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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1120_Библиотеки_им_академика_М_И_Перельмана
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Feeding an Infant With a Cleft
Palate
One of the most pleasurable tasks for parents of a newborn is
feeding their infant. It is usually a quiet time when they can enjoy
interacting and bonding with the new addition to their family. When
a child is born with a cleft, and particularly when the cleft is
unexpected, the weeks following their child's birth can be very
stressful for parents. Not only must they come to grips with the
diagnosis of clefting and what it means for their child in the longterm (e.g., multiple doctor visits, surgeries, speech therapy), but also
immediate problems must be addressed (e.g., choosing a surgeon).
Once parents have been assured that their child's cleft can be “fixed,”
they usually want to know, “How will I feed my baby”?
It often comes as a surprise to parents (and professionals who
have no previous experience with cleft lip and palate) to learn that
although feeding their infant can be difficult and initially requires a
lot of patience, most babies with isolated cleft lip and palate do not
have significant, long-term feeding problems. A palatal cleft presents
very specific challenges to feeding, and those challenges can be
minimized (if not overcome) for many of these infants with some
simple modifications to the process. In this chapter, we discuss
modifications to the feeding process that are commonly
recommended for babies with cleft palate.
Feeding a healthy infant is typically a straightforward process.
When a nipple is placed in an infant's mouth, the lips close around
the nipple and the tongue presses it against the hard palate. As the
tongue moves back, negative pressure is created and milk is
expressed. This process is compromised for babies with cleft palate
because they cannot separate the oral cavity from the nose and so are
unable to create the negative intraoral pressure (i.e., create a
vacuum) needed to suck milk or formula. The baby may “imitate”
normal feeding motions, moving the lower jaw up and down in
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response to the presence of the nipple inside the mouth, but such
actions do not mean that he or she is actually sucking. The inability
to suck can lead to inefficient feeding characterized by a reduction in
milk or formula expressed from the nipple that in turn can lead to
excessive air intake, lengthy feedings, and fatigue. Nasal
regurgitation that occurs secondary to the cleft palate is a frequent
problem.
Babies whose clefts involve only the lip or the lip and alveolus
typically do not have problems feeding (Reid et al., 2006) (Box 2-1).
Even when a wide cleft lip is present, these babies successfully nurse
at the breast because breast tissue covers the cleft during nursing.
Similarly, a baby who is bole fed with a wide-based nipple (e.g.,
NUK orthodontic nipple, Nestlé, Vevey, Swierland) can obtain the
lip seal needed for adequate feeding because the base of the nipple
occludes the cleft as the baby feeds. If a baby with cleft lip has
problems feeding, something else is usually wrong. The infant may
have a previously undiscovered defect of the posterior portion of the
palate (see the discussion of submucous clefts in Chapter 1) or
perhaps a subtle neurological problem.
Box 2-1
How Prevalent Is the Problem?
In an interesting study out of Australia, a group of researchers
examined the prevalence of feeding problems in 46 babies with
isolated cleft lip (CL), cleft palate (CP), and cleft lip and palate (CLP)
at 2 weeks, 2 months, and 14 months of age (Reid et al. 2006). All
babies with CL demonstrated good or satisfactory feeding skills at
each age studied. Most babies with CP and CLP (80%) also
demonstrated good feeding skills at 2 weeks of age. By 3 months of
age, 94% (33 of 35) of these babies were feeding well, and that
percentage rose to 97% (34 of 35) at 14 months of age. Reid et al.
concluded that although some babies with CP with or without CL
may have problems feeding during the first month, these problems
are usually resolved by the time the babies are 3 months old. Not
surprisingly, nasal regurgitation was the most common feeding
problem identified in these babies.
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Families who are enrolled with a cleft palate or craniofacial team
usually receive the benefit of feeding counseling from either the
team nurse or the team speech-language pathologist. Unfortunately,
many families either are not linked up with a team immediately
following their child's birth or are in the care of individual
practitioners (e.g., plastic surgeons) who may be unable to address
the early intervention needed for feeding problems adequately. Not
even pediatricians are always adequately prepared to give advice on
feeding for babies with cleft palate. So where do parents go to obtain
information on feeding when the professionals who care for their
child are unprepared to provide such information? The Internet, of
course! An overwhelming amount of information on feeding can be
found on the Web and through various professional organizations.
The disadvantage is that nothing on the Web is peer reviewed,
meaning that anyone can put anything on a website whether the
“information” is true or not. Having read that special technical
“aids” are available, either parents or clinicians may feel obligated to
try a special feeding device or nipple because it has been reported to
be effective. The one Internet resource that we routinely refer parents
to is the Cleft Palate Foundation (CPF: www.cleftline.org). The CPF
has developed instructional feeding videos (also in booklet form) for
parents that many professionals find informative as well. Three of
the four nursers described in the next section are demonstrated on
these videos (www.cleftline.org/who-we-are/what-we-do/feeding-
your-baby/).
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Specialized Bottle Systems Used with
Cleft Palate
Several boles on the market today have been developed specifically
for children with cleft palate or are recommended for use because
they address many of the feeding problems that these children have
(Box 2-2). We review the more commonly used boles here but
should stress that not all babies with clefts of the palate need special
feeding devices. Some parents feed their infants quite successfully just
by making simple adaptations in technique that are discussed in the
next section.
Box 2-2
Ask the Expert
What Feeding System Is Best to Use for Babies
With Cleft Palate?
A common and important question from parents is what works best
for babies with cleft palates. On the surface, this would seem to be
an easy question to answer—we just need to compensate for the
baby's difficulty with creation of negative pressure or vacuum.
