ABM Clinical Protocol #17: Guidelines for Breastfeeding Infants with Cleft Lip, Cleft Palate, or Cleft Lip and Palate, Revised 2013
Abstract
A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.
Definitions
When a cleft lip (CL) occurs, the lip is not contiguous, and when a cleft palate (CP) occurs, there is communication between the oral and nasal cavities.1 Clefts can range in severity from a simple notch in the upper lip to a complete opening in the lip extending into the floor of the nasal cavity and involving the alveolus to the incisive foramen.2 Similarly, CP may involve just the soft palate or extend partially or completely through the hard and soft palates.1 In CP, the alveolus remains intact. A CP may be submucous and not immediately detected if there are subtle or no corresponding clinical signs or symptoms.1
Background
Incidence
The worldwide prevalence of CL and/or CP (CL/P) ranges from 0.8 to 2.7 cases per 1,000 live births.3 There are differences in incidence rates across racial groups, with the lowest reported incidence among African-American populations (approximately 0.5 per 1,000)4,5 and white populations (approximately one per 1,000 births)3 and higher incidence among Native American (approximately 3.5 per 1,000)6 and Asian (approximately 1.7 per 1,000)7 populations.
Although reports vary considerably, it is estimated that out of the total number of infants with CL/P, approximately 50% have combined cleft lip and palate (CLP), whereas 30% have isolated CP, and 20% have isolated CL; CL extending to include the alveolus occurs in approximately 5% of cases.8 Clefts are usually unilateral (Fig. 1); however, in approximately 10% of cases, clefts are bilateral.9
Breastfeeding and CL/P
In these guidelines, breastfeeding refers to direct placement of baby to the breast for feeding, and breastmilk feeding refers to delivery of breastmilk to baby via bottle, cup, spoon, or any other means except breast. Babies use both suction and compression to breastfeed successfully. The ability to generate suction is necessary for attachment to the breast, maintenance of a stable feeding position, and, together with the let-down reflex, milk extraction. Normally, when a baby is feeding, his or her lips flange firmly against the areola, sealing the oral cavity anteriorly. The soft palate rises up and back to contact the pharyngeal walls and seal the oral cavity posteriorly. As the tongue and jaw drop during sucking, the oral cavity increases in size, and suction is generated, drawing milk from the breast.10 Compression occurs when the baby presses the breast between the tongue and jaw. Suction and compression help milk transfer delivery during breastfeeding.10–12
There is a relationship between the amount of oral pressure generated during feeding and the size/type of cleft and maturity of the baby.13 For this reason, babies with CL are more likely to breastfeed than those with CP and CLP.14 Some babies with small clefts of the soft palate generate suction,15 but others with larger clefts of the soft and/or hard palate may not generate suction.15,16 Newborns and premature babies generate lower suction pressures compared with older babies.13,17,18 Babies with CP or CLP have difficulty creating suction19 because the oral cavity cannot be adequately separated from the nasal cavity during feeding. For these infants, negative consequences may include fatigue during breastfeeding, prolonged feeding times, and impaired growth and nutrition.
The literature describing breastfeeding outcomes is limited, and the evidence is anecdotal and contradictory, making the recommendations that follow challenging.20
Recommendations
Quality of evidence (levels of evidence I, II-1, II-2, II-3, and III) for each recommendation, as defined in the U.S. Preventive Services Task Force Appendix A Task Force Ratings,21 is noted in parentheses.
Summary of recommendations for clinical practice
Based on the reviewed evidence, the following recommendations are made:
1. Mothers should be encouraged to provide the protective benefits of breastmilk. Evidence suggests that breastfeeding protects against otitis media, which is highly prevalent in this population.22,23 (II-2) Breastmilk feeding (via cup, spoon, bottle, etc.) should be promoted in preference to artificial milk feeding. Additionally, there is speculative information regarding possible benefits of breastfeeding versus bottle feeding on the development of the oral cavity.
2. At the same time, mothers should be counseled about likely breastfeeding success. Where direct breastfeeding is unlikely to be the sole feeding method, the need for breastmilk feeding should be encouraged, and, when appropriate, possible delayed transitioning to breastfeeding should be discussed.
