Why Do Babies with Clefts Have Difficulty with Feeding?
Babies with clefts have trouble with feeding because the normal anatomy of the oral cavity is disrupted.
Normally, a baby pulls the nipple into the mouth and makes a seal with the lips around the nipple. When a baby sucks and swallows, their soft palate rises up and closes off the mouth from the nose. This creates suction so that the breast or bottle nipple is held in the mouth and the milk is drawn out.
When a cleft lip is present, it may be difficult for the baby to make a good seal around the nipple.
When a cleft palate is present, the mouth cannot be closed off from the nose and little or no suction can be created.
How Do I Feed My Baby with Cleft Lip?
Infants with cleft lip can usually be fed by breast or regular bottle. Some help from the nurses or infant-feeding specialists may be needed to ensure that the infant can get a tight seal around the nipple.
For breastfeeding babies, the soft breast tissue often will fill the opening in the lip and/or gum line well, sealing off the mouth and allowing the baby to create adequate suction. Sometimes it is helpful for the mother to hold a finger across the cleft during feeding.
Swallowing noises and a bowel movement after feeding are signs that breast-feeding is going well. If the baby is "noisy" with feeding, making clicking or kissing noises, suction may not be adequate.
Mothers who choose to bottle-feed their babies with cleft lip should try using nipples with a wider base, or their infants may need specialty bottles or nipples.
When starting a feeding, hold the baby in a slightly upright position. Touch the baby's lower lip with the nipple. When the baby latches on, direct the nipple slightly downwards.
Try to keep the nipple in the center of the baby's mouth. Do not let it slip up into the cleft.
How Do I Feed My Baby with Cleft Palate, with or without Cleft Lip?
Babies with cleft palate usually need special bottles and techniques to feed adequately.
It's rarely possible to breastfeed or use a regular bottle because the baby's nose and mouth are not separated and they cannot create suction to get the milk out of the breast or bottle.
A baby who is put to the breast may look like they are latching on and sucking well, but they are using up energy and getting little or no milk.
We encourage mothers who planned to breastfeed to express their milk and feed it to their infants using a special bottle.
While breast milk is considered the most ideal food for all babies, there are added benefits for babies with cleft palate, such as a lower incidence of middle ear infection.
This situation is often difficult for mothers who were looking forward to breastfeeding their babies. It is common for mothers to feel great sadness at the loss of this experience.
It is important to acknowledge this loss and help mothers maintain closeness with their infants.
What Kind of Bottle Should I Use for Feeding with Cleft Palate?
There are three types of bottles that we recommend for feeding babies with clefts - the Mead-Johnson Cleft Palate Nurser, the Haberman Feeder and the Pigeon Nipple:
Mead-Johnson Cleft Palate Nurser
Mead-Johnson cleft palate nurser
The Mead-Johnson Cleft Palate Nurser is a low-cost soft squeezable bottle that is available in most nurseries. We suggest that you replace the long yellow nipple that comes with the bottle with a shorter, softer nipple.
Before using the bottle for the first time, put some water or milk in the bottle and practice squeezing the liquid out of the nipple. This will help you get a feel for how firmly you need to squeeze.
When you squeeze the bottle, the liquid should flow easily but not too rapidly.
As the baby begins to suck, squeeze the bottle with a firm steady pressure to the count of "squ-e-e-ze-two-three," relaxing your squeeze on the two-three count. This provides the baby with an intermittent flow of milk.
You should only squeeze when the baby is sucking. If the baby pauses to breathe, you should pause also. Watch your baby closely and listen for swallowing sounds.
Pause every few seconds to allow your baby to take a breath. You should see air bubbles come back into the bottle when you pause if the baby is getting milk out of the bottle.
If you forget to stop squeezing the bottle when the baby pauses, the baby may cough and sputter a bit. Just take the nipple out of the baby's mouth for a moment and then resume feeding.
This often happens, especially at first, but you will very quickly learn to adjust your squeezing to your baby's sucking rhythm.
The Haberman Feeder works well for babies who are small or premature, or who have cleft palate only. It has a one-way valve that keeps milk in the nipple.
