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Episode 041: Feeding Tips and Tricks for Infants

with Cleft Palate & Craniofacial AnomaliesFeaturing Raquel Garcia, M.S.,CCC-SLP, BCS-S

Feeding my baby with cleft lip and/or cleft palate

Created by: Raquel Garcia, M.S., CCC-SLP, BCS-S, 2018

BOTTLE FEEDING Cleft Lip

SEAL: to bottle should be possible if ONLY cleft lip. •Feeder could use fingers to promote labial seal. •If NAM in place, will promote labial seal

SUCTION : with adequate SEAL , suction should present within functional limits.SUCK : with adequate SUCTION, bolus expression present within functional limits.

NIPPLE SELECTION : Typical flow rate nipple that best fits your baby’s PO feeding skills.

Seal – suction - suck work in tandem!

Created by Raquel Garcia, M.S., CCC-SLP, BCS-S

2018

BREAST FEEDING

Cleft Lip

SEAL: Breast feeding should be possible if ONLY cleft lip. •Breast tissue should fill cleft lip to create labial seal. •Feeder could use fingers to promote labial seal. •If NAM in place, will promote labial seal

SUCTION : with adequate SEAL , suction should present within functional limits.SUCK : with adequate SUCTION, bolus expression should present within functional limits.

***Monitor for labial/lingual clicking, may not be achieving adequate seal.

Seal – suction - suck work in tandem!

Created by Raquel Garcia, M.S., CCC-SLP, BCS-S

2018

BOTTLE FEEDING

Cleft Palate or Cleft Lip and Cleft Palate (CL+P)

SEAL: should be possible if ONLY cleft palate. If CL+P, then feeder could use fingers to promote labial seal. •If NAM in place, will promote labial seal

SUCTION : Impaired secondary to cleft palate.

SUCK : Impaired secondary to cleft palate.

NIPPLE SELECTION : ADAPTIVE SPECIALTY BOTTLE/NIPPLE to match baby’s anatomy differences and PO feeding skills. Created by Raquel Garcia, M.S., CCC-SLP, BCS-S

2018

BREAST FEEDING Cleft Palate or CL+P

Seal, Suction, and suck IMPAIRED secondary to cleft palate not readiness skills.

“except in rare cases, a baby with a cleft palate cannot sustain nutrition -hydration via exclusive breast feeding” (Cleft Palate Foundation, 2009)

SEAL: Typically not able to obtain suction/suck, thus seal may lead mother to suspect expression of bolus with good suck, when baby is actually expressing limited bolus and expending copious amounts of energy in an attempt to PO feed.

SUCTION : Impaired secondary to cleft palate.

SUCK : Impaired secondary to cleft palate. Created by Raquel Garcia, M.S., CCC-SLP, BCS-S

2018

BREAST FEEDINGHow can breast feeding still play a role with mother & baby with cleft

palate?

Pumping Skin to Skin

Bonding = Milk

Production

Non-nutritive

Stimulation

(Nursing crib.org/breastisbest, 2016)Created by Raquel Garcia, M.S., CCC-SLP, BCS-S

2018

Nipple Selection Best for … Does not fit infant with …

Smaller bolus size – increased oral control

Cleft palate

Decreases anterior liquid loss, secondary to flow rateBetter SSB coordination secondary to flow rate

Slow Flow

Standard Flow

Best for … Does not fit infant with …Larger bolus size – baby has good oral control

Cleft palate

More experienced PO feederSSB coordination is appropiate (Lessard, 2015)

Created by Raquel Garcia, M.S., CCC-SLP, BCS-S, 2018

Best for … Does not fit infant with …

Also referred to as: Y-cut, X-cut, cereal cut, variable flow

Cleft palate

Thickened feeds due to reflux or pharyngeal dysphagia

Cross Cut

Best for … Does not fit infant with …Decreased lingual cupping Cleft palateLow tone– decrease need to generate strong intra-oral suctionIncreased stimulation to hard palate

Orthodontic

Nipple Selection

(Lessard, 2015)Created by Raquel Garcia, M.S., CCC-SLP, BCS-S, 2018

Best for … How Does it workBaby with cleft palate 3 different lines on nipple –

different flow rates: slow, medium, fast

Variable flow rate – can adjusted according to baby’s bolus control and suck coordination.

