Breastfeeding babies with Cleft Lip and / or Cleft Palate

Author: dr.  Asti Praborini, SpA, IBCLC;  dr.  Ria Subekti;  dr.  Shella Riana;  dr.  Aini  dr.  Wilda

 

What are Cleft Lip and Cleft Palate?

 

Cleft lip and / or cleft palate are congenital disorders that occur as a result of a failure in development of frontonasal prominence (a structure that forms of the nose, palate, and lips). This failure occurs in the first weeks of pregnancy.  Formation of the face, jaw, palate, nose and lips begins at the 4th week of pregnancy.  At that time, there was a movement of cells in primitive grooves (of the nose, lips, jaw and palate) that caused these parts to fuse and form a perfect lip, nose, jaw and palate.  If a failure happens, an abnormal gap will be formed. This gap will be present as a ‘cleft’ after the developmental process was done.

 

The ‘cleft’ can exist on the upper lip (labioschizis) and or palate (palatoschizis). Cleft lip is an abnormal opening in the upper lip that separates the two sides of the upper lift.  This opening can occur on one side only (unilateral) or both sides (bilateral).  Cleft palate is an abnormal opening found in the palate, both in the hard palate (palatum durum) and soft palate (palatum molle).  This abnormal opening causes the oral cavity connected to the nasal cavity with varying degrees of severity.  The opening can be a small or narrow. In some cases, the hole can be wide and extends from the upper jawbone to the front section of the mouth.

 

Cleft Lip and / or Palate Occurrence Rate

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The incidence of cleft lip and / or palate varies worldwide from 0.8 to 2.7 per 1000 births.  The variation is influenced by race.  The lowest incidence rates were found in Africans, Americans, and Caucasians, while higher incidence was found in Native Americans and Asians.  Based on research conducted in the United States in 2001, cleft lip and / or palate is the second most common congenital disorder in the world after Down’s Syndrome.

 

About 50% of all cases of cleft lip and / or palate are combination of both cleft lip and palate, and about 30% of all cases are solely cleft palate, and the remaining 20% ​​is cleft lip without cleft palate.  Most cases show that cleft lip and / or palate are mainly affecting one side (unilateral) and about the remaining 10% are on both sides (bilateral).

 

Problems occurred in babies with cleft Lips and / or cleft Palate

 

Infants who have cleft lip and / or palate have some limitations, especially in terms of feeding (feeding problems). Cleft lips may impair the baby’s lips in creating a vacuum inside the baby’s mouth during a suckling process in breastfeeding. The existence of a cleft palate also causes reduced pressure in the oral cavity, making it difficult for babies to suck the breast directly.

 

Furthermore, babies with cleft palate are more susceptible to ear infections.  Abnormal opening at the palate can also cause the fluid from the mouth to enter the nose through reverse direction (regurgitation).  Inside the nasal cavity there is Eustachian tube that is directly connect the nose to the middle portion of the ear.  Therefore, the presence of a cleft palate can increase the risk of inflammation of the middle ear (otitis media) in infants.  Another significant problem in babies with cleft lip and palate is the risk of failure to thrive.  Ineffective suckling ability and recurring infections might increase the risk of infants experiencing failure to thrive.

 

In older babies, there are some difficulties in swallowing solid food, impaired articulation or speech problems, disruption of tooth eruption, and aesthetic problems.  Due to the problems and complications, the treatment for cleft lip and / or palate requires high attention from various disciplines.

 

Breastfeeding Babies with Cleft Lip and / or Palate: How is it done? 

 

Breastfeeding a baby with a cleft lip and / or palate is not easy, but is possible to be done.  One thing that needs to be underlined from the case of babies with cleft lip and / or palate is breastfeeding will always be better than formula feeding. Breastfeeding can be done through direct suckling combined with special device.

 

Immune properties in breast milk will minimize the risk of infection in babies with cleft lip and / or palate, especially respiratory infections and ear infections.  Breastfeeding also increase the babies’ own immune response and reduce the risk of infection in postoperative injuries when the baby undergoes surgery to correct the cleft lip and / or palate.  On the contrary, formula feeding will increases the risk of respiratory infections, middle ear infections, allergies, asthma, and other diseases leading to increased morbidity.  Therefore, every parent who has a baby with a cleft lip and / or palate needs to be assured and assisted to be able to keep breastfeeding their baby.

 

Breastfeeding infants with cleft lip and / or cleft palate need to be evaluated holistically, case by case.  Although we can find similarities between the cases, it is necessary to evaluate each case regarding the baby’s suckling ability, specially designed feeding aid, nutritional and hydration status.

 

Direct Breastfeeding Babies with Cleft Lip and / or Palate: Is It Possible?

 

In certain cases, babies with cleft lip and / or palate are able to suckle at breast, after various evaluations and treatments from various medical disciplines.  Babies with only one sided lip opening (unilateral labioschizis) are most likely to be able to suckle directly at breast.  The baby can be breastfed using the straddle position or koala position (the baby is positioned slightly seated and facing the mother’s body) with the thumb of the mother’s closes the opening of the baby’s lips when suckling, thus helping the baby to create a vacuum inside the mouth.

 

Babies with opening on the soft palate (palatum molle) are more often to have complicated problems. Unlike the babies with only a cleft lip, babies with cleft palate are often more difficult to create a vacuum in the oral cavity. They are less likely to be able to suckle the breast effectively. Because of this, it is necessary to do a more in-depth evaluation on the effectiveness of the baby’s sucking and their nutritional status.  Under certain conditions the baby may be able to suckle directly at breast and assisted with a supplementary device attached to the mother’s breast.