3. Babies with CL/P should be evaluated for breastfeeding on an individual basis. In particular, it is important to take into account the size and location of the baby's CL/P as well as the mother's wishes and previous experience with breastfeeding. There is moderate evidence to suggest that infants with CL are able to generate suction19 (III), and descriptive reports suggest that these infants are often able to breastfeed successfully.24 (III) There is moderate evidence that infants with CP or CLP have difficulty generating suction15 (I) and have inefficient sucking patterns16 (I) compared with normal infants. The success rates for breastfeeding infants with CP or CLP are observed to be lower than for infants with CL or no cleft.14,24 (III) (Appendix)
4. As in normal breastfeeding, knowledgeable support is important. Mothers who wish to breastfeed should be given immediate access to a lactation specialist to assist with positioning, management of milk supply, and expressing milk for supplemental feeds. Several studies have suggested that there is a need for and benefit from having access to a health professional who specializes in CL/P, such as a clinical nurse specialist, during the newborn/infant periods for specialized advice on feeding a baby with CL/P as well as referrals to appropriate services.25 Surveys of parents with a child with CL, CLP, or CP indicated a desire for more instruction on feeding challenges as early as possible.26 (III)
5. Families may benefit from peer support around breastmilk feeding or breastfeeding found through associations like Wild Smile27 in addition to routine referral to breastfeeding support groups.
6. Monitoring of a baby's hydration and weight gain is important while a feeding method is being established. If inadequate, supplemental feeding should be implemented or increased. (See “ABM clinical protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009.”28) Infants with CL/P may require supplemental feeds for adequate growth and nutrition.24 (III) There is one study that demonstrated that additional maternal support by a clinical nurse specialist can both improve weight gain outcomes and also facilitate referral to appropriate services.29 (III)
7. Modification to breastfeeding positions may increase the efficiency and effectiveness of breastfeeding. Positioning recommendations that have been recommended on the basis of weak evidence (clinical experience or expert opinion) and should be evaluated for success are:
a. For infants with CL:
iii. For bilateral CL, a “face on” straddle position may be more effective than other breastfeeding positions.31 (III)
b. For infants with CP or CLP:
ii. A “football hold”/twin position (the body of the infant positioned alongside the mother, rather than across the mother's lap, and with the infant's shoulders higher than his or her body) may be more effective than a cross-cradle position.36 (III)
iii. For infants with CP it may also be useful to position the breast toward the “greater segment”—the side of the palate that has the most intact bone. This may facilitate better compression and stop the nipple being pushed into the cleft site.37 (III)
v. If the cleft is large, some experts suggest that the breast be tipped downward to stop the nipple being pushed into the cleft.30 (III)
vi. Mothers may need to manually express breastmilk into the baby's mouth to compensate for absent suction and compression and to stimulate the let-down reflex.38 (III)
9. Evidence suggests that breastfeeding can commence/recommence immediately following CL repair and that breastfeeding may be slightly more advantageous than spoon feeding.41,42 (I) Breastfeeding can commence/recommence 1 day after CP repair without complication to the wound.41 In a survey of CP surgeons regarding postoperative care after palatoplasty, two-thirds of surgeons allowed mothers to breastfeed immediately after surgery.43 (III)
10. Assessment of the potential for breastfeeding of infants with CL/P as part of a syndrome/sequence should be made on a case-by-case basis, taking into account the additional features of the syndrome that may impact on breastfeeding success.
Recommendations for future research
The most pressing issue for healthcare professionals working with mothers who wish to breastfeed their infants with CL/P is the lack of evidence on which to base clinical decisions. Well-designed, data-driven investigations that document feeding success rates, management strategies, and outcomes for infants with CL/P are imperative. Furthermore, investigators must clearly describe their sample of infants and intervention techniques so that the research outcomes are able to be generalized.
Acknowledgments
This work was supported in part by a grant from the Maternal and Child Health Bureau, U.S. Department of Health and Human Services.
References
1.
Shprintzen RJBardach J. Cleft Palate Speech Management: A Multidisciplinary ApproachMosby, St. Louis1995. 1. Shprintzen RJ, Bardach J. Cleft Palate Speech Management: A Multidisciplinary Approach. Mosby, St. Louis, 1995.
2.
Shah CPWong D. Management of children with cleft lip and palateCan Med Assoc J198012219-24. 2. Shah CP, Wong D. Management of children with cleft lip and palate. Can Med Assoc J 1980;122:19–24.
3.
