Failure to Thrive
Non-Organic Failure to Thrive (NOFTT)
• is a condition in infants and young
children characterized by inadequate
growth and development, not caused by
any underlying medical or organic issues.
• Instead, it results from a complex interplay
of environmental, psychosocial, and
nutritional factors that impede normal
growth. Children with NOFTT typically show
poor weight gain, height, and
developmental progress,
often falling below the expected growth
percentiles for their age.
• Understanding the essentials of NOFTT is
needed to effectively identify and address
the underlying causes, optimize nutrition,
and foster a supportive environment for
affected children to thrive and reach their
full developmental potential.
WHAT IS NON-ORGANIC FAILURE TO
THRIVE?
• Four principal factors are necessary for
human growth: food, rest and activity,
adequate secretion of hormones, and a
satisfactory relationship with a caregiver or
nurturing person who provides consistent,
loving human contact and stimulation.
• Infants who fail to gain weight and
who show signs of delayed
development are classified as failure-
to-thrive infants.
• Failure to thrive has been defined in a
number of ways, but most definitions
include a weight less than the 5th
percentile on the growth chart or a
decreasing rate of weight gain.
TWO CLASSIFICATIONS OF FAILURE TO
THRIVE
• Organic failure to thrive. Organic
failure to thrive is a result of a disease
condition.
• Non-organic failure to thrive. Non-
organic failure to thrive has no
apparent physical cause.
PATHOPHYSIOLOGY
Non-organic failure to thrive is often the
result of interacting medical, behavioral,
developmental, and psychosocial factors.
• A child is said to have failure to thrive
when they don’t meet recognized
standards of growth; it is not a disease
or disorder.
• Instead, it describes a situation in
which a child is undernourished and
either doesn’t receive or is unable to
process enough calories.
• The doctor determines a child’s ideal
weight by comparing their weight,
age, and gender to national
averages.
• Children who fail to thrive usually fall
well below their ideal weight.
• A child may also be diagnosed with
failure to thrive if their growth rate in
terms of height stalls when it should be
on an upward trend.
STATISTICS AND INCIDENCES
The statistics of non-organic failure to
thrive include:
• Up to 80% of children with growth failure
do not have an apparent growth-
inhibiting disorder, growth failure occurs
because of environmental neglect,
stimulus deprivation, or both.
• In the United States, it is seen in 5 to 10
percent of children in primary care
settings, and in 3 to 5 percent in hospital
settings.
• The prevalence of failure to thrive
depends mainly on the definition being
used and the demographics of the
population being studied, with higher
rates occurring in economically
disadvantaged rural and urban areas.
• Approximately 80% of children with failure
to thrive present before 18 months of age.
CAUSES
• Not enough food is offered. Incorrect
formula
measurement, breastfeeding problems,
problems with transitioning to solid foods,
restricted fat intake, and financial
constraints mostly cause failure to thrive.
• The child eats too little. Some children
have trouble eating enough food
because of prematurity, developmental
delays, or conditions like autism.
• Health problems involving the digestive
system. Several health conditions can
prevent a child from gaining weight.
• Food intolerance. Food intolerance means
the body is sensitive to certain foods.
• An ongoing illness/disorder. A child who
has trouble eating may not take in
enough calories to support normal growth.
• Infections. Parasites, urinary tract
infections, tuberculosis, and other
infections can force the body to use
nutrients rapidly and decrease appetite.
• Metabolic disorders. Metabolic disorders
are health conditions that make it hard for
the body to break down, process, or take
energy from food.
CLINICAL MANIFESTATIONS
• Infants with non-organic failure to thrive
exhibit the following:
• No weight gain. Lack of weight gain is a
common manifestation of failure to thrive.
• Developmental delays. Delays in reaching
developmental milestones, such as rolling
over, crawling, and talking cannot be
achieved on time.
• Poor muscle tone. Infants with non-organic
failure to thrive have poor muscle tone
and a loss of subcutaneous fat.
• Immobility. They are immobile for long
periods of time due to a lack of energy.
• Unresponsive. They may be unresponsive
or actually try to avoid cuddling and
vocalization.
• Irritable. Children with failure to thrive
often fall into the classification of “difficult”
or irritable babies, but others may be
listless and passive and do not seem to
care about feedings.
ASSESSMENT AND DIAGNOSTIC FINDINGS
• Growth charts. Doctors use standard
growth charts to plot weight, length, and
head circumference, which are measured
at each well-child exam.
• Health history. To see if there’s a
problem, doctors will ask for a child’s
detailed health history, including
a feeding history.
• Physical exam. Signs of deprivation are
important elements in the diagnosis; when
the child begins to improve in a nurturing
environment, the diagnosis is confirmed.
• Laboratory tests. If a thorough history or
physical examination does not indicate a
particular cause, most experts
recommend limiting screening tests to
CBC with differential, ESR, BUN,
serum creatinine, electrolyte levels,
urinalysis and culture, and stool for pH,
reducing substances, odor, color,
consistency, and fat content.
MEDICAL MANAGEMENT
Treatment of failure to thrive is aimed at
providing sufficient health and environmental
resources to promote satisfactory growth,
• Nutritional treatment. Eliminate empty
calories from items, schedule regular
 meals and snacks, usually 3 meals and 2
snacks, offer solids before liquids, consider
fortifying calories with extra oils and carbs,
increase protein, and consider vitamin
and/or mineral supplements, especially
zinc and iron.
• Psychosocial evaluation. Psychosocial
evaluation must be detailed and must
provide an in-depth look at the
functioning of the family and the child in
the context of the family.
NURSING MANAGEMENT
• Treatment initially depends almost entirely
on good nursing care.
NURSING ASSESSMENT
• Routine assessment is needed in order to
identify potential problems.
• Physical exam. Conduct a careful
physical exam of the child, including
observing skin turgor, anterior fontanel,
signs of emaciation, weight, temperature,
apical pulse, respirations, responsiveness,
listlessness, and irritability.
• Interaction. When interviewing the family
caregiver, carefully observe the
interaction between the caregiver and
the child and note the caregiver’s
responsiveness to the child’s needs and
the child’s response to the caregiver.
• History. Take a careful history
of feeding and sleeping patterns or
problems.
NURSING DIAGNOSIS
Based on the assessment data, the
major nursing diagnoses are:
• Disturbed sensory perception related to
insufficient nurturing.
• Imbalanced nutrition: Less than body
requirements related to inadequate
intake of calories.
• Deficient fluid volume related to
inadequate oral intake.
• Impaired urinary elimination related to
decreased fluid intake.
• Constipation related to dehydration.
• Risk for impaired skin integrity related to
malnourishment.
• Impaired parenting related to lack of
knowledge and confidence in parenting
skills.
NURSING CARE PLANNING AND GOALS
The major nursing goals for the patient are:
• Improve alertness and responsiveness.
• Increase caloric and oral fluid intake.
• Maintain normal urinary
and bowel elimination.
• Maintain skin integrity.
• Improve parenting skills and build parental
confidence.
NURSING INTERVENTIONS
These interventions address general concerns
related to nutritional deficits in the hospital or
home setting. Provide sensory
stimulation. Attempt to cuddle the child and
talk to him or her in a warm, soothing tone and
allow for play activities appropriate for the
child’s age.
• Maintain adequate nutrition and fluid
intake. Feed the child slowly and carefully
in a quiet environment; during feeding,
the child might be closely snuggled and
gently rocked; it may be necessary to
feed the child every 2 to 3 hours initially.
• Post feeding instructions. Burp the child
frequently during and at the end of each
feeding, and then place him or her on the
side with the head slightly elevated or
held in a chest-to-chest position.
• Participation of caregiver. If a family
caregiver is present, encourage him or her
 to become involved in the child’s
feedings.
• Document the intake. Carefully document
food intake with caloric intake and
strict intake and output records.
• Monitor elimination patterns. As food and
fluids are gradually increased and the
child becomes hydrated, bowel activity
and urine production return to normal.
• Promoting skin integrity. Lanolin or A and
D ointment can be used to lubricate dry
skin; apply the ointment at least once
each shift and turn the child at least every
2 hours.
• Providing family teaching. While caring for
the child, point out to the caregiver the
child’s development and responsiveness,
noting and praising any positive parenting
behaviors the caregiver displays.
• I&O, fluid balance, changes in weight,
presence of edema, urine specific
gravity, and vital signs.
• Results of diagnostic studies.
• Parenting skill level, deviations from
normal parenting expectations, family
makeup, and developmental stages.
• Availability and use of support systems
and community resources.
• Plan of care.
• Teaching plan.
• Responsiveness to interventions,
teaching, and actions performed.
• Attainment or progress toward desired
outcomes.
• Modifications to plan of care.

