Feeding Methods, Modifications,

and Facilitation Techniques

• With simple modifications, most infants with a cleft are able to feed with relative ease
and obtain an adequate amount of nutrition in a reasonable amount of time.

• There is no single feeding method that will be successful for infants with different
types of clefts or craniofacial abnormalities.

• Instead, the infant’s performance during the initial feedings determines which
feeding method and technique is most appropriate for that child
 BREASTFEEDING
• Most pediatricians and health care providers agree that breast milk is best for the
newborn infant for several reasons.

• It contains the mother’s antibodies against illnesses and therefore can provide the
infant with some immunity.

• In addition, early food allergies can be avoided through the use of breast milk.

• It also has been suggested that feeding with breast milk offers some protection
from otitis media

• However, opinions regarding the feasibility of breastfeeding a child with a cleft vary
across centers
• As with other feeding methods, the success of breastfeeding depends on the location
and severity of the cleft.

• If the mother wishes to breastfeed her infant with a cleft, consultation with a certified
lactation consultant is advisable.

• In general, breastfeeding is usually not a problem for the infant who has only a cleft lip
because the infant should still be able to achieve adequate suction.

• Even with a cleft in the lip and alveolus, the breast tends to fill the opening by molding
to the shape of the oral cavity.

• Upright positioning while attempting breastfeeding is generally recommended.

• Supplemental bottle-feeding or a complete switch to the bottle may be necessary if

difficulties with breastfeeding are immediately apparent.
• Breastfeeding an infant with a cleft palate is very challenging because the infant is
unable to generate negative pressure for suction

• This can be a particular disappointment for new mothers.

• Monitoring weight gain closely during a trial period of breastfeeding will provide both
objective evidence regarding its feasibility and definitive information as to whether a
supplementary feeding method is needed.

• Future research investigations that monitor the success of breastfeeding, document the
efficacy of management strategies, and follow overall infant feeding outcomes are
needed to establish generalized clinical protocols
• If a trial of breastfeeding proves unsuccessful and the mother still wishes to
continue breastfeeding, a supplemental nursing system may be an option

• The supplemental nursing system utilizes a reservoir that is filled with formula or
milk that the mother has expressed.

• A thin tube, connected to the reservoir, is taped above the mother’s breast and
nipple.

• As the infant latches onto the breast for feeding, the mother supplements the
breast milk with milk that is squeezed manually from the reservoir through the
tube.

• The flow of milk needs to be simultaneous with the baby’s efforts at sucking.
• With this method, the baby is supplemented at the breast while
maintaining the important physical contact for the infant and mother.
In addition, this method stimulates the breast to continue to produce
and maintain the milk supply

• Drawbacks to the use of supplemental nursing systems include the

potential for difficulty in maintaining the proper flow rate, though
adjustable flow rate systems are available on some supplemental
nursing systems.

• There is also the possibility that the baby will reject intraoral placement
of the tube during breastfeeding.
• After attempting breastfeeding with modifications, some mothers may find that
using a modified bottle and/or a modified nipple is easier and more efficient.
• These mothers can still use breast milk, but in this case, the breast milk is given
via the modified bottle or nipple.
• Breast milk can be expressed through the use of a breast pump
• There are several kinds of breast pumps, including manual pumps, battery-
operated pumps, and electric pumps.
• The electric pumps tend to be more efficient and faster than the manual pumps.
• As such, they allow both breasts to be pumped at the same time, thus reducing
the amount of time required to express the milk
MODIFIED NIPPLES

• If problems with feeding are immediately apparent, a variety of

specialized nipples are available

• When choosing a nipple for enhancement of sucking, there are five

basic characteristics to consider with the nipple: pliability ,shape, size,
hole type, and hole size
PLIABILITY

• The nipple must be pliable enough to release breast milk or formula, with limited compression
and suction.
• At the same time, the nipple has to be firm enough to provide an appropriate degree of
proprioceptive input to stimulate sucking.
• A soft nipple tends to have a higher flow rate than a firmer nipple and thus requires less
compression effort and suction.
• The degree of pliability must match the infant’s strength of sucking and provide an appropriate
flow rate to allow the baby to coordinate the suck–swallow–breathe sequence.
• For example, nipples designed for premature infants (“preemie” nipples) or the specialized Pigeon
nipple® may be used for infants with cleft palate because they are very soft and pliable.

• A standard nipple can also be softened through boiling.

