Breastfeeding the Infant with Cleft Lip and Palate Objectives

7/23/2014
Breastfeeding the Infant with Cleft Lip and Palate
Jennifer Pollock, CCC‐SLP, CLC
Memorial’s Kids at Koke Mill
Objectives
• Participants will identify types of clefts and th i i
their impact on breastfeeding.
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• Participants will identify ways to support and assist mothers and infants with cleft lip/palate.
• Participants will identify professionals who Participants will identify professionals who
can assist with cleft lip/palate issues and make appropriate referrals.
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A Normal Palate
What is Cleft Lip & Palate?
• Arises in early pregnancy development‐ by about 10 weeks gestation
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• Structures do not fuse properly in midline
• Causes‐ genetic and environmental factors
• Reduced folic acid intake can contribute to lip clefts Vitamin B?
clefts; Vitamin B?
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What is Cleft Lip/Palate?, cont.
• Lip with/without palate‐ more common in males
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• Palate only‐ more common in females
• About 5% have identifiable syndromes with CL/P or isolated CP
Classification of Clefts
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Davis and Ritchie
Veau
Kernahan and Stark
International Confederation of Plastic and Reconstructive Surgery
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Cleft Lip
• Clefts of the lip can range from simple notch in upper lip to a complete opening in the lip, li t
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extending to the floor of the nasal cavity and involving the alveolus to the incisive foramen.
Normal Palatal Anatomy
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Cleft Lip
Cleft Palate
• May involve soft palate or extend partially or completely through the hard and soft palates
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• Alveolus remains intact
• May be sub‐mucous and difficult to detect
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Cleft Palate
Cleft Lip and Palate
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Cleft Lip and Palate
Prevalence and Incidence of CL&P
• ABM 2007: Worldwide .8‐2.7 cases per 1000 li bi th
live births
• Cochrane Collaborative 2011: 1 out of every 700 births
• Highest incidence in Native American (3 5/1000) and Asian (1 7/1000)
(3.5/1000) and Asian (1.7/1000)
• Lowest incidence African American (.5/1000) and Caucasian (1/1000)
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Lip, Palate, or Lip AND Palate
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Of total # of infants with cleft lip/palate‐
50% combined CL/P
30% isolated CP
20% isolated CL
5% CL extending to include alveolus
*Usually unilateral but 10% bilateral
Oral Motor Skills and Breastfeeding
• To be successful, there needs to be both suction and compression
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• Suction‐ attachment, stability, extraction of milk
• Compression‐ pressing of breast between the tongue and palate with the jaw
tongue and palate with the jaw
• Both combine to help with milk transfer and delivery
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Normal Feeding in Infants
• Responds to feeding cues with appropriate reflexes
• Coordination of breathing and swallowing
• Maintaining active suck‐swallow‐breathe
• Create/maintain negative pressure
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• Manage milk
• Receive milk in stomach
• Digest and metabolize milk
Feeding the CL/P Infant
• Cleft Lip‐ may have problems creating seal
• Cleft Palate‐ poor negative pressure, poor compression of nipple, leading to increased length of feeds, breathing issues, nasal regurgitation, milk supply issues, etc.
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Can the Infant Breastfeed??
Answer= “Maybe!!!”
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Size/type/location of cleft
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Age of infant at birth
Oral motor skills
Development of skills to compensate
Emphasize importance of breast milk/feeding
Emphasize importance of breast milk/feeding carefully
• Let infant try!
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“Maybe”. Now What do I do?
• Back to the beginning
• Put on our investigative hats and look at history
• Get out the counseling couch!
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Interview Questions
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Was parent aware of a cleft prior to birth?
How are they dealing with knowledge?
Do they have questions or concerns?
How is the infant feeding currently?
What have they tried‐ successfully and not
Is family being followed by a Team?
Counseling Parents
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Be sensitive
Listen, don’t judge
Respect grief
Acknowledge emotion
Perform education‐ repeat, go slow, be direct
Be realistic‐ case‐by‐case recommendations
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Patient Education Materials
• Handout examples
Repair of Clefts
• Lip‐ Typically repaired 1st
• Time frame varies
• Improves appearance which can improve interactions
• Palate‐ Typically done between ages 6 months 3 years
months‐
3 years
• Many types‐ Involves Plastics, ENT, Oral Surgery, etc.
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Goals of Surgical Intervention
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Separation of nasal and oral cavities
Construction of a tight velo‐pharyngeal valve
Preservation of facial growth
Development of aesthetic dentition and functional occlusion
Feeding Plan
• Written, verbal, pictures to increase understanding and compliance
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• Individualized but may be a standard form 13
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Prior to Lip Repair‐Strategies
• Positioning‐ Trial and error
• Try holding infant with lip oriented toward top T h ldi i f t ith li
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of breast
• Oral Facilitation‐ mom may try to occlude with fingers and/or support cheeks to decrease width of cleft and increase closure
• May also manipulate breast tissue to get better closure
• Bilateral‐straddle may work better
Prior to Palate Repair‐ Strategies
• Use of semi‐elevated position
• Football hold
• Position breast toward greatest segment‐
where is the most bone
• May need chin/jaw support
• Support breast and tip downward to keep nipple from entering cleft
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Cleft Strategies, cont.
• Massage
• Manual expression
• PUMP!!!
Exclusive Breastfeeding?
• Study from 2010‐ examined hospital rate in Kh K
Khon Kaen, Thailand from Jan 2008 through Th il d f
J 2008 th
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2009
• Began protocol in 2000‐ rooming in, skin‐to‐
skin, dancer hold, and compression.