EVALUATION

After the implementation of the care plan,

evaluation includes:

• Improved alertness and responsiveness.

• Increased caloric and oral fluid intake.

• Maintained normal urinary and bowel

elimination.

• Maintained skin integrity.

• Improved parenting skills and build

parental confidence.

DOCUMENTATION GUIDELINES

Documentation for a patient with failure to

thrive includes:

• Individual findings, noting specific

deficitss and associated symptoms,
perceptions of client/SOs.

• Caloric intake.

• Individual cultural or religious

restrictions, and personal preferences.

• Degree of fluid deficit and current

sources of fluid intake.
 NURSING PROBLEM PRIORITIES
Cleft lip and palate
The following are the nursing priorities for
• A cleft lip and palate is a defect caused patients with cleft lip and cleft palate:
by the failure of the soft and bony tissue to
• Feeding Difficulties. Infants with cleft
fuse in utero. These may occur singly or
lip and cleft palate may have
together and often occur with other
difficulties in breastfeeding or
congenital anomalies such as spina
bottle feeding due to structural
bifida, hydrocephalus, or cardiac
abnormalities. Ensuring adequate
defects.
nutrition and
• In infants diagnosed with cleft lip, the addressing feeding challenges are
fusion fails to occur in varying degrees, crucial for their growth and
causing this disorder to range from a small development.
notch in the upper lip to total separation
• Speech and Language
of the lip and facial structures up into the
Development. Cleft lip and cleft
floor of the nose, with even the upper
palate can affect speech production
teeth and gingiva absent. Cleft lip
and intelligibility. Early intervention by
deformities can occur unilaterally,
speech therapists and regular
bilaterally, or rarely in the midline.
monitoring of speech and language
• A cleft palate is an opening of the palate development are essential to address
and occurs when the palatal process any potential communication
does not close as usual at approximately difficulties.
weeks 9 to 12 of intrauterine life. The
• Dental and Orthodontic Issues. Cleft
incomplete closure is usually on the
lip and palate can impact the
midline and may involve the anterior hard
alignment and development of teeth
palate, the posterior soft palate, or both. It
and jaws. Dental problems, such as
may occur as a separate anomaly or in
malocclusion, missing teeth, and
conjunction with a cleft lip.
dental decay, may require
• Treatment consists of surgical repair, orthodontic and dental interventions
usually of the lip between 6 to 10 weeks of to ensure proper oral health and
age, followed by the palate between 12 function.
to 18 months of age. The surgical
• Ear Infections
procedures depend on the child’s
and Hearing Problems. Children with
condition and physician preference.
cleft palate are more prone to middle
Management involves a multidisciplinary
ear infections (otitis media) and
approach that includes the surgeon,
hearing loss due to the dysfunction of
pediatrician, nurse, orthodontist,
the Eustachian tube. Frequent
prosthodontist, otolaryngologist, and
monitoring and timely intervention are
speech therapist.
necessary to prevent potential
• Nursing goals for clients diagnosed with hearing impairment.
cleft lip and palate include maintaining
• Psychological and Social Well-
adequate nutrition, increasing family
being. Individuals with cleft lip and
coping, reducing the parents’ anxiety and
cleft palate may face challenges
guilt regarding the newborn‘s physical
related to self-esteem, body image,
defects, and preparing parents for the
and social interactions due to visible
future repair of the cleft lip and palate.
facial differences. Providing
psychological support and addressing
any emotional difficulties can
contribute to their overall well-being.