SHAPE

• The shape of the nipple has to facilitate adequate contact between

the nipple and the tongue for compression.
• The shape also should enhance the oral-motor patterns desired
during sucking
• Nipple shapes basically fall into two categories: traditional nipples
and orthodontic nipples
• The traditional nipple has a straight configuration, which gradually
tapers to a flared base.
• The orthodontic nipple has a broad, flat bulb-type end that flares to a
large, wide base.
• This style is perhaps best known as the NUK® nipple; however, many
manufacturers, including Gerber and Playtex, now make nipples
shaped similarly to the original NUK style.
• These nipples are generally advantageous for infants with cleft lip and
alveolus as they may conform to the cleft and reduce air leakage
while sucking.
LENGTH
• The length of the nipple should be based on what is needed to
provide adequate contact between the nipple and tongue.
• Nipple length can vary substantially with regard to the type of base
and the distance from the tip to the base, especially for those nipples
that have tapered bases.
• The strength of the infant’s suck, the degree of lip closure around the
nipple, and the control the feeder provides to maintain the nipple
position are other factors that should be considered.
HOLE TYPE
• Both the type and the size of the nipple hole determine flow rate
• Nipples include either a standard round hole or a crosscut hole, which
is basically an “X” configuration.
• A standard nipple hole can be modified to a crosscut with a single-
edged sterile razor blade.
• The crosscut configuration allows the milk to flow only when the infant
compresses the nipple, which makes the crosscut open.
• This allows the infant to control the milk flow with the normal rhythm
of sucking and swallowing and prevents the infant from getting too
much liquid, which can cause problems with coordinating sucking,
swallowing, and airway protection during feeding.
HOLE SIZE

• The size of the nipple hole can vary widely across different styles of
nipples.
• A nipple with a traditional hole should have an opening that is large
enough so that when the bottle is held upside down, the liquid drips
out but does not run out rapidly.
• A standard nipple can be enlarged or slit to increase the fluid flow
rate; however, the increased flow may cause the infant to have
difficulty with coordination of swallowing and breathing.
 COMMERCIALLY AVAILABLE NIPPLES AND BOTTLES
1.Orthodontic Nipple:
• This style nipple is wide based and has a fast flow rate.
• It can be used with a squeeze bottle for infants who show good ability to rapidly
coordinate the suck–swallow–breath sequence.

2. Pigeon Nipple® (Pigeon Corporation, Chuo-ku, Tokyo, Japan):

• The pigeon nipple® has a thick side that is placed against the roof of the mouth and a thin
side that enables the infant to express milk through a suckling motion.
• Due to its thin wall, it does not vent rapidly and therefore has a tendency to collapse.
• The pigeon nipple® can be used with any type of bottle, including bottles designed to
prevent excessive air intake, such as the Playtex Ventair® or Dr. Brown® bottle.
• The feeder can squeeze the bottle to assist with fluid flow.
3. Ross® Premature Nipple:
• This nipple is smaller, thinner, and softer than a standard nipple, making suction
easier.
• This is a fast- flow nipple that should be used only by those infants who have
demonstrated tolerance for the increased respiratory effort associated with fast fluid
flow.

4. Standard Traditional Nipple:

• This nipple (widely available) has a narrow base and has been shown to be effective
when used in conjunction with a squeeze bottle while feeding infants who have
demonstrated the ability to develop some suction independently.
• A slight enlargement of the nipple hole may be necessary.
 FLEXIBLE BOTTLES AND ASSISTED FLUID DELIVERY

Flexible Bottles and Assisted Fluid Delivery

• Specialized bottle and nipple systems are commercially available for infants with
cleft palatethat allows the feeder to express the milk as needed by squeezing the
bottle.
• This helps the infant to conserve energy and reduce calorie expenditure during
feeding.
• Even use of a simple plastic bottle liner in conjunction with a variety of nipples can
be effective for providing assistance with breast milk or formula flow.
• The feeder can apply intermittent pressure to the liner to push fluid out as the
infant compresses the nipple
• Pushing the air out of the liner before the feeding reduces excess intake of air.
• Regardless of the device used, the pressure applied to a squeeze bottle, plastic
liner, or nipple reservoir must be in rhythm with the infant’s suck and swallow
efforts to ensure that the infant does not become disco-ordinated with the suck–
swallow–breathe synchrony.

• An inappropriately rapid rate or continuous squeezing will result in an increased

rate of swallowing, which will decrease available breathing time.