Conway HWagner KJ. Incidence of clefts in New York CityCleft Palate Craniofac J199633284-290. 3. Conway H, Wagner KJ. Incidence of clefts in New York City. Cleft Palate Craniofac J 1996;33:284–290.
4.
Croen LAShaw GMWasserman CR et al. Racial and ethnic variations in the prevalence of orofacial clefts in California, 1983–1992Am J Med Genet19987942-47. 4. Croen LA, Shaw GM, Wasserman CR, et al. Racial and ethnic variations in the prevalence of orofacial clefts in California, 1983–1992. Am J Med Genet 1998;79:42–47.
5.
Niswander JDBarrow MVBingle GJ. Congenital malformations in the American IndianSoc Biol197522203-215. 5. Niswander JD, Barrow MV, Bingle GJ. Congenital malformations in the American Indian. Soc Biol 1975;22:203–215.
6.
Cleft Lip. Palate Association of Ireland. The incidence of clefts2003www.cleft.ie/what-is-a-cleft/incidence-of-cleftsApril262013. 6. Cleft Lip and Palate Association of Ireland. The incidence of clefts. 2003. www.cleft.ie/what-is-a-cleft/incidence-of-clefts (accessed April 26, 2013).
7.
Young G. Cleft lip and palate. UTMB Department of Otolaryngology Grand Rounds1998www.utmb.edu/otoref/Grnds/Cleft-lip-palate-9801/Cleft-lip-palate-9801.htmApril262013. 7. Young G. Cleft lip and palate. UTMB Department of Otolaryngology Grand Rounds. 1998. www.utmb.edu/otoref/Grnds/Cleft-lip-palate-9801/Cleft-lip-palate-9801.htm (accessed April 26, 2013).
8.
Mulliken JB. Repair of bilateral complete cleft lip and nasal deformity—State of the artCleft Palate Craniofac J200037342-347. 8. Mulliken JB. Repair of bilateral complete cleft lip and nasal deformity—State of the art. Cleft Palate Craniofac J 2000;37:342–347.
9.
Wolf LSGlass RPFeeding and Swallowing Disorders in Infancy: Assessment and ManagementTherapy Skill BuildersTucson, AZ1992. 9. Wolf LS, Glass RP. Feeding and Swallowing Disorders in Infancy: Assessment and Management. Therapy Skill Builders, Tucson, AZ, 1992.
10.
Brake SFifer WPAlfasi G et al. The first nutritive sucking responses of premature newbornsInfant Behav Dev1988111-9. 10. Brake S, Fifer WP, Alfasi G, et al. The first nutritive sucking responses of premature newborns. Infant Behav Dev 1988;11:1–9.
11.
Weber FWooldridge MWBaum JD. An ultrasonographic study of the organization of sucking and swallowing by newborn infantsDev Med Child Neurol19862819-24. 11. Weber F, Wooldridge MW, Baum JD. An ultrasonographic study of the organization of sucking and swallowing by newborn infants. Dev Med Child Neurol 1986;28:19–24.
12.
Reid JA. Feeding difficulties in babies with cleft lip and/or palate: An overrated problem or a neglected aspect of care?[PhD thesis]La Trobe UniversityMelbourne2004. 12. Reid JA. Feeding difficulties in babies with cleft lip and/or palate: An overrated problem or a neglected aspect of care? [PhD thesis]. La Trobe University, Melbourne, 2004.
13.
Reid JAReilly SKilpatrick NM. Breastmilk consumption in babies with cleftsPresented at the 63rd Annual Meeting of the American Cleft Palate-Craniofacial AssociationVancouver, BC, Canada2006. 13. Reid JA, Reilly S, Kilpatrick NM. Breastmilk consumption in babies with clefts. Presented at the 63rd Annual Meeting of the American Cleft Palate-Craniofacial Association, Vancouver, BC, Canada, 2006.
14.
Reid JReilly SKilpatrick N. Sucking performance of babies with cleft conditionsCleft Palate Craniofac J200744312-320. 14. Reid J, Reilly S, Kilpatrick N. Sucking performance of babies with cleft conditions. Cleft Palate Craniofac J 2007;44:312–320.
15.
Maserai AGSell DHabel A et al. The nature of feeding in infants with unrepaired cleft lip and/or palate compared with healthy noncleft infantsCleft Palate Craniofac J200744321-328. 15. Maserai AG, Sell D, Habel A, et al. The nature of feeding in infants with unrepaired cleft lip and/or palate compared with healthy noncleft infants. Cleft Palate Craniofac J 2007;44:321–328.
