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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4578_Библиотеки_им_академика_М_И_Перельмана
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Another bole that has gained popularity is Dr. Brown's Natural
Flow Bole (Handi-Craft Company, St. Louis, Mo.). This vented bole
has a patented air flow system that prevents air from entering the
milk or formula when a baby sucks and minimizes the vacuum effect
that makes suction more difficult. This bole has been recommended
for babies who experience problems with colic, spiing up, burping,
and gas. Although this bole was not originally designed specifically
for babies with cleft lip and palate, some clinicians consider it to be a
good option for these babies when it is used in conjunction with a
Pigeon one-way flow valve. (This valve is designed to prevent milk
in the nipple from flowing back into the bole, so a baby has only to
compress the nipple—not suck—to nurse.) Different nipples can be
purchased, each providing a different milk flow rate. Clinicians who
have used this bole have recommended starting with either the
Level 2 nipple (which provides faster milk flow than Level 1) or a
Pigeon nipple and the Pigeon valve.
Traditional baby boles were unvented (or partially vented), which
resulted in air passing through the nipple into the bole as a baby
sucked. A vacuum (negative pressure) was created that required a
baby to suck harder over time to express the milk. Vented boles
(e.g., Dr. Brown's Natural Flow Bole [(Handi-Craft Company)])
direct air away from the milk and allow a baby to nurse without
sucking against negative pressure or swallowing air in the milk.
More recently, the company began marketing the Dr. Brown's
Specialty Feeding System (Handi-Craft Company) for babies with
complex feeding problems. This bole includes a one-way flow
valve, called the Infant-Paced Feeding Valve, that is similar to the
Pigeon valve (Fig. 2-4).
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FIGURE 2-4 Dr. Brown's Specialty Feeding System (Handi-
Craft Company, St. Louis, Mo.). (Photo © 2014 Brian Harrington,
Laramie, Wyo.; www.bhpimaging.com)
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General Guidelines for Feeding
1. Amount: Newborns need to take in 2 ounces of milk or formula per
each pound of weight in each 24-hour period to gain weight. For
example, a 6-pound baby needs to take in 12 ounces a day. Parents
have to apportion those ounces among the total number of feedings
(variable from infant to infant) each day. The baby's weight gain
should be monitored weekly by the pediatrician or by the team
nurse until successful weight gain is established.
2. Feeding time: Each feeding should take no more than half an hour.
Otherwise, the baby will be expending so much energy in trying to
feed that the number of calories spent in the feeding effort will
exceed the number of calories taken in by the child. It may be
necessary to feed smaller amounts in more frequent feedings.
3. Positioning: The baby should be held in an upright or semiupright
position (45+-degree angle) when feeding to reduce regurgitation of
the milk or formula through the nose.
4. Nipples: When using a regular nipple (not those that come with the
Pigeon, Medela Special Needs, or Dr. Brown's bole), you should
select one that is soft and easily compressed (e.g., a Similac preemie
nipple [Abbo Laboratories, Lake Bluff, Ill.]). To facilitate the flow of
milk with only compression of the nipple, you may need to expand
the hole. A cross-cut of approximately 5 mm (made across the tip) is
usually sufficient to ensure that compression of the nipple easily
expresses milk into the mouth. Be aware, however, that making a
hole too large can result in a flow rate that is too fast for the baby to
handle. Parents need to learn to place the nipple on the baby's
tongue and press down rather than pushing up toward the palate.
To prevent the nipple from slipping into the cleft itself, place it
against the tongue on the noncleft side of the palate. If the cleft is
bilateral, the nipple should be placed on the side with the larger
palatine shelf or segment.
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5. Burping: Because infants with clefts may take in excessive air as
they feed, it is best to burp them frequently (e.g., after every one half
ounce of formula).
6. Although babies with clefts cannot suck, it is important that the
“suckle” response nevertheless be stimulated and encouraged to
develop in the early weeks of life. This is why it is critical that
dropper or tube feeding be avoided when possible. Droppers or
nasogastric tubes bypass the suckle response. An infant who has
been fed in this manner will not develop the suck-swallow feeding
paern that will allow him or her to feed normally once the cleft has
been repaired. Babies who have been fed through tubes often
develop “oral aversion,” meaning that they respond negatively to
anything placed in the mouth. Such babies become very difficult to
convert to normal feeding paerns.