• Facial Aesthetics and Plastic

Surgery. Reconstructive surgery plays
 a vital role in correcting the cleft lip
and palate, improving facial
aesthetics, and restoring normal
function. Surgical interventions are
typically staged and performed by
experienced plastic surgeons.
• Nasal Resonance and Breathing
Difficulties. Cleft palate can affect
nasal resonance and lead to nasal
airway obstruction. Management may
involve speech therapy, nasal surgery,
and continuous monitoring of nasal
function.
NURSING DIAGNOSIS
• Following a thorough assessment,
a nursing diagnosis is formulated to
specifically address the challenges
associated with cleft lip and cleft
palate based on the nurse’s clinical
judgment and understanding of the
patient’s unique health condition.
• While nursing diagnoses serve as a
framework for organizing care, their
usefulness may vary in different clinical
situations. In real-life clinical settings, it
is important to note that the use of
specific nursing diagnostic labels may
not be as prominent or commonly
utilized as other components of the
care plan. It is ultimately the nurse’s
clinical expertise and judgment that
shape the care plan to meet the
unique needs of each patient,
prioritizing their health concerns and
priorities.
NURSING GOALS
Goals and expected outcomes may
include:
• The infant will maintain a clear airway
as evidenced by clear breath sounds
and the absence of cyanosis.
• The infant will display a respiratory rate
of 20 to 30 breaths per minute,
absence of retractions, and
respiratory distress.
• The neonate will exhibit adequate
nutritional status to maintain growth
and healing.
• The family will report decreased
anxiety levels concerning the infant’s
condition.
• The family will demonstrate problem-
solving skills and the use of resources
effectively.
• The family will increase coping ability
concerning the infant’s condition and
care needs.
• The parents will verbalize that they
believe there will be a positive
outcome for the infant.
• The parents will demonstrate coping
behaviors evidenced by holding and
helping with infant care.
• The family will obtain an increased
knowledge about the infant’s
preoperative and postoperative care.
• The family will verbalize understanding
of the disease process and treatment
regimen.
• The family will identify possible
complications that necessitate
medical attention.
• The infant will not
experience injury from the incision.
• The infant will be free of trauma,
accumulation of substances,
and infection.
• The infant will be free of signs and
symptoms of ear infection.
• The parents will verbalize
understanding of the importance of
early treatment.
• The parents will list signs of diminished
hearing.
• The parents will verbalize appropriate
agencies for support and guidance.
NURSING INTERVENTIONS AND ACTIONS
Therapeutic interventions and nursing actions
for patients with cleft lip and cleft palate may
include:
1. Maintaining Airway Clearance and
Preventing Aspiration
Infants diagnosed with a cleft palate cannot
suck effectively either because pressing their
tongue or a nipple against the roof of
their mouth forces milk into their pharynx,
possibly leading to aspiration. Additionally,
because of the local edema that occurs after
a cleft lip or palate surgery, it’s important to
observe children closely in the immediate
postoperative period for respiratory distress.
After surgery, the infant has to learn to breathe
through the nose, possibly adding to the
respiratory difficulty.
Assess skin color and capillary refill.
• Bluish discoloration of the skin or
prolonged capillary filling happens
because of the decreased oxygenation
produced by the defect. The nurse should
note, however, that the peripheral
circulation of a newborn remains sluggish
for at least the first 24 hours, which can
cause cyanosis in the infant’s feet and
hands (acrocyanosis).
Assess for abdominal distention.
• The infant may swallow excess air during
bottle feeding, causing abdominal
distention that may result in upward
pressure on the diaphragm and lungs,
compromising respiration. To facilitate
palpation (if not contraindicated), the
knees and legs should be flexed toward
the hips, which allows the abdominal
muscles to relax.
Place the infant in an infant seat at 30° to 45°.
• This position prevents the infant’s
tongue from falling back and
obstructing the airway. If possible, the
infant can be placed in an infant
bouncy seat. The semi-upright position
facilitates burping, limits regurgitation
of fluids, and prevents milk from
entering the Eustachian tube and
middle ear space, thus minimizing ear
infections (Burca et al., 2016).
Position the infant in an upright position greater
than 60° during feeding and elevate the head
of the crib to 30° after.
• General recommendations for body
mechanics in infants with cleft lip or palate
while feeding include the following: head
support for neutral alignment of head and
neck; arms forward, trunk midline, hips
flexed; and lip, cheek, and jaw
stabilization to provide a platform for
sucking movements. Infants with cleft
palate are fed in an upright position
greater than 60° to allow gravity to
facilitate fluid transfer and decrease the
tendency for nasopharyngeal reflux
(Burca et al., 2016).
Allow the infant time to swallow during
feedings and provide oral care as
appropriate.
• Placing a small amount of breast milk or
formula into the infant’s mouth and
allowing time for swallowing will prevent
aspiration. Offering small amounts of sterile
water will cleanse the mouth after
feeding. Formula or drainage is gently
cleaned from the suture line with saline
solution.
Provide oral and nasal suctioning as needed.
• The purpose of suctioning is to maintain
a patent airway and improve oxygenation
by removing excess fluids and secretions in
the oral and nasal cavities. Following
either cleft lip or cleft palate surgery,
infants may need their mouth suctioned to
remove mucus, blood, and unswallowed
saliva. When doing this, be exceedingly
gentle, so you don’t touch the suture line
with the catheter. Place the infant on their
side to allow mouth secretions to drain
forward.
Feed the infant slowly and burp frequently.
• Burping frequently during feeding will
reduce spitting up and prevent
excessive swallowing of air. Holding the
infant during feedings, burping
frequently, and placing the infant in an
infant seat after feeding or on the right
side propped with a rolled blanket will
aid in a positive outcome for this infant.
 Position the infant appropriately after surgery.
• Following a cleft lip repair, be sure the
infant does not turn onto their abdomen
because this could put pressure on the
suture line, possibly tearing it. Careful
positioning ensures the prevention of
injury to the operative site.
Provide special nipples or feeding devices
such as pigeon feeders with a one-way valve.
• Feeding may work better using special
bottles or nipples with a wider base. A
syringe with a rubber tip, a long nipple
with a large hole attached to a squeeze
bottle, or a medicine dropper can be
used to feed the infant formula or breast
milk before and after surgery because
