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Cleft lip and/or palate - feeding your baby

Disclaimer: This fact sheet is for education purposes only. Please consult with your doctor or other health professional to make sure this information is right for your child.

Sucking is an important skill babies need to feed well. When a baby is born with a cleft lip and/or palate it is often difficult for the baby to suck milk out of the breast or bottle. With some adjustments to feeding methods and positioning, your baby should be able to get all the benefits of the feeding experience, eg. enough nutrition for growth and development, bonding with carer and use of the muscles of the mouth.

Babies with a cleft lip

Babies born with a cleft lip don't usually experience feeding difficulties. In most cases, your baby will still be able to breastfeed. See the section on Breast milk and breastfeeding for more information.

Babies with a cleft of the soft palate only

If your baby's cleft is narrow and limited to the soft palate, he or she may be able to feed from the breast. In some cases they may need supplementary feeds from a bottle with either expressed breast milk or formula.

Babies with a cleft of the lip and the soft and hard palate

In most cases, these babies are unable to breastfeed. This is because they do not have a separation between the nose and mouth, so they cannot create enough pressure in the mouth to draw milk from the breast. These babies usually feed successfully with bottles and teats specifically designed for babies with clefts.

You can always try to breastfeed, but remember that the important issue is that your baby has adequate nutrition, gains weight and is content. If this is not happening with breast-feeding, then it may be necessary to bottle feed. These babies too may start their feed on the breast, and complete the feed with a bottle of formula or expressed milk. This combination of feeding methods often provides the best nutrition.

Cleft palate babies:

• May have nasal regurgitation (milk coming out through the nose) during feeding. Gently wipe the milk away.
• May need a longer time to finish a feed (active feeding time may be up to 45 minutes in the first month (active feeding time refers to actual feeding time as distinct from burping, nappy changes etc).
• Need to be burped more often (at least 2-3 times during a feed).

Feeding methods

As discussed above, breastfeeding, bottle-feeding or a combination of the two may be chosen, depending on the baby's cleft condition.

Breast milk and breastfeeding

As most people are aware, current research findings indicate that breast milk is best for babies.

Even though breastfeeding may be difficult for a baby with a cleft palate, there is the option of the mother expressing her milk and giving it to her baby via the bottle. Many mothers of babies who have cleft palates and have not been able to breastfeed opt for this method.

A baby with a cleft of the lip only might successfully breastfeed with some modification in positioning. If the cleft is on one side, positioning the baby with the cleft towards the breast may be helpful. This allows for the cleft to be tucked into the breast tissue and makes it easier for your baby to attach, reducing the amount of air sucked in whilst feeding.

Use of the "football" breastfeeding position can be helpful in positioning the cleft lip toward the breast (see photograph below).

Keeping the baby as upright as possible during feeding will allow the milk to flow down into your baby's stomach easily and help prevent choking. It may also stop milk from going into the nose and the ear canals.

Breastfeeding will be more difficult for babies who have a cleft on both sides of the lip. This is because they have more difficulty forming an airtight seal around the nipple.

For most babies with a cleft palate, breastfeeding as the only feeding method is not successful in providing enough nutrition for growth. This is because of the cleft and difficulties drawing milk from the breast.

If breastfeeding is chosen, here are some things to consider:

• When breastfeeding an infant with an extensive cleft lip/palate extra effort is needed to maintain milk supply because these babies tend to have weak sucks and difficulty emptying the breasts.
• Most of these babies will require supplementary feeds via a squeeze bottle, so it is important to express milk immediately after each feed, to maintain an adequate milk supply and to ensure milk is available for the bottle feed. This can be done by hand or with a manual or electric breast pump.
• At the beginning of the feed, put the nipple into the baby's mouth and "milk" the breast surrounding the areola area by applying gentle pressure with the fingers and squeezing toward the areola. This may help compensate for the lack of suction.
• Breastfeeding can be time-consuming, especially when the time taken to express milk between feeds is factored in. For some mothers, it may be impractical; especially when there are other children to care for.

Bottle-feeding

There is a choice of bottles and teats available for babies with cleft conditions. The bottles are made of soft, squeezable plastic. The teats are specially designed to help the baby draw milk from the bottle even with very little pressure of the tongue against the teat.

The speech pathologist or Clinical Nurse Consultant at your Cleft Palate Clinic will be able to advise you on the most suitable type of bottle and teat to use for your baby. They can also provide you with information about where you can purchase these products.

Alternatively, information about purchasing bottles and teats can be found on the fact sheet: "Cleft palate feeding bottles and teats."

If your baby is able to feed effectively with a standard teat and bottle available from supermarkets or chemists, there is no obligation to use any special equipment.

Feeding Techniques using a squeeze bottle:

When you first get a squeeze bottle, it is a good idea to practice squeezing a water filled bottle over a sink before feeding. This will give you some idea about how firmly and frequently the bottle needs to be squeezed to get a steady flow of milk.

Establish a rhythm of squeezing the bottle just after the baby suckles. Allow the baby to swallow the milk before squeezing again.

Some further information

• There is no particular formula designed for babies with cleft conditions. If in doubt about the most suitable one, consult a GP, early childhood nurse or paediatrician.
• Clean the area around the cleft thoroughly after each feed with a cotton bud and sterile water.
• Sterilise the squeeze bottles and teats in solution for no longer than one hour so that they will last longer.
• If the baby is fitted with a plate and there are concerns about feeding, talk to the orthodontist and speech pathologist in the Cleft Palate team.

Babies with cleft conditions :

• Develop their feeding skills in the same way and at the same times as other babies. For example, solids are introduced from around6 months of age.
• Should gain weight at similar rates to other babies without cleft conditions.
• Should not cough and choke at every feed. If this happens, please consult the speech pathologist at your cleft palate clinic.

As discussed above, a combination of breast and bottle feeds using expressed breast milk or formula may be an option, depending on the baby's type of cleft.

Breastfeeding after your baby has had surgery

If the baby has had some success breastfeeding up until the time of surgery, he or she is likely to be able to breastfeed following surgery.

Breastfeeding immediately following surgery should be discussed with your managing surgeon.

If the baby has not been breastfed prior to surgery, breast-feeding may be difficult to establish following surgery. Ways to maximise the chance of the baby successfully breast-feeding following surgery can be discussed with the speech pathologist and lactation consultant.

• Babies with a cleft take longer to feed, especially in the first month.
• Get familiar with using a squeeze bottle before starting to feed the baby.
• Keep the baby in an upright position during feeds.
• Babies with cleft conditions develop their feeding skills in the same way and at the same times as other babies.
• Babies with cleft conditions should gain weight at a similar rate to other babies
• Babies with clefts should not cough and choke during feeding.
• If you have concerns about feeding, contact the speech pathologist at your Cleft Palate Clinic for advice.

The Children's Hospital at Westmead Tel: (02) 9845 3585 Fax: (02) 9845 3562 www.chw.edu.au	Sydney Children's Hospital, Randwick Tel: (02) 9382 1688 Fax: (02) 9382 1451 www.sch.edu.au	Kaleidoscope, Hunter Children's Health Network Tel: (02) 4921 3670 Fax: (02) 4921 3599 www.kaleidoscope.org.au