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Steps for Success
1. Experienced RN to educate mother 1‐on‐1
2. Proper positioning
3. Dancer hold
4. Moms pump immediately after delivery & practice squeeze/suckle with baby at breast
• LATCH score, track weights and I/O
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• Privacy for mom, infant and family
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Results
• 20 newborns‐ at 1 wk and 1 month post di h
discharge, were exclusive. At 3‐4 months, 16 l i At 3 4
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were on formula (mothers back to work?) • Study concluded that it is possible to have exclusivity with complete CL‐CP
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Products That May Help Bottles, Nipples, Syringes, Oh My!
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Cups
Bottles/nipples
Finger feeder
Syringes
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Bottles and Nipples
Rigid vs. Squeezable Bottles
• Cochrane Collaboration 2011
• No statistically significant differences between N t ti ti ll i ifi t diff
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types for QOL
• ½ studies showed benefit for head circumference at greater than 6 mo, but pooled analysis showed no difference for weight or head circ at any time. i ht h d i t
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• Squeezable better for protein intake at 3 and 6 months
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Other Options
Breastfeeding vs. Spoon
• Cochrane Collaboration 2011
• Darzi 1996‐ cleft lip study
• 6 wks post surgery‐ difference shown in favor of breastfeeding • Showed spoon‐fed infants required more IV fluids and analgesia/sedation and more total
fluids and analgesia/sedation, and more total cost of hospitalization
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Transition to Cup
• Before palate repair, infants need to be off of b ttl
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bottles and pacifiers
• Free flowing, no value • DO NOT advocate removal
• of valves!
• Avent rimmed cup Æ
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• Offer all liquids in trials
Keep in Mind
• Monitor infant for hydration and weight gain
• Use of supplemental feedings as appropriate
• Consult with Pediatric Registered Dietician, if appropriate
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Referrals to Other Professionals
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Head and Neck Team
Speech Pathology
Registered Dieticians
Occupational Therapy/Physical Therapy
Social Work
Orthodontics/Oral sx
Early Intervention
Teams in Illinois
• Chicago‐ Shriners Hospital for Children, Laurie Child ’ H it l f Chi
Children’s Hospital of Chicago; Craniofacial C i f i l
Canter at U of I Chicago; Rush Craniofacial Center
• Maywood‐Loyola University Ronald McDonald Children's Hospital
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• Park Ridge‐ Cleft Palate Team at Lutheran General Hospital
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Teams in Illinois
• Peoria‐ Central Illinois Orofacial Anomalies team
• Springfield‐ SIU School of Medicine CHNAC
• Urbana‐ Carle Cleft Lip and Palate Team
• Source: www.cleftline.org
www.CleftAdvocate.org
• Links to various agencies and local support people in cities in IL
l i iti i IL
• Includes DSCC, IDHS, SSI/SSDI, WIC, Easter Seals, Early Intervention, etc
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Contact Information
• Jennifer Pollock, CCC‐SLP, CLC
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Memorial’s Kids at Koke Mill
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3136 Old Jacksonville Rd Ste. 140
Springfield, IL 62704
Ph 217‐862‐0400
Fax 217 862 0440
Fax 217‐862‐0440
Pollock.jennifer@mhsil.com
References
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Bessell A, Hooper L, Shaw WC, Reilly S, Reid J, Glenny AM. Feeding interventions for growth and development in infants with cleft lip, cleft palate, or cleft lip and palate (review). The Cochrane Library. 2011; 2: 1‐34 Cohen M, Marschall MA, Schafer ME. Immediate unrestrictive feeding of infants following cleft lip and palate repair. J Craniofac Surg 1992; 3:30‐32
Darzi MA, Chowdri NA, Bhat AN. Breastfeeding or spoon feeding after cleft lip repair. Br J Plast Surg 1996; 49:24‐26
Donovan K. Breastfeeding the Infant With Cleft Lip and Palate. Infant Child Adolesc Nutr. 2012;4(4):194‐198 Garcez L and Giugliani E. Population‐based study on the practice of breastfeeding in children born with cleft lip and palate. The Cleft Palate‐
Craniofacial Journal. 2005;42(6):687‐693
LLLI. Nursing a baby with a cleft lip or palate. Revised edition. Schaumburg, IL:LLLI, 1996.
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Mojab C. Congenital disorders: Implications for breastfeeding. Leaven. Dec 99‐Jan 00;35(6): 123‐128
Mossey PA & Little J.Epidemiology of Oral Clefts: An International Perspective. In: Wyszynski DF, ed. Cleft Lip and Palate: From Origins to Treatment. NY:Oxford University Press, 2002: 127‐158
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Pathumwiwatana P, Tongsukho S, Naratippakorn T, Pradubwong S, Chusilp K. The Promotion of Exclusive Breastfeeding in Infants with Complete Cleft Lip and Palate during the First 6 Months after Childbirth at Srinagarind Hospital, Khon Kaen Province, Thailand. J Med Assoc Thai. 2010;93(4): S71‐77
Reilly S, Reid J, & Skeat J. ABM Clinical Protocol #17:Guidelines for breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate. Breastfeeding Med. 2013
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Photos‐ 3. 3 http://www.nlm.nih.gov/medlineplus/ency/images/ency/fullsize/12709.jpg
http://www nlm nih gov/medlineplus/ency/images/ency/fullsize/12709 jpg
8. http://voiceandalexandertechnique.eu/onewebstatic/fb643d4791‐Hard‐palate‐Gorman.gif
9. http://www.sparrow.org/HealthLibrary/MayoContent/global//images/image_popup/fl7_cleft_lip.jpg
11. http://www.cdc.gov/ncbddd/birthdefects/images/cleft_palate_small.jpg
12. http://www.chw.org/~/media/Images/Medical%20Care/Fetal%20Concern%20Center/cleft525CR.jpg
13. http://pimg.tradeindia.com/01023916/b/1/Cleft‐lip‐Palate.jpg
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