sucking motions must be avoided to keep
from applying tension on the suture line.
Coordinate with other healthcare teams for the
holistic care and management of the infant.
• Treatment of the infant diagnosed with
cleft lip and palate requires
multidisciplinary teamwork with a surgeon,
pediatrician, pediatric dentist,
orthodontist, nurse, psychologist, speech
therapist, and social worker. The public
health nurse should be responsible for
coordinating parental counseling and
referral as needed.
2. Improving Nutritional Status and Teaching
Feeding Methods
Before a cleft lip or palate is repaired, feeding
the infant becomes a concern because the
infant has difficulty maintaining suction with a
bottle or breast; there is evidence of slower
growth compared to infants without a cleft
disorder. Because the deviation of the lip
interferes with sucking, infants may be at a
better surgical risk as newborns than they are
after a month or more of poor nourishment.
Feeding is a problem because the cleft
prevents negative pressure from being formed
within the mouth, which is necessary for
successful sucking.
Assess infant sucking and swallowing ability.
• The infant with a cleft lip or palate may
find it challenging to establish breast and
bottle feeding due to impaired sucking
ability, compromising nutrition. The cleft
may not be readily apparent at birth, so
careful examination of the oral cavity and
upper palate at birth is essential. To assess
sucking ability, the evaluator places an
index finger on the infant’s tongue for the
infant to suck. Gently feeling the inside of
the mouth and identifying the strength of
the suck will allow the evaluator to locate
the cleft and assess the severity (Burca et
al., 2016).
Record the daily weight of the infant.
• Documenting daily weight evaluates
whether the feeding pattern is successful
or needs to be adjusted. Initially, the
infant’s anthropometric measurements of
weight and height are recorded and
plotted for age-appropriate parameters.
After initial weight loss in the newborn
period, a weight gain of 15 to 30 g per
day is the goal (Burca et al., 2016).
Educate the mother on how to massage her
breasts and nipples before nursing the infant.
• Breast and nipple massage will cause milk
to flow freely near the surface for a
comfortable suck and will harden breasts,
allowing the infant to hold the nipple in
his/her mouth. If the surgery will be
delayed for one month, the mother will
need continuing support from the nursing
staff to support her efforts on pumping
and to remind her that her breast milk will
be very beneficial to her infant and the
healing process.
Instruct the mother to apply pressure to the
areola using her fingers, guide the nipple to
the side of the infant’s mouth, and hold it there
during feeding.
• Holding the nipple in the infant’s mouth
allows the infant to nurse with its gums
rather than by sucking if sucking is difficult.
It may be possible for an infant with a cleft
lip to breastfeed because the bulk of the
mother’s breast tends to form a seal
against the incomplete upper lip.
Although the infant needs the enjoyment
of sucking, some surgeons do not want
the infant to either breastfeed or suck on
a nipple before surgical correction of the
 disorder to avoid any local bruising of
tissue.
Encourage frequent burping after feeding.
• When an infant drinks from a bottle, they
can swallow some air, which goes down
into their stomach along with the milk or
formula. Burping will help to prevent
aspiration after feeding. Following a
feeding, be certain the infant with a cleft
lip is burped well because the inability to
securely grasp a nipple or syringe edge
causes the infant to swallow more air than
usual.
Hold the infant upright or a sitting position
while feeding.
• An upright or a sitting position improves
swallowing and prevents milk from coming
through the defect and out of the nasal
cavity, therefore reducing the risk of
aspiration. Therefore, the best feeding
method for the infant diagnosed with cleft
lip may be to support the infant in an
upright position and feed the infant gently
using a soft bottle and a commercial cleft
lip nipple or a spoon.
An alternative is for the mother to pump her
breasts and feed the infant with a bottle.
• Pumping breast milk satisfies the mother’s
desire to breastfeed and provides an
excellent source of nourishment. Review
with the mother how to pump or manually
express breast milk to maintain a milk
supply prior to surgical correction and
after, if needed.
Educate the mother regarding the different
forms of feeders appropriate for the infant.
• Infants diagnosed with a cleft palate
cannot suck effectively either because
pressing their tongue or a nipple against
the roof of their mouth forces the milk into
their pharynx. The most successful method
for feeding this infant is to use a
commercial cleft palate nipple that has
an extra flange of rubber to close the roof
of the mouth. A Breck feeder may also be
used to feed infants with a cleft palate.
Educate parents about the possibility of solid
food at the appropriate time.
• If the surgery is delayed beyond six months
of age or the time when solid food would
usually be introduced, teach the parents
to be certain any food they offer is soft
because particles of coarse food could
invade the nasopharynx and be a cause
of aspiration.
Instruct the mother who bottle feeds to use
some cereal to thicken the milk.
• Thicker milk will make swallowing easier
due to the increased gravity flow brought
about it. Additionally, the infant should be
held during feedings or placed in an infant
seat after feeding for a positive outcome.
Offer small sips of fluid between feedings.
• If a cleft extends to the nares, so the nose
and mouth are joined, breathing causes
the oral mucous membranes and lips to
become dry. Offering small sips of fluids
between feedings can help keep the
mucous membranes moist and prevent
cracks and fissures that could lead to
infection.
Refrain from removing the bottle nipple from
the infant’s mouth unless necessary.
• Removing the nipple may cause the infant
to cry, making feeding more challenging.
The infant should also be prevented from
crying postoperatively because it could
cause tension on the suture line. Care
should be taken to avoid touching the
suture line when inserting the nipple of a
bottle or of the medicine dropper.
Keep the infant NPO after the surgery and
gradually introduce appropriate diets.
• After surgery for cleft lip or palate, an
infant is kept nothing by mouth (NPO) for
approximately 4 hours and then
introduced to liquids such as plain water.
Be certain to begin this process with only a
small amount each time to
prevent vomiting. After palate surgery,
only liquids are generally given for the first
3 or 4 days, followed by a soft diet until
healing is complete.
Avoid feeding milk post-surgery.
• Be certain milk is not included in the first
fluids offered because milk curds tend to
adhere to the suture line and are difficult
to remove. After a feeding, always offer
the child a sip of clear water to rinse the
suture line and keep it as clean as