Align appropriate flow rate with the baby’s nose during feeding

Squeeze nipple when baby is sucking

Follow baby’s suck rhythm when squeezing nipple

Do not squeeze nipple if baby is taking rest break

Special Needs Feeder

NIPPLE SELECTION


Best for … How Does it work

Baby with cleft palate Large broad nipple fills oral cavity

Bilateral Cleft Palate Baby expresses bolus via tongue pumping with up and down rhythm to hard palate

Fast flow rate, larger bolus size – baby has good oral control, appropriate suck-swallow-breath synchrony

Does not require active squeezing during PO feeding.

Pigeon Nipple

NIPPLE SELECTION



Baby with cleft palate Long narrow nipple

Fast flow rate Squeeze BOTTLE when baby is sucking

Larger bolus size , baby has good oral control

Follow baby’s suck rhythm when squeezing nipple

Appropriate suck-swallow-breath synchrony

Do not squeeze nipple if baby is taking rest break

Cleft Lip/Palate Nurser by Mead Johnson

NIPPLE SELECTION



Baby with cleft palate “Infant-Paced Feeding Valve®”

Bilateral Cleft Palate Baby expresses bolus via tongue pumping with up and down rhythm to hard palate

Can use any Dr. Brown Nipple as long as feeding valve is in place (e.g., preemie, Y-cereal cut)

Tongue and jaw movements during sucking to adequately express bolus

Parent socialization - Commercial bottle, does not look different

Does not require active squeezing during PO feeding.

Dr. Brown’s Specialty Feeder

NIPPLE SELECTION


Quality vs. QuantityIncreasing nipple flow rate to can result in:• Overfilling infant’s mouth and/or pharynx

• Disorganized suck-swallow-breathe sequence

• Respiratory fatigue (difficulty breathing, breath hold)

• Instability : bradycardia or desaturation

• Adverse sensory-motor experiences

• Risk for penetration/aspiration Created by Raquel Garcia, M.S., CCC-SLP, BCS-S, 2018

What are the feeding issues related to?• Anatomy • Respiratory• Cardiac• Prematurity• Gastrointestinal• Neurological • Developmental

So ask yourself…


CLEFT PALATE FOUNDATION • cleftline.org/who-we-are/what-we-do/feeding-your-baby

AMERICAN CLEFT PALATE CRANIOFACIAL ASSOCIATION • acpa-cpf.org

SIG 5- Craniofacial and Velopharyngeal Disorders• Asha.org

Cleft Palate Feeding Resources


Amstalden‐Mendes, L. G., Magna, L. A., & Gil‐da‐Silva‐Lopes, V. L. (2007). Neonatal care of infants with cleft lip and/or palate: feedingorientation and evolution of weight gain in a nonspecialized Brazilian hospital. Cleft Palate‐Craniofacial Journal, 44(3), 329‐334.

Aniansson, G., Svensson, H., Becker, M., & Ingvarsson, L. (2002). Otitis media and feeding with breast milk of children with cleft palate. ScandJ Plast ReconstrSurgHand Surg, 36(1), 9‐15.

Barone, C. M., & Tallman, L. L. (1998). Modification of Playtex nurserfor cleft palate patients. J CraniofacSurg, 9(3), 271‐274. • Beaumont, D. (2008). A study into weight gain in infants with cleft lip/palate. PaediatrNurs, 20(6), 20‐23.

Bessell, A., Hooper, L., Shaw, W. C., Reilly, S., Reid, J., & Glenny, A. M. (2011). Feeding interventions for growth and developmentininfants with cleft lip, cleft palate or cleft lip and palate. Cochrane Database SystRev(2), Cd003315.

“Breast Is Best” retrieved information 2-1-16 nursingcrib.org/breastisbestcampaign

Brine, E. A., Rickard, K. A., Brady, M. S., Liechty, E. A., Manatunga, A., Sadove, M., et al. (1994). Effectiveness of two feeding methods in improving energy intake and growth of infants with cleft palate: a randomized study.J Am Diet Assoc, 94(7), 732‐738.