The baby can obtain milk by compressing the nipple against the roof of the mouth, without need for suction. The flow of the milk can be adjusted by rotating the nipple in the mouth.
Many babies can obtain milk from this feeder by themselves. The baby can control the flow of milk, and it is less tiring for the person feeding because no squeezing is needed.
The Pigeon Nipple can be used with any bottle. It has a faster flow than the Haberman or squeeze bottle, and works well for slightly older infants.
Some newborns tolerate the flow of the Pigeon Nipple well, but feeding with this nipple should be checked by a nurse or infant feeding specialist on the cleft team.
The Pigeon Nipple works by compression only. The nipple has a firm side that goes toward the roof of the mouth and a softer side that goes on the tongue.
A small notch at the base of the nipple serves as an air vent. This notch should be uppermost under the baby's nose when feeding.
Tightening the nipple and collar slows the flow of milk. Loosening it makes the flow faster. If the nipple collapses, loosen and retighten the nipple.
A plastic one-way valve fits into the nipple to keep milk in the nipple. The valve should be placed with the flat side toward the tip of the nipple. When the baby begins to suck, milk flows readily. The infant controls the flow of milk and no squeezing is needed.
How Do I Care for the Bottles and Nipples?
All of these bottles and nipples can be hand washed in hot soapy water, rinsed and allowed to thoroughly air dry.
Do not boil the bottles or parts, wash them in the dishwasher or put them in a microwave. They may soften and start to leak.
How Do I Express Breast Milk for My Baby?
Mothers who choose to express breast milk (using a pump or the hand to get milk out of the breast) for their babies should get a hospital-grade electric breast pump with a double pumping system.
Birth hospitals have pumps for mothers to use in the hospital and can assist families with obtaining pumps for home use. Breast pumps can be rented or purchased. Rental of a breast pump for a baby with a cleft is often covered by insurance.
Mothers should pump at least eight times in 24 hours at first, including at least once during the night. After several weeks of this intensive pumping, most mothers can provide enough milk for their babies by pumping about six times a day.
How Much Should My Baby Eat?
Newborn babies begin taking small amounts, one ounce or less, of milk often, and gradually increase the amount they are able to drink.
By 2 weeks of age, a baby needs to drink at least two to two and a half ounces of milk per pound of weight each day. For example, an eight-pound baby should have at least 16 to 20 ounces of breast milk or formula in 24 hours.
No feeding session should take longer than 30 minutes. If it takes longer, the infant is working too hard and burning calories needed for growth. The measure of success of any feeding plan is adequate weight gain.
We recommend that babies get weighed weekly at first.
How Often Does My Baby Need to Eat?
During the first month of life, a baby will feed eight to twelve times per day, or every two to three hours. A baby this young usually feeds at least twice during the night.
At 2 to 4 months old, a baby will feed six to eight times per day, or every three to four hours.
How Will I Know If My Baby Is Gaining Enough Weight?
A baby usually loses weight the first week of life. Most times, the loss is 5 to10% of body weight. This weight is regained with a baby returning to birth weight by 2 weeks old.
The amount of weight gain expected for a baby is about five to seven ounces per week. At 4 to 6 months old, the rate of weight gain slows to about three-and-a-half to four-and-a-half ounces per week.
What If My Baby Is Not Gaining Enough Weight?
Sometimes infants with cleft lip and palate will have difficulties taking enough breast milk or formula to grow. To help these babies grow, formula powder can be added to breast milk or regular formula for added calories, protein and vitamins.
This should only be done under the supervision of the medical team and only with an approved recipe.
What About Starting Solid Foods?
Babies with clefts can start solid foods at the same age as other babies, usually between 4 and 6 months of age. Experiment to find the right consistency for solids.
It needs to be just right so that the baby can eat without the food coming through the nose. Again, this isn't harmful to the child and sneezing will usually clear the food out of the nose.
Most babies learn quickly to get the food down their throats rather than out their noses.
Can My Baby Drink from a Cup?
Cup feeding can also be started at the usual age. Avoid spill-proof cups, as these require that the baby create suction to obtain any fluid.
Thickening the fluid slightly with rice cereal or a commercial thickener at first may help the baby control the fluid from a cup.