possible.
Instruct the parents regarding oral care.
• Educate the parents to be diligent about
oral health care. In infants with clefts
involving the maxillary alveolar ridge
(upper gum), it is common for some teeth
to be misshapen or turned. Prudent twice-
daily gum and teeth brushing with an
age-appropriate toothbrush and
toothpaste are crucial, as are bi-yearly
dental visits for monitoring.
3. Reducing Anxiety and Enhancing Coping
A mother’s first reaction to a disfigured
newborn is one of shock, hurt, disappointment,
and guilt. Some parents may regard the
deformity as a result of their inadequacies.
They may desire to hide the child from
relatives and friends. The client and the family
need understanding, a concrete basis for
hope, and practical advice. Family stress often
occurs because of the multiple surgeries that
may be required throughout childhood.
Assess the level of anxiety and need for
information.
• This provides information to allay anxiety
manifested by the infant’s appearance at
birth with a level increased with the
location and extent of the defect.
Children can be affected by
the fear experienced by their parents, thus
magnifying the psychological impact on
the child.
Assess family coping methods used and their
effectiveness.
• This provides information about coping
methods and the need to develop new
coping skills. Family attitudes directly
affect a child’s feeling of self-worth, and a
child with special needs may strengthen
or strain family relationships.
Observe the parent’s interaction with the
infant.
• Observe whether the parents look at their
infant’s face while feeding or caring for
the infant. This helps identify the parents’
acceptance of the infant’s condition and
helps them progress toward the
improvement of their coping skills.
Determine the parent’s current knowledge and
perception of the situation.
• The lack of information or unrealistic
expectations can interfere with family
members and the client’s response to the
defect and the situation.
Encourage expressing concerns and questions
about the condition to discuss feelings about
the infant’s appearance.
• This provides an environment conducive
to venting feelings to facilitate the
adjustment to the infant’s defect. It also
provides an opportunity to examine
realistic fears and misconceptions about
the condition.
Provide an accepting environment and
attitude and handle the infant in a gentle,
caring way.
• This promotes trust and conveys to parents
that an infant is a valuable human baby
deserving of love and caring. Provide an
open environment wherein the parents,
and the child feel accepted in their
present condition without feeling judged
and can promote a sense of dignity and
control.
Communicate with parents in a calm and
honest way.
• This promotes a calm and supportive
environment to reduce anxiety and instill
hope. Provide accurate and consistent
information to reduce the parents’ anxiety
and enable them to make decisions and
choices based on realities.
Assist the family or parents in recognizing or
clarifying fears to begin developing coping
strategies for dealing with these fears.
• Coping skills are often stressed after
diagnosis and during the different phases
 of treatment. Support and counseling are
often necessary to enable the parents to
recognize and deal with fear and to
realize that control and coping strategies
are available.
Allow parents to stay with the infant and
encourage them to assist in care as
appropriate.
• This reduces anxiety and promotes
bonding that may be blocked by an
infant’s appearance. It is equally
important from a psychological
standpoint as a parent may need caring
support to bond with an infant whose face
is deformed in this way.
Emphasize the infant’s positive features when
providing information.
• This promotes positive feelings for the
infant. The developing child senses the
parents’ feelings and acquires either a
positive or a negative self-image. The
client and family need understanding, a
concrete basis for hope, and practical
advice.
Explain procedures and stay with the family
during anxiety-producing procedures and
consultations, as appropriate.
• Accurate information allows the parents or
family to deal more effectively with the
reality of the situation, thereby reducing
anxiety and fear of the unknown.
Suggest visits with parents who have a child
with a similar defect and were successfully
repaired, or show them photos.
• This provides support and information to
reduce anxiety. The surgical repair of cleft
lip and palate results is currently excellent.
It is also helpful to show parents
photographs of infants with good repairs
to assure their child’s outcome can be
successful.
Inform parents of usual ages for cleft lip repair
and/or cleft palate, stages of surgery, and
type of procedure performed.
• This provides information to reduce fear
and anxiety and to know what to expect.
If a cleft lip is discovered while the infant is
still in utero, fetal surgery can repair the
condition, although this procedure is not
usually attempted. If the disorder is
discovered at birth, a cleft lip can be
repaired surgically shortly thereafter, often
at the time of the initial hospital stay or
between 2 and 12 weeks of age.
Refer the parents to additional resources for
necessary counseling and support.
• Referrals to community support groups
may be useful from time to time to assist
the parents in dealing with anxiety. Many
communities have support groups for
parents of children born with cleft lip or
palate. Referral to these groups can offer
the parents additional support. The
National Cleft Palate Foundation is one
such support group.
Encourage family members to express
problem areas and explore solutions together.
• This reduces anxiety, enhances
understanding, and provides an
opportunity to identify problems and
problem-solving strategies. Help them
understand that any negative feelings
they feel toward the infant or themselves,
such as sadness or anger, are normal. This
assurance does not instantly make them
feel better about what has happened,
but the knowledge the feelings they are
experiencing are normal can help them
begin to deal with such emotions.
Assist family members in identifying three
healthy coping mechanisms they can use.
• This empowers the family to find the
solution appropriate for them. Recognizing
one’s own strengths and areas for
improvement provides an opportunity for
personal growth, enhancing the potential
for success once the infant returns home
with the parents.
Assist the family in establishing the child’s
short- and long-term goals and the
importance of integrating the child into family
activities.
• This promotes involvement and control
over situations and maintains parental
roles. To promote effective bonding, the
parents need to hold and interact with
 their infant during both the preoperative
and postoperative periods.
Encourage them to follow home routines and
meet the child’s needs with the participation of
family members.
• This increases the child’s sense of security
and sense of belonging. The mother or
parents who have fed their infant