Campbell, A. N., & Tremouth, M. J. (1987). New feeder for infants with cleft palate. Arch Dis Child, 62(12), 1292.

Choi, B. H., Kleinheinz, J., Joos, U., & Komposch, G. (1991). Sucking efficiency of early orthopaedicplate and teats in infants with cleft lip and palate. IntJ Oral MaxillofacSurg, 20(3), 167‐169.

Chuacharoen, R., Ritthagol, W., Hunsrisakhun, J., & Nilmanat, K. (2009). Felt needs of parents who have a 0‐to 3‐month‐old child with a cleft lip and palate.Cleft Palate‐Craniofacial Journal, 46(3), 252‐257.

Clarren, S. K., Anderson, B., & Wolf, L. S. (1987). Feeding infants with cleft lip, cleft palate, or cleft lip and palate. Cleft Palate J, 24(3), 244‐249.

Cohen, M., Marschall, M. A., & Schafer, M. E. (1992). Immediate unrestricted feeding of infants following cleft lip and palate repair.J CraniofacSurg, 3(1), 30‐32.

Development of Feeding and Swallowing Skills, retrieved information 1-19-16, https://mypickyeaters.wordpress.com/2009/04/23/development-of-feeding-and-swallowing-skills

“Feeding Flock Basics” retrieved information on 12-27-15 Feedingflock.unc.edu

Ferguson, N, Estis, J, “Feeding my Premature Infant”, Neonatal Journal of Medicine, Issue 3, June 2014

Lessard, Courtney, Speech Pathologist, Wasie Neonatal Intensive Care Unit – Nursing education Forms, 2015

Park,J, Thoyre, S, Knafl, G, Hodges,E, Nix,W . Efficacy of Semielevated Side-Lying Positioning During Bottle-Feeding of Very Preterm Infants, A Pilot Study, Neonatal Journal of Nursing, Issue 2, 2013

Shaker, Catherine “Reading The Feeding”, retrieved article on 1-25-16 from Shaker4Feeding.com

Shaker, C, Thoyre,S ; Early Feeding Skills Assessment, . Neonatal Journal of Nursing, Issue 5, 2014

Thoyre,S., Shaker,C; Nix,W. “Readiness Cues and Beyond” Neonatal Care Journal, June 2011

“What is a Term Infant?” Information retrived on 1-20-2016www.nlm.nih.gov/medlineplus/ency/article/001562.htm

References

Duarte, G. A., Ramos, R. B., & Cardoso, M. C. (2016). Feeding methods for children with cleft lip and/or palate: a systematic review.BrazJ Otorhinolaryngol, 82(5), 602‐609.

Foster, J. P., Psaila, K., & Patterson, T. (2016). Non‐nutritive sucking for increasing physiologic stability and nutrition in preterm infants.Cochrane Database SystRev, 10, Cd001071.

Greives, M. R., Anderson, C. L., Dean, R. A., Scerbo, M. L., Doringo, I. L., Bebbington, M. W., et al. (2016). Survey of Parent Experiences in Prenatal Visits for Infants With Cleft Lip and Palate. Cleft Palate CraniofacJ.

Griffith, T., Rankin, K., & White‐Traut, R. (2017). The Relationship Between Behavioral States and Oral Feeding Efficiency in Preterm Infants. Adv Neonatal Care, 17(1), E12‐e19.

Johansson, B., & Ringsberg, K. C. (2004). Parents' experiences of having a child with cleft lip and palate. Journal of Advanced Nursing, 47(2), 165‐173.

Kaye, A., Thaete, K., Snell, A., Chesser, C., Goldak, C., & Huff, H. (2016). Initial Nutritional Assessment of Infants With Cleft Lip and/or Palate: Interventions and Return to Birth WeightCleft Palate CraniofacJ.

Kim, E. K., Lee, T. J., & Chae, S. W. (2009). Effect of unrestricted bottle‐feeding on early postoperative course after cleft palate repair.J CraniofacSurg, 20 Suppl2, 1886‐1888.

References

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