (in which cleft palate is accompanied by micrognathia and glossoptosis) because of the position of the infant during feeding. It is not as effective in producing normal weight gain in cases of infants born with a CP ± CL associated with multiple congenital abnormalities, such as in infants with trisomy 13 or 18 syndrome or those with CNS damage.
feeding
and by placing the infant in the prone position while in the crib. Adequate intake and weight gain is achieved by the first month after referral. Finally, visits to the Cleft Palate Clinic for demonstration of feedings are reduced to a minimum (two visits, six weeks apart). To assure normal progress, telephone contact between the mother and the clinic nurse at first weekly and then once every two to three weeks is main¬ tained. None of the mothers has had a problem learning the technique. A copy of the pamphlet outlining the care of the child born with a cleft palate with or without cleft lip at the Boston Floating Hospital Cleft Palate Clinic is available on request. Correspond¬ ing measurements for height and head circum¬ ference of cases given in Tables 1 and 2 are available on request.
COMMENT
References
The advantages of our method are as follows: It costs the same as feeding an infant without a cleft palate. The equipment used is standard, easily available, and not unusual in appear¬ ance. It provides the infant with the daily recommended intake without undue effort on the part of mother or infant. The infant's oral gratification and emotional needs are not impaired since the infant is allowed to suck and the mother can cuddle the infant during feeding. Nasal régurgitation is controlled by varying the size of the cut and reduced by positioning of the infant. Aspiration between feedings is reduced by burping the infant frequently during and after each
1. Paradise JL, MacWilliams BJ: Simplified feeder for infants with cleft palate, Pediatrics 53:566-568, 1974. 2. Zickefoose M: Feeding problems of children with cleft palate. Children 4:225-227, 1957. 3. Drillien CM, Ingram TTS, Wilkinson EM: The Causes and Natural History of Cleft Lip and Palate. Baltimore, Williams & Wilkins, 1966. 4. Lifton JC: Methods of feeding infants with cleft palates. J Am Dent Assoc 53:22-31, 1956. 5. Burston WR: The early orthodontic treatment of cleft palate conditions. Dent Pract 9:41\x=req-\ 52, 1958. 6. Williams AC, Rothman BM, Seidman IH: Management of a feeding problem in an infant with cleft palate. Am Dent Assoc 77:81-83, 1968. 7. Molson TS: Prosthesis for the newborn. Prosth Dent 21:384-387, 1969. 8. Pashayan HM, Lichtenstein GA: Growth patterns of infants with isolated cleft of the palate with or without cleft lip treated with presurgical orthopedics. Presented at 33rd annual meeting of the American Cleft Palate Association, New Orleans, February 1975. J
J
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