• This may cause the infant to have problems maintaining an appropriate

respiratory rate and could cause aspiration into the airway.
SPECIALIZED NIPPLE AND BOTTLE SYSTEMS

1. Mead Johnson Cleft Lip/Palate Nurser (Mead Johnson Nutrition,

Glenview, Illinois):

• This is a soft bottle that is easily squeezed and also has a long, soft,
crosscut nipple.
• A standard nipple will also fit onto the Mead Johnson bottle.
• The caregiver can help to regulate the liquid through assistive squeezing.
• The use of either the crosscut nipple or a standard nipple with a
modified hole depends on the oral-motor skills of the infant.
2. Ross Cleft Palate Nurser:

• This bottle has a long, thin nipple that requires assistive squeezing to
deliver milk to the posterior part of the oral cavity.
• The long length may cause gagging in some infants.
• In addition, the small diameter of this nipple does not facilitate
tongue movements for sucking.
• Fluid flow is steady and rapid, but this can be difficult for infants who
cannot tolerate a rapid flow rate.
• In fact, the rapid rate could result in disorganization of airway
protection and possible aspiration.
3. SpecialNeeds® Feeder (formerly the Haberman and Mini-Haberman FeederTM):

• This specialized nipple and bottle system is designed to allow the release of milk
through the infant’s compressions alone, without the need for suction.
• There is a soft nipple that is filled with breast milk or formula.
• The nipple has a one-way valve that limits the intake of air.
• It also prevents rapid fluid flow because it only opens when the infant sucks.
• In addition, the nipple has raised markings that indicate the position of the slit valve in
the infant’s mouth; the longer the raised mark, the greater the flow.
• To adjust the rate of flow, the feeder is turned so that the required line (minimum,
medium, or maximum) points toward the baby’nose
• Light finger pressure can be applied on the nipple to assist with fluid flow as needed.
• The Mini SpecialNeeds® Feeder is a smaller version of the feeder that is designed for
smaller or premature babies with cleft palate or other special feeding problems.
4. Medela SoftCup® Feeder and Bottle:

• The SoftCup Feeder is designed to be used with the Medela 80 ml

polypropylene bottle.
• Other bottles can be used, but some leakage may occur in the collar
area.
• The SoftCup Feeder does not require the infant to actively suck
because fluid is delivered via a small flexible cup-like reservoir.
• The feeder controls the flow rate.
POSITIONING THE INFANT
• Placing the infant in a horizontal position during feeding is a common mistake.
• This position increases the potential for nasal regurgitation, coughing, and
sneezing.
• In addition, there may be flooding of the Eustachian tube and reflux into the
middle ear, causing middle ear effusion.
• A semi-upright position (of at least 60 degrees) is best for feeding because it
facilitates control of jaw, cheek, lip, and tongue movements for sucking and
swallowing coordination
• This position also allows gravity to assist with swallowing, and it helps to prevent
nasal regurgitation
• The baby’s head should be supported in a neutral anterior–posterior alignment
with the shoulders symmetric and forward, trunk in midline, and the hips flexed.
• The use of a bottle with an angled neck provides a downward flow of milk and
simplifies feeding the infant in upright positioning.
POSITIONING THE NIPPLE

• Finding the optimal intraoral position for the nipple is critical for
feeding success.
• The difference in nipple placement of only a few millimeters can affect
feeding success
• It is important to position the nipple under the bone of the palate to
provide a base for nipple compression.
• Using the right nipple size and shape, based on the patient’s cleft,
facilitates proper intraoral positioning.
PACING INTAKE

• The feeder should carefully pace the flow rate during feeding by providing fluid in
rhythm with the infant’s sucking compressions
• Flow can be regulated by tilting the nipple slightly upward or partially removing
the nipple from the oral cavity.
• The feeder should modify the pace when there are signs of stress, including eye
widening, changes in facial expression, a decrease in alertness, or subtle
avoidance of feeding.
• If the infant begins feeding rapidly and then shows signs of swallowing
disorganization, such as coughing or choking, the feeder should slow the pace of
fluid presentation.
• If the infant begins to slow down or stop sucking during the feeding, this
suggests that the infant has tired and needs a pause before continuing
feeding.
• The infant may show signs of excessive air intake and need a pause in
feeding to allow burping.
• Although the feeder must be able to deliver enough nutrition before the
infant becomes tired, allowing enough time to facilitate safe feeding is vital
to feeding success.
• Consulting a dietitian about the use of a higher calorie formula
preparation with a lower volume intake requirement will allow the infant
to spend less time feeding and to use a slower pace of intake while still
ingesting an adequate amount of calories for growth
ORAL FACILITATION STRATEGIES

• As a result of an oral-motor/feeding assessment, oral facilitation techniques, such

as jaw and cheek support, may be recommended to increase the infant’s oral
control during feeding

• The type of bottle used can support the use of certain strategies to increase oral
control

• For example, the use of a small diameter bottle, such as the infant Volu-Feed
DisposableTM Nurser (60 ml capacity), allows the feeder to use hand and finger
positioning to facilitate support to the jaw and cheeks during feeding
PREVENTING EXCESSIVE AIR INTAKE

• Because the infant with a cleft palate takes in an increased amount of

air during feeding, the feeder may need to increase the frequency of
burping

• As a general rule of thumb, the infant should be burped after every

ounce to prevent the discomfort associated with the intake of air that
inevitably occurs with each feeding.
MANAGING NASAL REGURGITATION

• Infants with a cleft palate often experience nasal regurgitation.

