Breastfeeding Baby with Cleft Lip and Palate: a Case Report

Author: dr. Aini, CIMI

Baby H, male, 29 days old was brought to the lactation consultant pediatrician at a hospital in South Jakarta with suckling difficulty problems. The baby was barely able to suckle on to the breast since born. The mother gave birth at Bogor regional hospital through a cesarean section due to the breech’s position of the baby. The baby had an opening in his palate since birth. The baby was breastfed with the help of Haberman feeder ™ as a respond to the plastic surgeon’s suggestion. Mother was routinely expressed her breast milk and constantly trying to attached the baby on to her breast. At our clinic, the baby was refused breastfeeding even though the mother wanted to breastfeed him until the age of 2 years.

Baby’s birth weight was 3715 g and weighed 3620 g at the age of 29 days when he came for the first time to our lactation clinic. During physical examination, we found an opening in the soft and hard palate extending to near the uvula. Moreover a grade 3 lip-tie and medial-type tongue-tie were also found. On the other hand mother’s milk production was abundant. Mother and baby were treated by the Praborini Lactation Team through hospitalization for 4 days and at the end the baby was willing to suckle on to the breast with the help of at-breast nursing aid until the baby was 9 months old. Based on the examination by an oral surgeon, an obturator (an artificial palate to close the opening on the palate) was recommended in aiding the baby’s breastfeeding process. The obturator was mounted at the baby’s palate at the age of 1 month 19 days. Further more the baby was scheduled and routinely controlled by the pediatric clinic for a periodic evaluation of his breastfeeding behavior and weight gain (BB).

During the first consultation with our team leader (who is a pediatrician and a lactation consultant), mothers are given 2 choices:

 

 

  • 1st Choice

Going through ‘hospitalization for nipple confusion’ to help the baby breastfed directly on to the mother’s breast while assisted by at-breast supplementation.

BANNER 728 x 90
  • 2nd Choice

Baby has the obturator mounted at the cleft palate and being given expressed breastmilk using the Haberman feeder ™. After that step, baby will start the re-lactation program to learn how to suckle on to the breast.

After several discussions the mother chose the 1st choice. Mother and baby were hospitalized for 4 days and 3 nights until the baby was willing to suckle on to the breast. Mother and baby were put in a continuous skin-to-skin contact for 24 hours using traditional cloth and kimono. The father occasionally replaced the mother when the mother went on to use toilet or shower. When the baby was not willing suckle, mother’s expressed breast milk was given using a syringe with the help of hospital nurses. Mothers were told to keep offering the breast to the baby. Once the baby was able to suckle on to the breast, he was breastfed using at-breast supplementation aid, in the form of SNS (Supplemental Nursing System), 6 × 60 cc breast milk a day. The mother was routinely expressing her breast milk. Double frenotomy were done to resolve the tongue-tie and lip-tie (with both parents permission) in order to increase the baby’s ability to easily attached on to the breast. Moreover the dyad was taught to do various maneuver and positions of breastfeeding: cradle position, football position and straddle position. At the end of the hospitalization the baby was finally able to suckle on to the mother’s breast. The breastfeeding assistance using SNS was done while also being given extra expressed or donor breast milk using Haberman feeder ™. The dyad was routinely visits our clinic to be closely followed up.

During the first visit after hospitalization, the baby was weighed 3800 grams at 1 month 4 days (good nutrition, -1SD). Baby was gaining weight by 30 grams per day. At this point the baby was occasionally being given the pasteurized donor breast milk (3x120cc) using Haberman Feeder ™ and expressed breast milk using SNS (at-breast supplementation) as much as 3 × 100 cc.

During the second visit, the baby was 1 month and 19 days old, weighed 4230 grams (-1 SD / median). The baby’s weight gained 28.6 grams per day. The obturator was placed on to the baby’s palate and can be easily removed. Haberman Feeder ™ was still continuously used . When the baby was breastfeed directly using at-breast supplementation, the obturator was unmounted.

During the third visit, the baby was 3 months 29 days, weighed 6170 grams (good nutrition, -1 SD) and gained 23.6 grams per day. The mother expressed her breast milk every 3 hours, except at night when she had night sleep.

During the fourth visit, the baby was 4 months 18 days, weighed 6430 grams (good nutritional status). He was gaining 14 grams per day. A complementary feeding planned to be additionally added on to the baby’s diet. The mother was taught how to cook adequate complementary feeding by the lactation doctor.

When he was 9 months, the baby was weaned from breast. He was being given breast milk using Haberman Feeder ™.

During the fifth visit, the baby was 11 months 2 days with body weight 8915 grams (good nutritional status). He had a good complementary feeding. Mother was expressing breastmilk routinely. Haberman Feeder ™ silicone teats need to be replaced every 2 weeks. Mothers came back to work when the baby was 6 months old.

During the sixth control, baby was 1 year and 7 days old, weighed 8970 grams (good nutritional status). At this point, the baby can eat and drink easily without obturator.

A lesson learned from this case was that the success of the breastfeeding process was mainly due to the mother’s strong determination in breastfeeding her baby even with congenital abnormalities. Moreover both father and the family provided a good support, so the mother can successfully achieved exclusive breastfeeding for the baby without the help of any formula milk. Moreover the baby was planned for a correctional surgery in order to close the opening on the palate, once the baby’s body weight reaches 10 kg. At the end of this report, the baby was 1 year 7 months with a weight of 9.5 kg.

Documentation (with patient’s permission)

  1. Obturator

Obturator terpasang pada mulut bayi

  1. Cleft palate (palatoschizis)

Image by dr. Dyah Febriyanti IBCLC

 

 

  1. Breastfeeding positions: football position
Image by dr. Dyah Febriyanti IBCLC

 

  1. Straddle position

Image by dr. Dyah Febriyanti IBCLC

References :

  1. World Health Organization Child growth standard for boys http://www.who.int/childgrowth/standards/cht_wfa_boys_p_0_2.pdf?ua=1

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