preoperatively and have been allowed to
assist with feedings during hospitalization
will feel more confident after discharge.
Give positive feedback to the family and
praise family efforts in the development of
coping and problem-solving techniques in
caring for the child.
• Praise encourages the family to continue
involvement in long-term care. Support
the parents with attention, compassion,
time, respect, honesty, advocacy, and
understanding. These are essential to
prepare the parents for the challenges
they may face and meet their needs for
compassion and caring.
Teach the family that overprotective behavior
may hinder growth and development and
treat the child as normally as possible.
• This enhances family understanding of the
importance of making a child one of the
family and the adverse effects of
overprotection of the child. Reinforce the
child’s positive attributes, stressing that a
scar is only one small aspect of who they
are.
Refer the family and the child to community
support groups as appropriate.
• Many communities have support groups
for parents of children born with a cleft lip
or palate. Referral to these groups can
offer the parents additional support. The
National Cleft Palate Foundation provides
parent education materials on its website.
Assist in the referral of the parents to genetic
counseling.
• Because of the genetic influence, the
parents of a child diagnosed with a cleft
lipo should be referred for genetic
counseling to ensure they understand they
have a small increased chance of having
another child with a cleft lip or palate and
that any future children are at a greater
risk than usual for this problem.
4. Preventing Injury and Infections
Cleft lip and cleft palate can lead to many
complications. Early feeding difficulties limit
the infant’s weight gain and growth and may
lead to learning disabilities, speech disorders,
recurring upper respiratory tract infections,
and chronic ear disease. Abnormal anatomy
of the orofacial cavity makes cleaning the
maxillary incisors difficult, leading to higher
dental caries rates (Burca et al., 2016).
Early identification of complications and the
prevention of several injury risks are keys to
ensuring optimal healing and recovery of an
infant or child diagnosed with cleft lip and/or
palate and who underwent surgical repair.
Changing the contour of the palate when it is
repaired also changes the slope of the
eustachian tube to the middle ear. This can
lead to a high incidence of middle ear
infection or otitis media because organisms
are able to reach this area from the oral cavity
more readily than usual.
Assess suture lines for cleanliness,
redness, swelling, or drainage frequency.
• This provides information indicating
possible infection and the need for
cleansing away formula or drainage. The
incision line should appear clean and
intact and free of erythema or drainage
during the postoperative period.
Assess for respiratory distress following palate
surgery.
• This monitors breathing through a smaller
airway caused by edema and breathing
through the nose. Because of the local
edema that occurs after a cleft lip or
palate surgery, it’s important to observe
the infant closely in the immediate
postoperative period for respiratory
distress. After surgery, the infant has to
learn to breathe through the nose,
possibly adding to the respiratory difficulty.
Assess for signs of infection such as fever, pain,
pulling on an ear, or discharge from the ear.
• Review the signs of infection such as fever,
pain, pulling on an ear, or discharge with
the parents. Fever can be as high as 40°C
(104°F). Infants’ Earaches may manifest by
general irritability, frequent rubbing or
pulling at the ear and rolling of the head
from side to side.
Visualize the inner ear and palpate
the mastoid process.
• With an infection, the tympanic
membrane appears inflamed or
reddened. It may bulge forward into the
external canal because of fluid and
edema behind it. Palpate the mastoid
process behind the ear to be certain it
doesn’t feel tender to your touch. If it
does, the infection probably has spread
out of the middle ear into the mastoid
cells, a serious complication that may
lead to meningitis.
Screen the infant/child for hearing loss.
• The child needs to be screened for
hearing difficulty because the angle of
the eustachian tube may be changed in
surgery, and they may develop more ear
infections than usual, which can possibly
lead to some hearing impairment. Hearing
loss may impair cognitive and language
development, which can hamper the
education and communication abilities of
the developing child.
Monitor lip protective device taped on
operative site.
• This relaxes the site and prevents tension
on sutures caused by facial movement or
crying. After cleft lip surgery, the suture line
may be held in close approximation by a
Logan bar (a wire bow taped to both
cheeks) or an adhesive bandage such as
a Band-aid simulating a bar that brings
together the incision line but does not
cover the incision. Assess that this is secure
and continues to protect the suture line
from tension after each feeding or
cleaning of the suture line.
Perform strict care of the suture line.
• Infection and subsequent scarring may
result if crusts from serous drainage are
allowed to form on a cleft lip suture line.
Most surgeons prescribe cleaning the
suture line with sterile water or sterile saline
with sterile cotton-tipped applicators after
every feeding or whenever the normal
serum that forms on suture lines
accumulates.
Provide ordered analgesics for pain, hold,
cuddle, or rock child, anticipate needs to
prevent crying.
• Furnish adequate pain relief, so the infant
does not cry because this puts increased
tension on the sutures. To help avoid
crying, try to anticipate the infant’s needs
by having formula ready to feed. Help the
parents use whatever measures, such as
rocking, carrying, or holding, that are
necessary to make the infant feel secure
and comfortable.
Apply soft elbow restraints and remove
periodically to perform ROM on arms and
allow for movement and holding; a child may
need a jacket restraint to prevent rolling over.
• This prevents the child from touching or
injuring the operative site. Keep elbow
restraints in place as necessary, so they do
not put their fingers in their mouth and
poke or pull at the sutures.
Remove sharp objects or toys, and avoid the
use of forks, straws, or other pointed objects.
• Nothing hard or sharp must come in
contact with a recent cleft suture line.
Observe the infant after palate repair
carefully, therefore, to be certain they do
not put toys with sharp edges into their
mouths. It’s also good practice to not
allow them to use a straw to drink or hold
a toothbrush to clean their teeth, so they
don’t brush the suture line accidentally.
Feed with a cup or spoon if palate repair was
done; avoid placing a spoon in the mouth.
• When the child begins to eat soft food,
observe that they don’t use a spoon
because spoons can invariably be pushed
against the roof of their mouth and
possibly disrupt sutures. If being fed rather
 than allowing the infant to use a spoon