16.
Mizuno KUeda AKani K et al. Feeding behaviour of infants with cleft lip and palateActa Paediatr2002911227-1232. 16. Mizuno K, Ueda A, Kani K, et al. Feeding behaviour of infants with cleft lip and palate. Acta Paediatr 2002;91:1227–1232.
17.
Mizuno KUeda A. Development of sucking behavior in infants who have not been fed for 2 months after birthPediatr Int200143251-255. 17. Mizuno K, Ueda A. Development of sucking behavior in infants who have not been fed for 2 months after birth. Pediatr Int 2001;43:251–255.
18.
Choi BHKleinheinz JJoos U et al. Sucking efficiency of early orthopaedic plate and teats in infants with cleft lip and palateInt J Oral Maxillofac Surg199120167-169. 18. Choi BH, Kleinheinz J, Joos U, et al. Sucking efficiency of early orthopaedic plate and teats in infants with cleft lip and palate. Int J Oral Maxillofac Surg 1991;20:167–169.
19.
Smedegaard LDorthe Marxen MJGlassou EN et al. Hospitalization, breast-milk feeding, and growth in infants with cleft palate and cleft lip and palate born in DenmarkCleft Palate Craniofac J199845628-632. 19. Smedegaard L, Dorthe Marxen MJ, Glassou EN, et al. Hospitalization, breast-milk feeding, and growth in infants with cleft palate and cleft lip and palate born in Denmark. Cleft Palate Craniofac J 1998;45:628–632.
20.
Reid J. A review of feeding interventions for infants with cleft palateCleft Palate Craniofac J200441268-278. 20. Reid J. A review of feeding interventions for infants with cleft palate. Cleft Palate Craniofac J 2004;41:268–278.
21.
U.S. Preventive Services Task Force Appendix A Task Force Ratingswww.ncbi.nlm.nih.gov/books/NBK15430April262013. 21. U.S. Preventive Services Task Force Appendix A Task Force Ratings. www.ncbi.nlm.nih.gov/books/NBK15430 (accessed April 26, 2013).
22.
Aniansson GSvensson HBecker M et al. Otitis media and feeding with breastmilk of children with cleft palateScand J Plast Reconstr Surg Hand Surg2002369-15. 22. Aniansson G, Svensson H, Becker M, et al. Otitis media and feeding with breastmilk of children with cleft palate. Scand J Plast Reconstr Surg Hand Surg 2002;36:9–15.
23.
Garcez LWGiuliani ER. Population-based study on the practice of breastfeeding in children born with cleft lip and palateCleft Palate Craniofac J200542687-693. 23. Garcez LW, Giuliani ER. Population-based study on the practice of breastfeeding in children born with cleft lip and palate. Cleft Palate Craniofac J 2005;42:687–693.
24.
da Silva Dalben GCosta BGomide MR et al. Breast-feeding and sugar intake in babies with cleft lip and palateCleft Palate Craniofac J20034084-87. 24. da Silva Dalben G, Costa B, Gomide MR, et al. Breast-feeding and sugar intake in babies with cleft lip and palate. Cleft Palate Craniofac J 2003;40:84–87.
25.
Chuacharoen RRitthagol WHunsrisakhun J et al. Felt needs of parents who have a 0- to 3-month-old child with a cleft lip and palateCleft Palate Craniofac J200946252-257. 25. Chuacharoen R, Ritthagol W, Hunsrisakhun J, et al. Felt needs of parents who have a 0- to 3-month-old child with a cleft lip and palate. Cleft Palate Craniofac J 2009;46:252–257.
26.
Owens J. Parents' experiences of feeding a baby with cleft lip and palateBr J Midwifery200816778-784. 26. Owens J. Parents' experiences of feeding a baby with cleft lip and palate. Br J Midwifery 2008;16:778–784.
27.
Wide Smiles1996www.widesmiles2.orgApril262013. 27. Wide Smiles. 1996. www.widesmiles2.org (accessed April 26, 2013).
28.
Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009Breastfeed Med20094175-182. 28. Academy of Breastfeeding Medicine Protocol Committee. ABM clinical protocol #3: Hospital guidelines for the use of supplementary feedings in the healthy term breastfed neonate, revised 2009. Breastfeed Med 2009;4:175–182.
