7/23/2014

BreastfeedingtheInfantwith
CleftLipandPalate
JenniferPollock,CCCSLP,CLC
MemorialsKidsatKokeMill

Objectives
Participantswillidentifytypesofcleftsand
th i i
theirimpactonbreastfeeding.
t
b
tf di
Participantswillidentifywaystosupportand
assistmothersandinfantswithcleft
lip/palate.
Participantswillidentifyprofessionalswho
Participants will identify professionals who
canassistwithcleftlip/palateissuesandmake
appropriatereferrals.

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ANormalPalate

WhatisCleftLip&Palate?
Arisesinearlypregnancydevelopment by
about10weeksgestation
b t 10
k
t ti
Structuresdonotfuseproperlyinmidline
Causes geneticandenvironmentalfactors
Reducedfolicacidintakecancontributetolip
clefts Vitamin B?
clefts;VitaminB?

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WhatisCleftLip/Palate?,cont.
Lipwith/withoutpalate morecommonin
males
l
Palateonly morecommoninfemales
About5%haveidentifiablesyndromeswith
CL/PorisolatedCP

ClassificationofClefts

DavisandRitchie
Veau
KernahanandStark
InternationalConfederationofPlasticand
ReconstructiveSurgery

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CleftLip
Cleftsofthelipcanrangefromsimplenotchin
upperliptoacompleteopeninginthelip,
li t
l t
i i th li
extendingtothefloorofthenasalcavityand
involvingthealveolustotheincisiveforamen.

NormalPalatalAnatomy

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CleftLip

CleftPalate
Mayinvolvesoftpalateorextendpartiallyor
completelythroughthehardandsoftpalates
l t l th
h th h d d ft l t
Alveolusremainsintact
Maybesubmucousanddifficulttodetect

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CleftPalate

CleftLipandPalate

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CleftLipandPalate

PrevalenceandIncidenceofCL&P
ABM2007:Worldwide.82.7casesper1000
li bi th
livebirths
CochraneCollaborative2011:1outofevery
700births
HighestincidenceinNativeAmerican
(3 5/1000) and Asian (1 7/1000)
(3.5/1000)andAsian(1.7/1000)
LowestincidenceAfricanAmerican(.5/1000)
andCaucasian(1/1000)

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Lip,Palate,orLipANDPalate

Oftotal#ofinfantswithcleftlip/palate
50%combinedCL/P
30%isolatedCP
20%isolatedCL
5%CLextendingtoincludealveolus
*Usuallyunilateralbut10%bilateral

OralMotorSkillsandBreastfeeding
Tobesuccessful,thereneedstobeboth
suctionandcompression
ti
d
i
Suction attachment,stability,extractionof
milk
Compression pressingofbreastbetweenthe
tongue and palate with the jaw
tongueandpalatewiththejaw
Bothcombinetohelpwithmilktransferand
delivery

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NormalFeedinginInfants
Respondstofeedingcueswithappropriate
reflexes
Coordinationofbreathingandswallowing
Maintainingactivesuckswallowbreathe
Create/maintainnegativepressure
g
Managemilk
Receivemilkinstomach
Digestandmetabolizemilk

FeedingtheCL/PInfant
CleftLip mayhaveproblemscreatingseal
CleftPalate poornegativepressure,poor
compressionofnipple,leadingtoincreased
lengthoffeeds,breathingissues,nasal
regurgitation,milksupplyissues,etc.

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CantheInfantBreastfeed??
Answer=Maybe!!!
Si /t /l ti
Size/type/locationofcleft
f l ft
Ageofinfantatbirth
Oralmotorskills
Developmentofskillstocompensate
Emphasize importance of breast milk/feeding
Emphasizeimportanceofbreastmilk/feeding
carefully
Letinfanttry!

Maybe.NowWhatdoIdo?
Backtothebeginning
Putonourinvestigativehatsandlookat
history
Getoutthecounselingcouch!

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InterviewQuestions

Wasparentawareofacleftpriortobirth?
Howaretheydealingwithknowledge?
Dotheyhavequestionsorconcerns?
Howistheinfantfeedingcurrently?
Whathavetheytried successfullyandnot
IsfamilybeingfollowedbyaTeam?