• When this occurs, the feeder should stop and allow the infant time to
cough or sneeze to clear the nasal passage.
• If nasal regurgitation occurs frequently during feeding, the caregiver
should ensure that the infant is in an upright position that allows
gravity to assist with downward flow of liquid.
• If coughing occurs frequently in conjunction with the nasal
regurgitation, the feeder should consider using a slower flow nipple.
• Also, slowing the presentation of fluid helps to reduce the nasal
regurgitation.
CONSISTENCY OF METHOD

• Consistency in how the baby is fed contributes to overall feeding

success.

• The baby should be fed in the same position, with the same nipple
and bottle and with the same technique during each feeding.

• The feeder must learn how to easily position the baby, how much of
an assistive squeeze is required, how long to keep feeding, how often
to burp the baby, and how to read the baby’s cues related to feeding.
• If several different nipples and bottles are intermittently tried, and
varying positions and different rates of assistive squeezing by a range
of feeders are used, it is almost certain that feeding confusion and a
poor feeding outcome will result.

• Fortunately, normal maturation and increased feeding experience of

the infant and caregiver helps to gradually improve the feeding
process in spite of variations in method which may occur.
USE OF FEEDING OBTURATORS

• A feeding obturator a prosthetic appliance that can be used in the

first few months of life to assist the infant with cleft palate in feeding

• It is retained in the crevices of the cleft and provides a partial seal

between the mouth and the nasal cavity.

• The obturator keeps the tongue from resting inside the cleft, and it
provides a solid surface so that the tongue can achieve com- pression
of the nipple against the plate.
• A pediatric dentist or prosthodontist is the professional who can construct the
feeding appliance and check it frequently so that it can be modified periodically
as the child grows.

• There are differing views regarding the use of feeding obturators for infants with
cleft palate

• Some craniofacial centers use feeding obturators routinely, believing that the
appliance improves the ability of the infant to compress the nipple , which can
lead to better weight gain

• Obturators do not improve the generation of negative pressure

• Most craniofacial centers do not routinely use these appliances because they feel that
with modifications of the nipple or bottle, correct positioning, and appropriate feeding
techniques, the obturator simply is not necessary.

• In fact, research has shown on significant difference in feeding abilities for infants fitted
with a maxillary plate compared to those without a plate

• In addition, there are certain disadvantages to using an obturator, including the expense
and need for periodic replacement to accommodate growth.

• Retention of the obturator can be challenging because the infant has no teeth to stabilize
it.

• Finally, there can be irritation of the oral tissues, and the obturator can cause hygiene
concerns.
Oral Hygiene
• With all infants, it is important to maintain good oral hygiene.

• Although the mouths of infants tend to be self-cleaning, it is

particularly important to attend to oral hygiene if the infant has a
cleft.
• This is because the open cleft allows fluid to enter the cleft area and
nose, even with an upright feeding position.

• The fluid can mix with mucous secretions from the mouth and nose
and form a hard crust, which can become infected, causing irritation
and soreness.
• For good oral hygiene, the caregiver should cleanse the cleft and
surrounding areas following feedings.

• This can be done by gently wiping the mucous membrane in the oral cavity
using a washcloth, a small piece of gauze, or a toothette®, which is soft and
spongy.

• These can be moistened with plain water or water with hydrogen peroxide.

• Although the caregiver should be careful not to cause discomfort or injury

during the cleansing process, it should be remembered that the cleft is not
a wound, and therefore it will not be sore to touch during gentle cleansing.
Transitioning to a Cup

• Most infants are ready to transition to the cup by 8 or 9 months of age, although
some show readiness as early as 6 to 8 months of age
• The initial response to the cup is generally sucking, with tongue protrusion and
loss of liquid from the mouth.
• The infant’s oral skills for cup drinking gradually increase so that she is able to
take one or two sip-swallows as the caregiver holds the cup.
• It is often beneficial initially to use a slightly thickened liquid to slow the liquid
flow during early cup training.
• There are many cup options for weaning the infant from a bottle to a cup.
Selecting a cup that does not promote continued sucking is important.
• A small open cup without a spout, straw, or valve is generally the best option for
transitioning away from sucking and toward true cup-drinking skills.
• Using the Medela SoftCup® Feeder is an alternative during the transitional period

• Milk or breast milk is delivered through a narrow, flexible cup reservoir, facilitating
development of oral skills for handling small amounts of liquid from a cup.