Introduction of Solid Foods
Introduction of solid foods for babies with cleft lip and palate
follows the same schedule used for other babies. Before palatal
surgery, food may be pushed into the nose and may be easily cleared
as a baby swallows (or by giving the infant a drink of water). Nasal
regurgitation of food will likely decrease as the baby becomes more
experienced (and thus more adept) at maneuvering food in the
mouth (Dailey, 2013). Some surgeons recommend diluting thicker
foods (to avoid the problem of foods becoming embedded in the
nose) and avoiding spicy foods altogether (to prevent irritation of
the nasal mucosa) until after the palatal cleft has been repaired.
What About Breastfeeding?
Breastfeeding is a viable option when a baby is born with an isolated
cleft of the lip (because breast tissue frequently occludes the cleft
during nursing), as well as in selected children with clefts involving
a small portion of the soft palate or submucous clefts. Babies with
more extensive clefts involving the hard and soft palate are typically
not successful in nursing at the breast. In addition to a weak suck,
these babies may demonstrate difficulty latching onto a breast.
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Because we have no way to measure the amount of milk a baby is
consuming at the breast, it is critical that weight gain be carefully
monitored in babies with a cleft palate who are being breastfed.
Many clinicians advise mothers to express their milk using a breast
pump, bole feed it to their baby, and then put the baby to the breast
for non-nutritive suckling to facilitate mother-infant bonding. See
Dailey (2013) for a review of breastfeeding outcomes in babies with
cleft palate.
Feeding Following Surgery
Be aware that although some surgeons may permit a baby to
continue nursing from a breast or bole immediately following lip
and palate surgery, others advise parents to use special feeders (e.g.,
syringe feeders) or a cup for a week or two.
When boles are prohibited in the immediate postsurgical period,
some teams recommend introducing cup drinking 1 month before
surgery so that the baby's postoperative feeding routine will be
familiar to both child and parent.
Pacifiers, cups with spouts, and straws are not typically permied
at all because their placement in the mouth (or the tension associated
with sucking on them) can damage the sutures. Kael et al. (2009)
surveyed approximately 800 surgeon members of the American Cleft
Palate-Craniofacial Association regarding their surgical practices. Of
the 288 surgeons who responded, 33% prohibited the use of a bole
following palatal surgery and advised the use of cup or syringe
feeding instead. Forty-three percent of the surgeons permied their
patients to resume an age-appropriate diet once they tolerated clear
liquids following surgery, and 98% recommended feeding
restrictions on hard foods (e.g., chips, crackers). The length of time
the restrictions were imposed varied from 1 to 3 weeks or longer.
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Feeding Children With Syndromes
Babies with multiple anomalies involving cleft palate have the same
cleft-related feeding problems described earlier, but they may have
additional problems as well. The complex nature of their problems
necessitates a comprehensive, multidisciplinary feeding assessment.
We briefly mention the feeding problems seen in two conditions that
are routinely encountered by speech-language pathologists working
with cleft palate: Robin sequence and 22q11.2 deletion syndrome.
The physical and functional problems associated with these
disorders are described in greater detail in Chapter 13.
Robin Sequence
Robin sequence is a condition characterized by cleft palate,
micrognathia (small lower jaw), and glossoptosis (tongue falling into
the airway). When micrognathia is present, the mandible is
posteriorly displaced, and the position of the tongue in the
oropharynx can obstruct the upper airway. Managing the airway is a
priority for these babies, and the type of intervention they receive
has implications for feeding. If the glossoptosis is mild, using a sidelying position during feeding may be effective in managing the
airway. More severe problems may require surgical treatment, either
with a lip-tongue adhesion (suturing the tongue to the lower lip to
prevent it from obstructing the airway) or with distraction
osteogenesis (lengthening the lower jaw through new bone growth).
Some surgeons may recommend a tracheotomy for patients with
severe airway obstruction.
In babies with nonsyndromic Robin sequence, the mandible should
grow rapidly during the first year of life, thus eventually
eliminating the worry about breathing and feeding. However,
babies with Robin sequence should be monitored carefully by the
team long after they leave the birthing hospital.
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Some surgeons routinely place a feeding tube at the time a
tracheotomy is performed. This is an unfortunate practice and one
that we discourage. Once a stable airway has been provided, there
should be no need for a feeding tube.