29.
Beaumont D. A study into weight gain in infants with cleft lip/palatePaediatr Nurs20082020-23. 29. Beaumont D. A study into weight gain in infants with cleft lip/palate. Paediatr Nurs 2008;20:20–23.
30.
Danner SC. Breastfeeding the infant with a cleft defectNAACOGS Clin Issu Perinat Womens Health Nurs19923634-639. 30. Danner SC. Breastfeeding the infant with a cleft defect. NAACOGS Clin Issu Perinat Womens Health Nurs 1992;3:634–639.
31.
Biancuzzo M. Clinical focus on clefts. Yes! Infants with clefts can breastfeedAWHONN Lifelines1998245-49. 31. Biancuzzo M. Clinical focus on clefts. Yes! Infants with clefts can breastfeed. AWHONN Lifelines 1998;2:45–49.
32.
Helsing EKing FS. Breastfeeding under special conditionsNurs J India19857646-47. 32. Helsing E, King FS. Breastfeeding under special conditions. Nurs J India 1985;76:46–47.
33.
Bardach JMorris HLMultidisciplinary Management of Cleft Lip and PalateWB Saunders Co.Philadelphia1990. 33. Bardach J, Morris HL. Multidisciplinary Management of Cleft Lip and Palate. WB Saunders Co., Philadelphia, 1990.
34.
Arvedson JC. Feeding with craniofacial anomaliesArvedson JCBrodsky LBPediatric Swallowing and Feeding: Assessment and Management2ndSingular Publishing GroupAlbany, NY2002527-561. 34. Arvedson JC. Feeding with craniofacial anomalies. In: Arvedson JC, Brodsky LB, eds. Pediatric Swallowing and Feeding: Assessment and Management, 2nd ed. Singular Publishing Group, Albany, NY, 2002:527–561.
35.
Glass RPWolf LS. Feeding management of infants with cleft lip and palate and micrognathiaInfants Young Child19991270-81. 35. Glass RP, Wolf LS. Feeding management of infants with cleft lip and palate and micrognathia. Infants Young Child 1999;12:70–81.
36.
Dunning Y. Child nutrition. Feeding babies with cleft lip and palateNurs Times19868246-47. 36. Dunning Y. Child nutrition. Feeding babies with cleft lip and palate. Nurs Times 1986;82:46–47.
37.
McKinstry RE. Presurgical management of cleft lip and palate patientsMcKinstry RECleft Palate DentistryABI Professional PublicationsArlington, VA199833-66. 37. McKinstry RE. Presurgical management of cleft lip and palate patients. In: McKinstry RE, ed. Cleft Palate Dentistry. ABI Professional Publications, Arlington, VA, 1998:33–66.
38.
Lebair-Yenchik J. Cleft palatesAWHONN Lifelines1998211-12. 38. Lebair-Yenchik J. Cleft palates. AWHONN Lifelines 1998;2:11–12.
39.
Masarei AG. An investigation of the effects of pre-surgical orthopaedics on feeding in infants with cleft lip and/or palate[PhD thesis]University CollegeLondon2003. 39. Masarei AG. An investigation of the effects of pre-surgical orthopaedics on feeding in infants with cleft lip and/or palate [PhD thesis]. University College, London, 2003.
40.
Prahl CKuijpers-Jagtman AMvan't Hof MA et al. Infant orthopedics in UCLP: Effect on feeding, weight, and length: A randomized clinical trial (Dutchcleft)Cleft Palate Craniofac J200542171-177. 40. Prahl C, Kuijpers-Jagtman AM, van't Hof MA, et al. Infant orthopedics in UCLP: Effect on feeding, weight, and length: A randomized clinical trial (Dutchcleft). Cleft Palate Craniofac J 2005;42:171–177.
41.
Cohen MMarschall MASchafer ME. Immediate unrestricted feeding of infants following cleft lip and palate repairJ Craniofac Surg1992330-32. 41. Cohen M, Marschall MA, Schafer ME. Immediate unrestricted feeding of infants following cleft lip and palate repair. J Craniofac Surg 1992;3:30–32.
42.