 

Babies with opening on both sides of the upper lip (bilateral labioschizis) have a greater degree of difficulty for direct sucking.  Based on the literature, babies with bilateral cleft lip still be able to suckle at the breast in the straddle position and the baby faces the mother’s breast. Unfortunately this technique is quite hard to do.  Babies with this condition usually need aids to suckle in the form of a special bottle designed for babies with cleft lip and / or palate, such as Haberman Feeder®.  Mothers need to be taught how to express milk from the day the baby is born, then mothers and other families are taught how to give milk using the Haberman Feeder®.

 

Either the babies are directly breastfeeding or breastfeeding using a feeder, it is necessary to closely assess the nutritional status of babies with cleft lip and / or palate. Babies need to have monthly visits to the pediatric clinic or lactation clinic to monitor their weight gain, mother’s milk production, evaluation of the breastfeeding process and the usage of Haberman Feeder®, and to keep the parents motivated in pursuing optimal breastfeeding.

 

Using Prosthesis (Palatal Obturator) on Cleft Lip and / or Palate: Is it Necessary?

 

A prosthesis named palatal obturator is a device specifically made to temporarily close the opening of the palatum.  This device is generally made of acrylic material and orthodontic wire made according to the shape and width of the opening.  The obturator is then mounted on the opening (the cleft palate) to prevent regurgitation, increase the baby’s ability to suck and swallow, and the speech development.

 

The obturator can be made by oral surgeon who often handles cases of cleft lip and / or palate.  After the device is mounted on the baby’s ceiling, a breastfeeding evaluation needs to be done.  Babies who have a palatal obturator will be assisted to learn the correct sucking technique, so that further assessment and assistance from the breastfeeding counselors is needed.  Every month a readjustment of the obturator is needed due to the growth the baby’s jaw.

 

Based on the literature, there are two expert opinions regarding the use of this obturator.  The first opinion says that this device is highly recommended so that the baby can suck and swallow properly; The other opinion says that the use of this device is not recommended due to the necessity to re-match every month of use, the possibility that the baby still unable to suck properly after use, and an increased risk of jaw erosion due to mechanical aspect.  However, in a clinical setting, the quality of the babies’ life remains to be considered.  Due to the risk of airway infections, middle ear infections, difficulty in sucking and swallowing, repeated regurgitation, and the possibility of failure to thrive, use of palatal obturator should be considered for babies with cleft lip and / or palate.

 

In this article, describe a case of breastfeeding babies with cleft lip and / or palate was describe based on how our team have handled the issue.

 

Babies with Small cleft on the soft palate

 

Baby A, female, aged 2 months and 29 days, came to the Permata Depok Lactation Clinic because the mother thought that her milk was insufficient. The baby was born at the Maternity Clinic in Cinere, and was said to have a small cleft palate from birth.  Baby A has a difficulty sucking and often choke during breastfeeding. Suckling ability was poor and the baby was easily slipping at breast.  The mother usually express milk and gave it using bottles. Hence, the mother’s expressed milk production is gradually decrease, and therefore she gave the baby formula milk 12 x 60 ml per day.  The mother wants to be able to breastfeed her child for up to 2 years.

 

The baby was weighed 6175 g. Weigh at birth was 3300g. The baby’s nutritional status was good according to WHO anthropometric standards.  On physical examination, we found a cleft on the soft palate measuring 1.5 x 2 cm extending into the back portion of the palate near the uvula; mother’s milk supply was normal-low. The baby was willing to latch directly to the breast with straddle position, yet she was still barely able to latch on to the breast. We assisted her with breast compression, thus she made a better latch and suckle at breast more continuously.

 

Mothers are motivated to continue breastfeeding directly, given counseling about the benefits of breast milk and the dangers of formula milk. We advised them to do breastfeeding using a supplemental nursing system (SNS®).  Babies are scheduled for routine control to the pediatric clinic in order to periodically evaluate the process of breastfeeding and monitor the baby’s weight gain.

Babies with cleft on hard palate (palatoschizis) have greater sucking difficulties compared to other cases.  Sometimes, cleft on hard palate is accompanied by a cleft on the lip and alveolar bone (labiognatopalatoschizis). This cleft in the palate causes difficulty to create a vacuum in the baby’s oral cavity during breastfeeding, leading to poor suckling ability.  Babies with cleft palate with or without cleft lip generally need special device for giving breast milk, namely Haberman Feeder®.  Mothers and other caregivers need to be taught how to express mother’s breast milk from the first day the baby is born and how to give the milk with Haberman Feeder®. Babies are scheduled for routine control to the pediatric clinic for routine evaluation of the breastfeeding process and infant weight gain.

 

References

 

Goyal A, Jena AK, Kaur M. Nature of Feeding Practices among Children with Cleft Lip and Palate. Journal of Indian Society of Pedodontics and Preventive Dentistry 2012; 30:47-9.

Hopper RA, Cutting C, Grayson B. Grab and Smith’s Plastic Surgery: Cleft Lip and Palate. Lippincott William and Wilkins; 2007:1-44.

Mossey PA, et al. Cleft Lip and Palate. Lancet 2009; 374:1773–85.

Reilly S, et al. ABM Clinical Protocol #17: Guidelines for Breastfeeding Infants with Cleft Lip, Cleft Palate, or Cleft Lip and Palate, Revised 2013. Breastfeeding Medicine 2013; 8:349-353.

Supit L, Prasetyono TOH. Cleft Lip and Palate: Epidemiology, Risk Factors, Quality of Life, and Importance of Classifications. Med J lndones 2008; 17(4):226-239.

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