Initially, the infant may be fed with a nasogastric tube while a
treatment plan is being developed. The tube will remain in place
until the airway is stable enough for oral feedings. Initially, oral
feeding trials for a baby with Robin sequence are carried out by a
nurse (or another therapist) who has experience with fragile airways
(Chibbaro et al., 2009). Chibbaro et al. described step-by-step
instructions on how to initiate an oral feeding trial for babies with
Robin sequence, but with the following caution: “It is challenging to
introduce an object into the infant's mouth without pushing the
tongue more posterior. The more unstable the infant's airway, the
less pacifiers and fingers will be tolerated. Feeding is aempted only
with great caution, and with a very low flow rate” (p. 161).
Nasogastric feedings are a temporary solution to ensure adequate
nutrition before the airway has been stabilized. Long-term
management with nasogastric tubes is associated with oral aversion,
and so oral feedings are typically introduced as soon as possible
once a stable airway has been established.
Even once the airway is stabilized, feeding problems may persist
because of the cleft and the micrognathia. A longer, soft nipple may
be needed with these babies to ensure proper placement on the
tongue and adequate compression (Dailey, 2013). Because these
infants employ great effort during feeding and they fatigue easily,
oral feedings should be limited to approximately 15 to 20 minutes or
less (Cooper-Brown et al., 2008). Other feeding-facilitating
techniques that have been linked to improved volume and decreased
feeding time for these infants (see Nassar et al., 2006) include the
following:
• Sucking a pacifier (to facilitate anterior movement of the tongue)
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• Lingual massage (to facilitate tongue relaxation and anterior
movement)
• Jaw support
• Symmetrical positioning
• Use of a long, soft nipple (with original or enlarged hole
depending on flow needed)
• Ensuring nipple placement on the tongue
• Rhythmic movement of the nipple in the oral cavity (to facilitate a
rhythmic paern of suction, swallowing, and respiration)
22q11.2 Deletion Syndrome (Velocardiofacial
Syndrome)
The 22q11.2 deletion syndrome is a very complex condition with a
heterogeneous phenotype. Palatal problems (overt cleft palate,
submucous cleft palate, or velopharyngeal inadequacy) are
frequently present as are other anomalies that can impact feeding
such as pharyngeal hypotonia, congenital cardiac problems, and
Robin Sequence to name a few. Early feeding problems and failure
to thrive are common in this population. In addition to any palatal
problems that may be present, heart problems and hypotonia may
contribute to fatigue, prolonged feeding times, and airway collapse.
Other problems that have been reported include the following (see
Dailey, 2013 for a review):
• Increased nasopharyngeal regurgitation
• Disorganized suck-swallow-breathe coordination
• Gastroesophageal reflux
• Esophageal dysmotility
• Chronic constipation and slow emptying of the digestive tract
• Difficulty adapting to volume increases and introduction of new
food textures
In their discussion of feeding babies with velocardiofacial syndrome
(one of the syndromes represented in the 22q11.2 deletion
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syndrome), Shprinen et al. (2008) recommended aggressive
treatment of constipation and pointed out that it leads to slow
emptying of the digestive tract, which in turn results in a poor
appetite (because the baby feels full). Aempts to continue feeding
the baby may result in overfeeding.
As you may suspect from this inventory of problems,
management of feeding issues in this population is very complex
and requires an interdisciplinary team of individuals familiar with
this syndrome. Appropriate intervention may require a combination
of medical, surgical, and behavioral interventions for some children.
If the baby is feeding orally, the feeding suggestions provided earlier
for babies with cleft palate will be relevant for many babies with the
22q11.2 deletion syndrome. Parents may need to be more aentive to
feeding time in infants with the 22q11.2 deletion syndrome because
these babies may fatigue more easily. In addition, chin and cheek
support may be needed when hypotonia is present (Cooper-Brown
et al., 2008).
For additional information on feeding babies with multiple
anomaly syndromes, the reader is referred to Chibbarro et al., (2009),
Cooper-Brown et al. (2008), and Shprinen et al., (2008).
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A Final Word
We should point out that although most babies with isolated cleft
palate can successfully feed with simple modifications to the feeding
process, the trial and error associated with feeding these newborns
requires considerable patience. In addition to helping a parent
identify the modifications in positioning and the bole and nipple
combination that work best for their baby, it is important to
acknowledge their frustration and support them through the process
until feeding their child becomes more routine. It is also important to
let parents know that despite their best efforts there will be times
when milk leaks through their child's nose, at least until the palate is
repaired. As long as their child is feeding easily and is gaining
weight, nasal regurgitation should be viewed as an inconvenience
(and may be a continual source of frustration) but not a cause for
alarm.
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