Bessell AHooper LShaw WC et al. Feeding interventions for growth and development in infants with cleft lip, cleft palate or cleft lip and palateCochrane Database Syst Rev20112CD003315. 42. Bessell A, Hooper L, Shaw WC, et al. Feeding interventions for growth and development in infants with cleft lip, cleft palate or cleft lip and palate. Cochrane Database Syst Rev 2011;(2):CD003315.
43.
Katzel EBBasile PKoltz PF et al. Current surgical practices in cleft care: Cleft palate repair techniques and postoperative carePlast Reconstr Surg2009124899-906. 43. Katzel EB, Basile P, Koltz PF, et al. Current surgical practices in cleft care: Cleft palate repair techniques and postoperative care. Plast Reconstr Surg 2009;124:899–906.
44.
Darzi MAChowdri NABhat AN. Breastfeeding or spoon feeding after cleft lip repair: A prospective, randomised studyBr J Plast Surg19964924-26. 44. Darzi MA, Chowdri NA, Bhat AN. Breastfeeding or spoon feeding after cleft lip repair: A prospective, randomised study. Br J Plast Surg 1996;49:24–26.
45.
Cleft Lip. Palate Association. Breastfeeding a baby with cleft lip and/or palate2009www.clapa.com/antenatal/faq/184April262013. 45. Cleft Lip and Palate Association. Breastfeeding a baby with cleft lip and/or palate. 2009. www.clapa.com/antenatal/faq/184 (accessed April 26, 2013).
46.
Gopinath VKMuda WA. Assessment of growth and feeding practices in children with cleft lip and palateSoutheast Asian J Trop Med Public Health200536254-258. 46. Gopinath VK, Muda WA. Assessment of growth and feeding practices in children with cleft lip and palate. Southeast Asian J Trop Med Public Health 2005;36:254–258.
47.
Paradise JLElster BATan L. Evidence in infants with cleft palate that breastmilk protects against otitis mediaPediatrics199494853-860. 47. Paradise JL, Elster BA, Tan L. Evidence in infants with cleft palate that breastmilk protects against otitis media. Pediatrics 1994;94:853–860.
48.
Erkkila ATIsotalo EPulkkinen J et al. Association between school performance, breastmilk intake and fatty acid profile of serum lipids in ten-year-old cleft childrenJ Craniofac Surg200516764-769. 48. Erkkila AT, Isotalo E, Pulkkinen J, et al. Association between school performance, breastmilk intake and fatty acid profile of serum lipids in ten-year-old cleft children. J Craniofac Surg 2005;16:764–769.
49.
World Health Organization Health. Factors which may interfere with breastfeedingBull World Health Organ198967Suppl41-54. 49. World Health Organization Health. Factors which may interfere with breastfeeding. Bull World Health Organ 1989;67(Suppl):41–54.
50.
Pierre Robin Network. Feeding your child2012www.pierrerobin.orgApril262013. 50. Pierre Robin Network. Feeding your child. 2012. www.pierrerobin.org (accessed April 26, 2013).
51.
Pandya ANBoorman JG. Failure to thrive in babies with cleft lip and palateBr J Plast Surg200154471-475. 51. Pandya AN, Boorman JG. Failure to thrive in babies with cleft lip and palate. Br J Plast Surg 2001;54:471–475.
Appendix
ABM protocols expire 5 years from the date of publication. Evidence-based revisions are made within 5 years or sooner if there are significant changes in the evidence.
Appendix: Frequently Asked Questions
Breastfeeding infants with CL, CP, or CLP
Except where noted, the literature reviewed relates to infants with non-syndromic clefts of the lip and/or palate.
1. Can infants with CL breastfeed successfully?
There is no strong evidence with regard to breastfeeding of infants with CL. There was moderate (II-2) evidence that babies with CL create suction during feeding.15,19 Descriptive (III) studies have demonstrated successful breastfeeding at rates approaching the normal population.23 Expert opinion (III) suggests that infants with CL may find breastfeeding relatively easier than bottle feeding because the breast tissue molds to the cleft and occludes the defect more successfully than an artificial nipple.44–46 Expert opinion suggests that modifications to positioning can facilitate breastfeeding for these infants.30–33