invokes an intense reaction, it is probably
better to leave a child on a liquid diet until
the sutures are removed.
Accompany the child when playing or
ambulating.
• This prevents trauma caused by
accidental falls and prevents crying as
much as possible. Play should be quiet,
particularly in the immediate
postoperative period. The nurse may
instruct the parents to provide reading,
drawing, or coloring materials.
Teach parents about cleansing suture sites
and applying antibiotic ointment. Let the
parents perform a return demonstration after.
• This prevents infection and enhances
comfort and healing. Instruct them not to
rub the suture line and use a smooth,
gentle, rolling motion to avoid loosening
the sutures. Teach them to gently dry the
suture line with a dry sterile cotton-tipped
applicator afterward. Remember that the
infant has sutures on the lip that need the
same meticulous care as those visible on
the outside.
Teach parents feeding methods for the infant
and allow them to practice appropriate
techniques using a syringe soft tube in the
mouth away from any suture line or a cup for
an older child.
• This promotes nutrition following surgery
without sucking on a nipple. Specialized
feeding bottles can make feeding easier
for the infant by reducing the need to
generate high negative pressures. In at
least one study, infants diagnosed with
cleft lip and palate with compressible
bottles gained more weight and required
less intervention compared with infants
using rigid bottles (Burca et al., 2016).
Provide diversional activities suitable for the
child’s developmental age and situation.
• Sutures on the lip or palate feel extremely
odd, so most children not only run their
tongue over their sutures but also don’t
respond to advice not to do this. Because
this often occurs when children have
nothing to think about, help the parents
provide diversional activities such as
reading or singing to keep the child’s
attention off the suture line.
Advise parents not to allow the child to play
with small toys or those that are sharp or
require sucking or blowing; suggest soft,
stuffed toys for an infant.
• This removes the possibility of placing a toy
in the mouth or damaging an incision.
Observe the infant after palate repair
carefully to be certain they do not put
toys with sharp edges into their mouths.
The nurse should also teach the parents to
keep objects such as the child’s thumb,
tongue blades, toast, cookies, forks, and
pacifiers out of the mouth.
Position the infant in an upright position during
feeding.
• Infants who underwent cleft palate repair
are fed in an upright position greater than
60° to allow gravity to facilitate fluid
transfer and prevent milk from entering the
eustachian tube and middle ear space,
thus minimizing ear infections (Burca et al.,
2016).
Educate the parents regarding signs and
symptoms of complications that are needed to
be reported immediately.
• Remind the parents of the importance of
recognizing and reporting signs of
pharyngeal infection to their primary care
provider promptly so it can be treated
before the infection spreads to the middle
ear.
Apply a warm or cold compress to decrease
pain and promote comfort.
• A warm compress may be applied locally
to increase the child’s comfort. Cold may
also be beneficial. An ice pack may be
prescribed to reduce edema and
pressure.
Instruct the parents never to insert anything
into the child’s ear.
• Parents are instructed not to insert cotton
swabs or any object into the child’s ears,
especially when cleaning. These objects
may rupture the tympanic membrane,
 further complicating the child’s ear
infection.
Encourage the intake of liquids and soft foods,
as indicated.
• Movement of the eustachian tube, such
as chewing, may increase the pain.
Liquids and a soft diet may reduce pain as
they do not involve vigorous chewing. The
child may name some foods and fluids
they are willing to eat; they may eat less
than usual but ensure that they take an
adequate amount.
Clean the skin around the ears thoroughly.
• The child may experience ear drainage,
which they may not notice at times. The
skin around the client’s ears must be clean
and protected from drainage to prevent
tissue breakdown.
Educate the parents regarding treatment using
myringotomy tubes.
• Because the eustachian tube may remain
partially closed in its changed position,
serous otitis media (accumulation of fluid
in the middle ear) also tends to occur
more frequently in these children than in
others. If this happens, myringotomy tubes
may be inserted to drain the middle ear
fluid and to help protect hearing.
Inform the parents about the importance of
routine screening for hearing loss.
• Be certain the parents understand the
need for routine screening for hearing loss
during childhood because this is a
common early sign of serous otitis media.
All children should be followed up to
make sure that the condition is resolved
and to evaluate any hearing loss that may
have occurred.
Administer analgesics and antipyretics as
prescribed.
• The child may need analgesics and
antipyretics such as acetaminophen and
decongestant nose drops to open the
eustachian tubes and allow air to enter
the middle ear. These are given for only 2
to 3 days because if they are given
longer, a rebound effect can occur,
causing edema and a subsequent
increase in mucous membrane
inflammation. Instruct the parents to
administer acetaminophen every 4 hours
or ibuprofen every 8 hours as prescribed.
Explain to parents that usual feeding patterns
may be resumed in 2 weeks for lip repair or in
4 to 6 weeks for palate repair.
• This provides an estimated time based on
suture removal and healing to resume
regular bottle feeding or return to baseline
dietary status. The infant receives feedings
by dropper until the wound is completely
healed (1 to 2 weeks). Care should be
taken to avoid touching the suture line
when inserting the medicine dropper.
Refer parents and the child to appropriate
professional resources after discharge.
• Children diagnosed with cleft problems
tend to receive better, more frequent,
and well-coordinated care when seen in
an interprofessional team setting,
including pediatric dentists, audiologists,
speech pathologists, geneticists, and
craniofacial surgeons, so referring parents
to an appropriate interprofessional center
before discharge is critical for these infants
and their families.
Provide instructions when complications are
identified at home.
• Ear infections and dental decay may
accompany cleft palate. Parents are
instructed to take the child to the health
care provider at the first sign of earache.
5. Initiating Patient Education and Health
Teachings
Mothers of infants diagnosed with cleft lip and
palate may have limited knowledge about
feeding their infants and may lack information
regarding regurgitation, colic, and swallowing
during feedings. Mothers may feel stressed or
confused when various healthcare
professionals provide conflicting feeding
suggestions. Feeding instructions help parents
develop confidence in properly caring for
their infant diagnosed with cleft lip and palate
(Burca et al., 2016).