• Most surgeons recommend weaning the infant from the bottle before palate repair
because sucking may cause a breakdown of the repair.

• Therefore, weaning an infant with cleft palate from bottle to cup drinking should be
done sometime before 9 or 10 months of age, which is the typical time for the palate
repair.
Introduction of Solid Foods

• Solid foods can be introduced to the baby with an unrepaired cleft palate at the
same time as with any infant.
• The timing of solid food introduction is usually dependent on the preferences of
the pediatrician and parent.
• Usually, rice cereals and strained foods are presented around 6 months of age.
• The baby will respond to the spoon-feedings at first by suckling.
• This may result in food being pushed into the nasal cavity.
• As the baby becomes more skilled in eating and begins to use more mature
tongue patterns, this occurs less often.
• Mixing the pureed fruit with the cereal provides a degree of thickness that can
reduce the tendency for nasal reflux.
• The feeder can assist the transition to solids by using appropriate positioning,
small boluses, and a slow pace, and by alternating food with liquid to assist with
clearance
• The slow rate of presentation is particularly important because it allows the baby
to gradually learn how to direct the food around the area of the cleft.
• The feeder should watch the baby for cues to know when to present the next
bite.
• The baby’s cues include leaning forward or opening the mouth in anticipation of
the spoon.
• Placing the spoon onto the baby’s tongue encourages the baby to
close his or her lips on the spoon and stimulate active tongue
movements to transfer the food for swallowing.

• This is especially important following the surgery for cleft lip repair.

• Rapid spoon-feeding or presentation of large spoonfuls can cause

more frequent nasal regurgitation as well as disorganized swallowing.
• The transition to more textured foods, including easily dissolvable and later bite-
sized, easy-to-manage table foods, also can be introduced in the same sequence
as for other children.

• Foods should initially be offered, with assistance of the feeder, with the baby
seated in an upright position to reduce nasal regurgitation.

• When developmentally appropriate, the baby should be provided with guided

opportunities to practice finger feeding with small pieces of crunchy but very
easily dissolvable solid foods such as toddler crackers and cookies, as well as soft,
easy-to-manage food items such as bite-sized pieces of soft fruits, shredded
cheese, or pasta pieces
• This helps to develop independence with self- feeding, gives the baby
practice with the tongue movements around the cleft, and increases
the efficiency of skills needed for mastication.
• If food is observed passing from the nose or becomes lodged in the
area of the cleft, it should be removed gently with either a finger or a
swab.
• Foods that are acidic or spicy should be avoided because the lining of
the nose is particularly sensitive to this kind of food.
• As the baby’s oral-motor skills become more proficient, the baby will
learn to efficiently manage transfer of solids for swallowing.
 Interdisciplinary Feeding Team Evaluation

• In severe cases, an evaluation by a team of feeding specialists is indicated.

• Typically, an interdisciplinary feeding team consists of a core group of
medical professionals that may include a gastroenterologist, nutritionist,
nurse, speech-language pathologist, occupational therapist, behavioral
psychologist, otolaryngologist, pulmonologist, and consulting radiologist.
• The composition of interdisciplinary feeding teams varies among centers
• With the coordinated assessment of these specialists, management and
long-term planning for treatment of complicated feeding problems can be
accomplished.
Alternative Feeding Methods for Severe Cases

• When the feeding problem is not easily resolved with modifications of

the nipple or bottle, supplemental feeding through an orogastric or
nasogastric (NG) tube may be required for a period of time.
• During this time period, treatment strategies for improving oral-
motor function for feeding are provided, as appropriate.
• If the feeding problems persist for a period of time and cannot be
adequately resolved with other measures, gastrostomy (G) tube
feeding may be considered.
• This is particularly indicated if the infant presents with abnormal oral
reflexes or shows poor ability to coordinate airway protection with
swallowing during a videofluoroscopic or endoscopic swallowing
study.
• A gastrostomy tube is inserted in the stomach through a surgical
procedure and may remain in place for an extended period of time.
• The tube is removed if and when the infant shows signs of
considerable progress with oral feeding skill development and oral
intake volume