Clef Palates and Feeding Nipples Cleft palate is a congenital deformity that causes numerous problems that represents special challenges to the medical community because special care is needed for patients with cleft palate (Biavati pp). Some of the developmental stages that may be affected include speech production, feeding, maxillofacial growth and dentition (Biavati pp). A team of specialists, such as otolaryngologists, oromaxillofacial surgeons, plastic surgeons, nutritionists, and speech pathologists, work together to improve the quality of life for patients with cleft palate (Biavati pp). Moreover, psychological effects on both the patient and the parents also need to be addressed (Biavati pp). Cleft palate deformity was described hundreds of years ago, however, even today there is no agreed-upon management algorithm that exists for patients with cleft palate (Biavati pp). As one of the most common congenital malformations, a cleft palate can be diagnosed as early as the 17th week of gestation by means of ultrasonography, and although, numerous studies exist, the exact environmental and genetic factors that play of role are still unknown (Biavati pp). Syndromic clefting may result from aberrant chromosomes (e.g., the trisomies), mutant genes or environmental teratogens (e.g., alcohol, thalidomide), and in the case of nonsyndromic clefting, the cause usually remains undetermined (Yetter pp).

Orofacial clefts (cleft lip, cleft lip and palate, cleft palate alone, as well as median, lateral (transversal), oblique facial clefts) are among the most common congenital anomalies, and occur in approximately one case in every 500 births, requiring several surgical procedures and complex medical treatments (Tolarova pp). The correct diagnosis is important for treatment, for further genetic and etiopathological studies, and for preventive measure correctly targeting the category of preventable orofacial clefts (Tolarova pp). The group of orofacial cleft anomalies is heterogeneous, and comprises typical orofacial clefts, such as cleft lip, cleft palate and lip, and cleft palate, and atypical clefts, including median, transversal, oblique, and other Tessier types of facial clefts (Tolarova pp). Typical and atypical clefts can "both occur as an isolated anomaly, as part of a sequence of a primary defect, or as a multiple congenital anomaly (Tolarova pp).

Clefts are classified under these three categories:

1) Unilateral vs. Bilateral

Unilateral - the cleft is on one side of the nose

Bilateral - the cleft is on both sides of the nose

2) Complete vs. Incomplete: The extent of the cleft

3) Primary vs. Secondary Palate

(Type pp).

The Primary Palate refers to the lip and gum ridge, and in normal development, it would close at the 7th gestational week in embryonic development, and is referred to as cleft lip (Type pp). The Secondary Palate refers to the hard and soft palate and the uvula, and in normal development, it would close between the 10th and 12th gestational week during pregnancy, and is referred to as cleft palate (Type pp).

There are two types of clefts:

1) Submucous Cleft -The palate appears normal, but the tissue covering the palate hides a cleft of the hard palate, soft palate, or both.

2) Rare orofacial Clefts

A cleft of the midline of the lower jaw

Lateral or horizontal cleft (from the corner of the mouth to the ear)

Naso-ocular cleft (from nose to eye)

Midline cleft of the upper lip or alveolar ridge

(Type pp).

The incidence of cleft palate with or without cleft lip is one case in 1,000 live births (Biavati pp). The incidence of cleft palate varies by race, with the highest rate among Native Americans, at 3.6 cases per 1,000 live births, and the lowest rate among African-Americans, with 0.3 cases per 1,000 births (Biavati pp). Among the total number of clefts, 20% are an isolated cleft lip, with 18% unilateral and 2% bilateral, 50% are a cleft lip and palate, with 38% unilateral and 12% bilateral, and 30% are a cleft palate...

Submucous cleft palate is more common, with an incidence of one case in 1,200 -- 2,000 patients (Biavati pp). Bifid uvula occurs in one of 80 patients and often occurs in isolation, with no clefting of the palatal muscles (Biavati pp). No racial predilection exists for cleft palate, with an equal incidence among all races, and although cleft lip and palate together occur more commonly in males, isolated cleft palate is more common in females (Biavati pp).
Generally, infants with a cleft of the lip only have fewer feeding difficulties than those with clefts of the lip and palate, or clefts of the palate only (Feeding2 pp). Usually a wide-based nipple or the soft tissue of the breast will compensate for the open portion of the lip, however, when the palate (the natural barrier between the mouth and the nose) is shorter than normal or partially or completely cleft, the baby will have difficulty creating and maintaining suction (Feeding2 pp).

The baby may have difficulty keeping the nipple in the mouth and may not be able to compress the nipple enough to extract the milk in an efficient manner (Feeding2 pp).

A cleft feeding nipple must have an opening that is large enough to allow the formula to flow easily to prevent sucking fatigue, yet so large as to cause choking, and nipples must be soft and compressible, allowing liquid to flow easily (Biavati pp). Often nipples designed for premature infants work well, although the hole in the nipple may need to be enlarged by creating an X-shaped opening to help increase the milk flow (Biavati pp).

A squeeze bottle or plastic bottle liner is another way to of increasing the flow of milk and conserving the infant's energy (Feeding1 pp). When using a plastic bottle liner, push all the air out of the liner before beginning a feeding, then apply intermittent pressure to the liner as the baby squeezes the nipple (Feeding1 pp). This method minimizes the amount of air the infant swallows and eases sucking (Feeding1 pp). Squeeze bottles, also called assisted delivery systems, for children born with cleft palate include the Mead Johnson Cleft Palate Nurser, the Haberman Feeder, and the Pigeon Bottle (Feeding1 pp).

The Mead-Johnson Cleft Palate Nurser is the most commonly used bottle and nipple for infants with clefts (Biavati pp). The nipple is long and soft with a crosscut hole attached to a flexible plastic bottle that can be squeezed to increase the liquid flow (Biavati pp). The bottle can be squeezed in conjunction with the baby's sucking/breathing rhythm to assist with swallowing (Biavati pp). Other devices include the Ross Cleft Palate Nurser, manufactured by Ross Laboratories, that allows a steady flow of liquid with minimal sucking, and moreover, the nipple can be shortened to individualize the flow speed (Biavati pp). In cases of severe feeding problems, the Haberman Feeder offers an alternative to spoons, enlarged and/or extra holes in bottle nipples, and nasogastric tubes (Haberman pp). Manufactured by Medela, the Haberman Feeder provides three flow rates determined by the position of the nipple in the oral cavity (Biavati pp). The nipple is larger and longer than most nipples and can be squeezed gently to help extract the liquid, and a one-way valve separates the nipple from the bottle to facilitate flow (Biavati pp). Air is squeezed out of the nipple before the feeding begins, and the valve allows the nipple to refill with liquid as it is sucked or squeezed, thus, decreasing the infant's overall intake of air (Biavati pp). This nipple comes in two sizes, regular, which is standard length, and mini, which is shorter and equivalent to a preemie nipple (Feeding1 pp). The placement of the nipple within the oral cavity is very important (Biavati pp). Optimally, "the nipple should be positioned to the back and along the side of the mouth on the noncleft side (in the case of unilateral cleft palate)...Supporting the cheek by gently squeezing the cheeks together around the nipple may also improve oral suction" (Biavati pp).

Immediately following the surgery to repair a cleft…