Assess the presence of acceptance of
methods used by parents and their knowledge
of the cause and type of defects.
• This provides information about a defect
that may be inherited or congenital,
partial or complete, unilateral or bilateral
cleft of the lip and/or palate, adequate
nutritional status, and freedom from
infection before surgery is done.
Assess the parent’s ability to feed the infant
with a defect and their knowledge about
preoperative and postoperative needs and
care.
• Education and support begin prenatally if
the deformity is diagnosed in advance of
delivery. A child born with a facial
deformity encounters many problems.
Feedings are difficult and may require
special nipples. As the child grows,
irregular tooth eruptions, drooling, delayed
speech, and the need for intermittent
hospitalization and frequent clinic
appointments can be frustrating.
Inform the parents of the general timing of
surgical repair and what to expect from the
neonate. Show them photographs of infants
before and after surgical repair.
• If the infant’s weight is optimal and he has
no other neonatal anomalies, he may
undergo surgery to repair a cleft lip shortly
after birth. Surgery may also occur in 2 to 3
months or as late as 8 months to allow for
bonding and rule out other congenital
anomalies. The cleft palate may be
repaired in two steps by 12 to 16 months,
or repair of the soft palate may proceed
in 6 to 18 months and repair of the hard
palate, as late as age 5. The timing of the
procedures is related to normal growth
changes, and repair usually takes place
before speech development.
Teach and observe parents hold the infant
while feeding in the appropriate position and
using the appropriate feeding devices.
• Holding the head upright reduces the
possibility of aspiration. The positioning
includes the head’s support, the midline
trunk, and the hips slightly flexed. Special
nipples or devices are used because the
cleft interferes with the ability to suck and
liquid often flows into the nose when taken
into the mouth. The act of breastfeeding
encourages the normal physiological
muscular movement and coordination of
the mouth and face (Burca et al., 2016).
Teach and observe to feed slowly and in small
amounts, burping frequently, and extend the
nipple or feeding device well back into the
mouth.
• This prevents choking, abdominal
distention, a possible liquid flow into the
nose, or aspiration into the lungs,
causing pneumonia, otitis media, or upper
respiratory infections. Following a feeding,
be certain the infant with a cleft lip is
burped well because the inability to
securely grasp a nipple or syringe edge
causes the infant to swallow more air than
usual.
Inform parents that feeding should not last any
longer than 20 to 30 minutes.
• Prolonged feedings may deplete an
infant’s energy and cause fatigue. Infants
may benefit from a learned rhythm during
feedings. Pacing the feeding in rhythm
with the infant’s reactions during feeding
may increase the infant’s control of oral
intake by helping maintain organization in
sucking, swallowing, and breathing (Burca
et al., 2016).
Instruct in the use and care of pre-operative
orthodontic devices (plastic palate mold) for
an infant with cleft palate.
• This promotes the alignment of the maxilla
and more normal speech sounds and
prevents food from entering the nasal
cavity. One issue that may remain is that
because palate repair narrows the upper
dental arch, a child may be left with less
space in the upper jaw for the eruption of
the teeth and would therefore require
follow-up treatment by a pediatric dentist.
Instruct parents to cleanse the lip, oral cavity,
and nose with water before and after feeding.
• This prevents infection or skin breakdown
with cleft lip or palate. Offering small sips
of fluid between feedings can help keep
the mucous membranes moist and
 prevent cracks and fissures that could
lead to infection.
Teach parents to avoid the prone position and
place the child on the back or side.
• This prepares the child for treatments that
will be done postoperatively. Following a
cleft lip repair, be sure that the infant does
not turn onto their abdomen because this
could put pressure on the suture line,
possibly tearing it. Placing the child in an
infant bouncy chair is another possibility.
Inform parents of procedures for correcting
defects, medications, procedures to prepare
the infant for surgery, and what to expect
postoperatively.
• This prepares the parents for surgical
correction of defects and what to expect
during convalescence. Because facial
contours change as a child grows, a
revision of the original septum may be
necessary when the child reaches 4 to 6
years of age. Some infants may have a
nasal mold apparatus applied before
surgery to shape a better nostril.
Educate parents regarding the importance of
future dental follow-up consultations.
• One issue that may remain is that because
palate repair narrows the upper dental
arch, a child may be left with less space in
the upper jaw for the eruption of teeth,
creating poor teeth alignment. All children
born with a cleft palate need follow-up
treatment by a pediatric dentist skilled in
children’s dental problems so that as the
child grows, extractions or realignment of
teeth can be done as indicated.
Inform the parents about the importance of
consulting with a speech therapist.
• Children also need follow-up to detect if
speech difficulty occurs. After surgical
repair, about 80% of children affected by
cleft palate progress to develop normal
speech, yet referral to speech therapy
early in infancy should always occur to
ensure successful speech development.
Provide educational resources regarding
breastfeeding and the manual expression of
breast milk.
• There are a variety of resources available
to teach mothers how to pump. One such
resource is the Maximizing Milk Production
with Hands-on Pumping video developed
by Dr. Jane Morton and Breast Milk
Solutions. One hospital’s quality
improvement project downloaded an
initiating pumping video on their intranet
site to support their standard education
for mothers who required this assistance
(Burca et al., 2016).
Provide discharge and follow-up instructions
clearly.
• Support the infant’s transition to home
after discharge with follow-up
appointments and home visits. Assessment
data for follow-up include quantitative
measurements (length, weight, head
circumference, growth, adequate
numbers of wet/dirty diapers, maternal
milk volume and comfort, and time spent
feeding) and qualitative reports from the
family (Burca et al., 2016).
Offer the parents information regarding home
care and community resources.
• In large cities, special cleft palate clinics
are available where several specialists
can collaborate in convenient
consultation. The parents are instructed
about the resources available in the state
in which they live. The American Cleft
Palate-Craniofacial Association, the Cleft
Palate Foundation, the March of Dimes
Birth Defect Foundation, and state
programs for children with special needs
are examples of community referrals that
should be offered to parents.