CounselingParents

Besensitive
Listen,dontjudge
Respectgrief
Acknowledgeemotion
Performeducation repeat,goslow,bedirect
Berealistic casebycaserecommendations

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PatientEducationMaterials
Handoutexamples

RepairofClefts
Lip Typicallyrepaired1st
Timeframevaries
Improvesappearancewhichcanimprove
interactions
Palate Typicallydonebetweenages6
months 3years
months
3 years
Manytypes InvolvesPlastics,ENT,Oral
Surgery,etc.

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GoalsofSurgicalIntervention

Separationofnasalandoralcavities
Constructionofatightvelopharyngealvalve
Preservationoffacialgrowth
Developmentofaestheticdentitionand
functionalocclusion

FeedingPlan
Written,verbal,picturestoincrease
understandingandcompliance
d t di
d
li
Individualizedbutmaybeastandardform

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PriortoLipRepairStrategies
Positioning Trialanderror
Tryholdinginfantwithliporientedtowardtop
T h ldi i f t ith li
i t dt
dt
ofbreast
OralFacilitation mommaytrytooccludewith
fingersand/orsupportcheekstodecrease
widthofcleftandincreaseclosure
Mayalsomanipulatebreasttissuetoget
betterclosure
Bilateralstraddlemayworkbetter

PriortoPalateRepair Strategies
Useofsemielevatedposition
Footballhold
Positionbreasttowardgreatestsegment
whereisthemostbone
Mayneedchin/jawsupport
Supportbreastandtipdownwardtokeep
nipplefromenteringcleft

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CleftStrategies,cont.
Massage
Manualexpression
PUMP!!!

ExclusiveBreastfeeding?
Studyfrom2010 examinedhospitalratein
Kh K
KhonKaen,ThailandfromJan2008through
Th il d f
J 2008 th
h
2009
Beganprotocolin2000 roomingin,skinto
skin,dancerhold,andcompression.

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StepsforSuccess
1.ExperiencedRNtoeducatemother1on1
2.Properpositioning
3.Dancerhold
4.Momspumpimmediatelyafterdelivery&
practicesqueeze/sucklewithbabyatbreast
LATCHscore,trackweightsandI/O
/
Privacyformom,infantandfamily

Results
20newborns at1wkand1monthpost
di h
discharge,wereexclusive.At34months,16
l i At 3 4
th 16
wereonformula(mothersbacktowork?)
Studyconcludedthatitispossibletohave
exclusivitywithcompleteCLCP

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ProductsThatMayHelp

Bottles,Nipples,Syringes,OhMy!

Cups
Bottles/nipples
Fingerfeeder
Syringes

17

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BottlesandNipples

Rigidvs.SqueezableBottles
CochraneCollaboration2011
Nostatisticallysignificantdifferencesbetween
N t ti ti ll i ifi t diff
b t
typesforQOL
studiesshowedbenefitforhead
circumferenceatgreaterthan6mo,but
pooledanalysisshowednodifferencefor
weightorheadcircatanytime.
i ht h d i t
ti
Squeezablebetterforproteinintakeat3and6
months

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OtherOptions

Breastfeedingvs.Spoon
CochraneCollaboration2011
Darzi1996 cleftlipstudy
6wkspostsurgery differenceshowninfavor
ofbreastfeeding
ShowedspoonfedinfantsrequiredmoreIV
fluids and analgesia/sedation and more total
fluidsandanalgesia/sedation,andmoretotal
costofhospitalization

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TransitiontoCup
Beforepalaterepair,infantsneedtobeoffof
b ttl
d
ifi
bottlesandpacifiers
Freeflowing,novalue
DONOTadvocateremoval
ofvalves!
Aventrimmedcup

Offerallliquidsintrials

KeepinMind
Monitorinfantforhydrationandweightgain
Useofsupplementalfeedingsasappropriate
ConsultwithPediatricRegisteredDietician,if
appropriate

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ReferralstoOtherProfessionals

