Professional

When a neonate with a cleft is born, a pediatrician has 3 major concerns:

• Risk of aspiration because of communication between oral and nasal cavities
• Airway obstruction (in addition to sequelae of aspiration, especially in Robin sequence in which the cleft palate [CP] is combined with micrognathia and the tongue has a normal size)
• Difficulties with feeding of a child with a cleft and nasal regurgitation

These 3 factors are influenced by the presence of other major or minor anomalies that may, in association with a cleft, represent 1 of 300 known cleft syndromes. Therefore, a neonate with an orofacial cleft should be seen by a medical geneticist as soon as possible.

As with any other medical condition, each case is different. A child with a severe cleft may do very well, whereas a child with a much less severe condition may experience many problems. An individual approach is necessary; however, several major rules apply to every neonate born with a cleft.

A pediatrician/neonatologist is usually the first person to take care of a neonate born with a cleft and the first to talk to the parents. As soon as possible, refer each baby born with orofacial cleft to the cleft palate or craniofacial center, where each specialist evaluates the baby, delineates the best management options and treatment plan, and continuously revises individual procedures and treatment during follow- up visits.

Feeding an infant with a cleft

The vast majority of children with cleft lip and palate (CLP) anomalies are born with a normal birth weight. However, because of feeding and other difficulties mentioned above, the most common problem the pediatrician has to deal with is insufficient weight gain. One of the pediatrician's main responsibilities is to closely monitor the infant's weight. Pediatricians may supervise mothers themselves or may refer them to a nutritionist, feeding specialist, experienced nurse practitioner, or other specialist.

Most children born with cleft lip and palate are unable to be breastfed. Those with cleft palate cannot produce the negative pressure necessary for suction. Mothers of children with a unilateral cleft lip may succeed with breastfeeding when the child is positioned so that the cleft in the lip is obstructed by the mother's breast.

No single right or correct method of feeding has been identified. Parents working together with the health care provider should choose the method that is best for their infant. Most infants can complete a feeding in 18-30 minutes. If more than 45 minutes is required, the infant may be working too hard and may be burning calories that should be used for weight gain. An infant who nurses or bottle feeds every 3-4 hours tends to gain weight better than an infant who feeds frequently (< 2 h apart) for short periods. Helpful hints for a parent are as follows:

• Breastfeeding an infant with a cleft.
• In a case of an isolated cleft lip, the infant typically does not experience feeding problems beyond learning how to "latch on" to the nipple at the beginning of the feeding. Infants with cleft palate must squeeze the milk out of the nipple by compressing the nipple between the tongue and whatever portion of the palate that remains.
• Massaging the breast and applying hot packs on the breast 20 minutes before nursing usually helps.
• The mother should apply pressure to the areola with her fingers to help the engorged nipple protrude. She should hold the infant in a semi-upright, straddle, or football position. She should support the breast by holding it between her thumb and middle finger, making sure that the infant's lower lip is turned out and the tongue is under the nipple.
• If the infant cannot hold onto the nipple any more, the mother can collect the remaining milk using an electrical or manual breast pump or by squeezing the breast with both hands and can finish the feeding with collected milk in a bottle.
• The mother should increase her fluid intake (drink lots of water).
• Feeding breast milk with a bottle.
• Particularly for infants with bilateral cleft lip and palate, breastfeeding is not possible.
• The mother can use a breast pump (an electric pump ensures the highest level of success). Then, she can feed the baby with a bottle (see below).
• Feeding milk formula with a bottle.
• The most appropriate milk formula should be selected by a pediatrician or feeding specialist.
• Various nipples and bottles are made specifically for infants with clefts. The goal is to find a nipple and bottle that make feeding easy for the infant and still allow ample opportunity to suck.
• A soft nipple is generally better than a hard nipple (some can be softened by boiling).
• Use a crosscut nipple to prevent choking. Any nipple can be crosscut manually using a single-edged razor blade. The crosscut is on the tongue side.
• The bottle should be squeezed and released, not continually squeezed.
• The nipple is angled to a side of the mouth, away from the cleft.
• Other recommendations.
• More upright or seated positions prevent the milk from leaking to the nose and causing the infant to choke.
• Advise the mother to stop feeding and allow the infant to cough or sneeze for a few seconds when nasal regurgitation occurs. A palatal obturator may be used.

Gaining weight and preventing aspiration and ear infections are the most important parts of caring for neonates with a cleft during their first days and weeks of life.