However, multiple factors in addition to the presence of a cleft
palate must be considered for successful feeding. Each infant may
have different needs in terms of flow from a nipple and differing
abilities to create positive pressure (compression) and negative
pressure. In addition, parents need to be comfortable with the
feeding method for it to be successful.
Each infant and family should be evaluated by a team to help
identify the best feeding system for a particular infant. The different
feeding systems described in this chapter offer nipples with
different shapes and flow rates. Sometimes a longer, narrower
nipple is needed for an infant with a smaller jaw. Other infants may
need to have the flow modified, and feeders can adjust the amount
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of flow with the amount of squeezing provided on assisted-delivery
feeders such as the Medela Special Needs Nurser (Medela, Inc.,
Breastfeeding U.S., McHenry, Ill.) or the Mead Johnson Nurser
(Mead Johnson and Company, LLC, Evansville, Ill.). Flow may also
be adjusted by choosing a different nipple, as can be done with Dr.
Brown Special Needs Nurser (Handi-Craft Company, St. Louis,
Mo.), or by using different nipples on the Mead Johnson Nurser to
slow the flow.
During the evaluation process, different feeding methods can be
aempted with an infant and family. Parents are instructed on the
feeding systems. An infant's responses to the bole or nipple flow
can be observed and adjustments made in either the nipple or the
amount of squeezing provided by the feeder. In many cases, a
feeding system is used for multiple feedings over several days for
parents to know whether they are comfortable, and many times
parents' comfort is affected by the infant's responses. Feeding and
growth must be monitored closely so that if adjustments are needed,
they can be made in a timely and efficient way for the best growth
and development of the infant and for the comfort of the parents.
The question of which feeding system works best for a baby with
a cleft palate has no simple answer. What does work best for a baby
with a cleft palate is multidisciplinary evaluation of feeding, close
monitoring of progress, and ongoing support of parents.
From Sco Dailey, Ph.D. CCC-SLP, University of Iowa Hospitals and Clinics, Iowa City,
Iowa.
Squeezable boles such as the Mead Johnson Cleft Lip/Palate Nurser
(Mead Johnson and Company, LLC, Evansville, Ill.) have long been
recommended for these children (Fig. 2-1). Because the wall of the
bole is soft, parents can gently squeeze it each time their baby
makes a sucking motion to facilitate the flow of milk. It can take a
while for parents to learn how hard to press (so that they do not
flood the baby's mouth with milk) and to coordinate the squeeze
with their baby's sucking. Some clinicians who use this bole
recommend replacing the nipple that accompanies it with one that is
shorter and softer.
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FIGURE 2-1 Mead Johnson (Enfamil) Cleft Lip/Palate
Nurser (Mead Johnson and Company, LLC, Evansville,
Ill.). (Photo © 2014 Brian Harrington, Laramie, Wyo.; www.bhpimaging.com)
Another bole that is commonly used is the Pigeon Cleft Palate
Nurser (Philips, Amsterdam, the Netherlands). This bole is harder
than the Mead Johnson Nurser and thus is not easily squeezed. The
advantage offered by this bole lies in the nipple design. This nurser
has a Y-cut nipple that is thin (soft and compressible) on one side
and thick (harder) on the other. When the nipple is placed in the
mouth, the soft side is placed against the tongue. When the baby
presses the tongue against the nipple, the soft side collapses against
the hard side, thus expressing milk more easily. A small notch
located at the base of the nipple vents air from the nipple during
feeding, thus minimizing the amount of air that a baby swallows.
Another unique feature of this nurser is a plastic one-way valve that
fits into the base of the nipple. The valve allows milk to flow into the
nipple but prevents it from flowing back into the bole after each
suck. To use this nurser, follow these instructions:
• Squeeze the nipple.
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q pp
• Turn the bole upside down.
• Release the nipple so that it fills with milk.
• Once the nipple is filled, turn the bole right side up and place it in
the baby's mouth (make sure that the soft side of the nipple is
against the tongue).
• Flow of milk can be slowed by tightening the nipple and collar or
increased by loosening them.
The Pigeon nipple comes in regular and small sizes and fits on
many other boles (Fig. 2-2).
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FIGURE 2-2 Pigeon Cleft Palate Nurser (Philips,
Amsterdam, the Netherlands). (Photo © 2014 Brian Harrington,
Laramie, Wyo.; www.bhpimaging.com)
The Medela Special Needs Feeder (Medela, Inc., Breastfeeding U.S.,
McHenry, Ill.) is another commonly used nurser that has a unique
design (Fig. 2-3). The slit-valve nipple is separated from the bole by
a one-way valve that allows milk to flow into the nipple but prevents
it from flowing back outward. The bole is rigid and cannot be
compressed. The large chamber at the base of the nipple, however,
can be squeezed to facilitate the flow of milk. To use this nurser,
follow these instructions:
• Squeeze the nipple.
• Turn the bole upside down.
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• Release the nipple so that milk will flow into it (repeat as needed to
fill the barrel).
• Flow of milk can be controlled using the two vertical lines on the
barrel as a guide (long line, regular or high flow; middle line,
medium flow; short line, slow flow); simply turn the bole so that
the line corresponding to the desired flow is lined up directly under
the baby's nose.
FIGURE 2-3 Medela Special Needs Feeder (Medela, Inc.,
Breastfeeding U.S., McHenry, Ill.). (Photo © 2014 Brian Harrington,
Laramie, Wyo.; www.bhpimaging.com)
The Medela Special Needs Feeder comes in a standard size and a
mini size.
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