HeadandNeckTeam
SpeechPathology
RegisteredDieticians
OccupationalTherapy/PhysicalTherapy
SocialWork
Orthodontics/Oralsx
EarlyIntervention

TeamsinIllinois
Chicago ShrinersHospitalforChildren,Laurie
Child H it l f Chi
ChildrensHospitalofChicago;Craniofacial
C i f i l
CanteratUofIChicago;RushCraniofacial
Center
MaywoodLoyolaUniversityRonaldMcDonald
Children'sHospital
p
ParkRidge CleftPalateTeamatLutheran
GeneralHospital

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TeamsinIllinois
Peoria CentralIllinoisOrofacialAnomalies
team
Springfield SIUSchoolofMedicineCHNAC
Urbana CarleCleftLipandPalateTeam

Source:www.cleftline.org

www.CleftAdvocate.org
Linkstovariousagenciesandlocalsupport
peopleincitiesinIL
l i iti i IL
IncludesDSCC,IDHS,SSI/SSDI,WIC,Easter
Seals,EarlyIntervention,etc

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ContactInformation
JenniferPollock,CCCSLP,CLC

MemorialsKidsatKokeMill
l d
k
ll
3136OldJacksonvilleRd
Ste.140
Springfield,IL62704
Ph2178620400
Fax 217 862 0440
Fax2178620440
Pollock.jennifer@mhsil.com

References

BessellA,HooperL,ShawWC,ReillyS,ReidJ,GlennyAM.Feedinginterventionsforgrowthanddevelopmentininfantswithcleftlip,cleftpalate,or
cleftlipandpalate(review).TheCochraneLibrary.2011;2:134
CohenM,MarschallMA,SchaferME.Immediateunrestrictivefeedingofinfantsfollowingcleftlipandpalaterepair.JCraniofacSurg1992;3:3032
DarziMA,ChowdriNA,BhatAN.Breastfeedingorspoonfeedingaftercleftliprepair.BrJPlastSurg1996;49:2426
DonovanK.BreastfeedingtheInfantWithCleftLipandPalate.InfantChildAdolescNutr. 2012;4(4):194198
GarcezLandGiuglianiE.Populationbasedstudyonthepracticeofbreastfeedinginchildrenbornwithcleftlipandpalate.TheCleftPalate
CraniofacialJournal.2005;42(6):687693
LLLI.Nursingababywithacleftliporpalate.Revisededition.Schaumburg,IL:LLLI,1996.

MojabC.Congenitaldisorders:Implicationsforbreastfeeding. Leaven.Dec99Jan00;35(6):123128
Mossey PA&LittleJ.Epidemiology ofOralClefts:AnInternationalPerspective.In:WyszynskiDF,ed.CleftLipandPalate:FromOriginstoTreatment.
NY:Oxford UniversityPress,2002:127158

PathumwiwatanaP,TongsukhoS,NaratippakornT,PradubwongS,ChusilpK.ThePromotionofExclusiveBreastfeedinginInfantswithComplete
CleftLipandPalateduringtheFirst6MonthsafterChildbirthatSrinagarindHospital,KhonKaenProvince,Thailand.JMedAssocThai.2010;93(4):
S7177
ReillyS,ReidJ,&SkeatJ.ABMClinicalProtocol#17:Guidelinesforbreastfeedinginfantswithcleftlip,cleftpalate,orcleftlipandpalate.
BreastfeedingMed.2013

Photos 3.
3 http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/12709.jpg
http://www nlm nih gov/medlineplus/ency/images/ency/fullsize/12709 jpg
8. http://voiceandalexandertechnique.eu/onewebstatic/fb643d4791HardpalateGorman.gif
9. http://www.sparrow.org/HealthLibrary/MayoContent/global//images/image_popup/fl7_cleft_lip.jpg
11. http://www.cdc.gov/ncbddd/birthdefects/images/cleft_palate_small.jpg
12. http://www.chw.org/~/media/Images/Medical%20Care/Fetal%20Concern%20Center/cleft525CR.jpg
13. http://pimg.tradeindia.com/01023916/b/1/CleftlipPalate.jpg

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