2. Can infants with CP breastfeed successfully?
There is no strong evidence with regard to breastfeeding infants with CP. There was moderate (II-2) evidence that infants with CP do not create suction when bottle feeding.15,19 Although infants with clefts of the soft palate may be able to create suction, this is not usually the case.13,15 Descriptive studies indicate that breastfeeding success for infants with CP is much lower than for infants with CL.25,31 There was weak (III) evidence to suggest that partial breastfeeding (with supplementation) can be achieved and that the size and location of the cleft are determining factors for breastfeeding success.35,36,45 As with infants with CL, modifications to positioning are reported to increase breastfeeding success.30,31,34–36 (III)
3. Can infants with CLP breastfeed successfully?
There is no strong evidence with regard to breastfeeding infants with CLP. There was moderate (II-2) evidence that infants with CLP are unable to create suction when measured using a bottle13,15,19 and moderate to weak evidence that infants with CLP are sometimes able to breastfeed successfully.26 Descriptive studies suggest breastfeeding success rates ranging from 0% to 40%.22,23 Modifications to positioning to increase breastfeeding success are recommended by experts.29,30,32,35,36,38 (III)
4. Is there evidence to guide assessment and management of breastfeeding in infants with CL/P?
Aside from strong evidence regarding the use of palatal obturators (considered separately), there was moderate evidence (II-3) that lactation education is important to facilitate feeding efficiency in infants with CL/P.46 The remaining evidence is weak (III) and focuses on (a) areas for monitoring and (b) recommendations for supplementation.
5. Is there evidence that palatal obturators facilitate breastfeeding success with infants with CLP or CP?
Breastfeeding outcomes may be affected by the use of feeding plates (which obturate some of the cleft and attempt to “normalize” the oral cavity for feeding)39 or presurgical orthopedics (prosthesis to reposition the cleft segments prior to surgery). These are collectively referred to as “obturators” for this report. There was strong (I) evidence that obturators do not facilitate feeding or weight gain in breastfed babies with CLP39 and that they do not improve the infant's rate of bottle feeding.40 There was moderate (II-2) evidence that obturators do not facilitate suction during bottle feeding.18 This is because obturators do not facilitate complete closure of the soft palate against the walls of the throat during feeding. Contradictory evidence exists supporting the use of obturators to facilitate breastfeeding in infants with CP or CLP, but it is from much weaker sources.29,44,46 (II-2, III)
6. Is there evidence for additional benefits of breastfeeding for infants with CL/P compared with the normal population?
Several moderate to weak (II-2) studies exist, with the majority of evidence representing expert opinion (III). It is well accepted that breastfeeding and breastmilk feeding convey positive benefits to both mother and baby. With regard to babies with CP, there was moderate to weak evidence that feeding with breastmilk protects against otitis media in infants with CP.22,47 These babies are more prone to otitis media than the general population because of the abnormal soft palate musculature.47 There was moderate to weak evidence that breastmilk can promote intellectual development and school outcomes in babies with clefts.48 Antibacterial agents in breastmilk promote postsurgical healing and reduce irritation of mucosa (compared with artificial milk).49 (III) Additionally, experts have suggested that breastfeeding facilitates the development of oral facial musculature,29 speech,29,36 bonding,36 and pacifying infants postsurgery.29,45
7. Is there evidence to indicate when it is safe to commence/recommence breastfeeding following surgery for lip or palate?
CL repair (cheiloplasty) is generally carried out within a few months of birth,7 and CP repair (palatoplasty) often takes place between 6 and 12 months of age. There are several studies that have yielded strong evidence to inform this area (I, II-2). There is moderate to strong evidence (I, II-2) that it is safe to commence/recommence breastfeeding immediately following CL repair,41,42 and there is moderate evidence (II-2) for initiating breastfeeding 1 day after CP repair.41 There is strong evidence (I) that breastfeeding immediately following surgery is more effective for weight gain, with lower hospital costs, than spoon feeding.41 Contradictory evidence exists, but it is from weaker sources (III) and is divided as to recommendations.32–34
8. Is there evidence to indicate whether infants with CP as part of a syndrome/sequence are able to breastfeed?
There are over 340 syndromes in which CL/P appears.35 It is beyond the scope of this protocol to review and make recommendations for them all in detail. However, some key data are presented to guide breastfeeding practice. Moderate to weak evidence suggests that, as well as the cleft, the additional oral facial anomalies associated with these syndromes (e.g., hypotonia, micrognathia, glossoptosis) impact feeding success.35,50,51 It is important to examine the influence of all anomalies on feeding and design treatment with this in mind.
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Published online: 25 July 2013
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