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Some infants with craniofacial anomalies might have difficulties coordinating an efficient suck swallow breathe pattern. One way to combat this issue is to have the feeder pace the infant by pausing the feeding to allow the infant to catch their breath.

Reference: Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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This table describes feeding deficits often  found in infants with craniofacial anomalies and ways to combats these deficits. 

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This table describes feeding deficits often  found in infants with craniofacial anomalies and ways to combats these deficits. 

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Reference: Miller, C. K., & Madhoun, L. L. (2016). Feeding and Swallowing Issues in Infants With Craniofacial Anomalies. Perspectives of the ASHA Special Interest Groups, 1(5), 13–26. https://doi.org/10.1044/persp1.SIG5.13

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It is important to note that infants with craniofacial anomalies require multiple facets of intervention. SLPs should collaborate with other healthcare providers and family members to provide the most efficient care.

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Beyond the Bottle: Interdisciplinary Cleft Feeding Care

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Purpose
The importance of individualized and comprehensive pediatric feeding management is well recognized. This type of care is especially important for children with complex medical diagnoses, such as craniofacial anomalies. While feeding therapists are often key to improving feeding outcomes, ot…

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Bottle Feeding Strategies for Infants with Cleft-Lip Palate 

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Bottle Feeding Strategies for Infants with Cleft-Lip Palate 

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Here are general positioning and feeding tips. Each baby with cleft palate/lip might need slightly different positioning or approaches.

Swaddle the infant to provide trunk stability, which supports respiration. Older infants don’t need swaddling if they are fully supported close into the feeder’s body for stability. The infant’s trunk should be elongated so they are not hunched over their diaphragm.

Position the infant close into the feeder’s body with head/shoulders high near the shoulder with hips slightly forward. Head/shoulders should not be positioned directly over hips until the infant is 4 months old, when the baby’s trunk strength can support respiration.

The infant’s nose should be up slightly in a “sniff” position. This is subtle. The head should not be extended, but a fingertip should fit between the chin and chest of a newborn, two fingertips for an older infant.

Prime the bottle nipple by placing a gloved index finger and thumb vertically along the nipple, turn the bottle upside down and release the nipple. When you bring the bottle upright, milk will remain in the nipple.

Place the bottle nipple along the palate to create maximum contact. Don’t place or allow the bottle nipple to slip into the cleft.

Facial taping initiated by the surgeon may assist in improving stability, and therefore, capacity to compress the lateral lips that may otherwise flair outward. Increased contact and pressure on the nipple by the infant with the tape present may improve feeding efficiency for some infants.

Allow full range of movement of the jaw. Infants using compression nipples compensate with pronounced use of compression to express and control the liquid bolus. Chin, jaw and/or cheek support can suppress this range of motion and can increase risk of aspiration.

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Side-lying is more appropriate for premature infants, however infants with cleft lip/palate tend to have more issues with nasopharyngeal reflux.

Feeding semi-upright to upright can limit material that enters the nasal cavity making breathing easier during PO feeding.

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Abstract

Approximately 5% of children experience difficulty with the complex coordination of sucking, swallowing and breathing required for feeding. Infants with craniofacial malformations may have anatomic and neurologic contributions to feeding problems. Examples include cleft lip and/or palate, micrognathia, maxillary hypoplasia, and pharyngeal dysfunction. Interventions may facilitate weight gain and avoid failure-to-thrive in these infants. An interdisciplinary approach to address feeding challenges in children with craniofacial differences is necessary. Positional changes, latching maneuvers, specialized feeder nipples, squeezable bottles, and cup feeding can be implemented early. Surgical intervention, including gastrostomy tube placement, tongue lip adhesion, mandibular distraction osteogenesis and tracheostomy, may be required in more severe cases.

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Feeding considerations for infants with craniofacial malformations

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Approximately 5% of children experience difficulty with the complex coordination of sucking, swallowing and breathing required for feeding. Infants with craniofacial malformations may have anatomic and neurologic contributions to feeding problems. Examples include cleft lip and/or palate, micrognathia, maxillary hypoplasia, and pharyngeal dysfunction. Interventions may facilitate weight gain and avoid failure-to-thrive in these infants.

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Typical feeding goals for infants with craniofacial anomalies include:
- Prevention of excessive air intake
- Improvement of milk flow to meet appropriate caloric intake
- Minimization of nasal regurgitation
- Using various management strategies to maintain physical stability

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Feeding Management in Infants with Craniofacial Anomalies

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The instinctual drive to gain nourishment can become complicated by structural differences,
physiologic instability and environmental influences. Infants with craniofacial anomalies
may experience significant feeding and swallowing difficulties related to the type
and severity of the anomalies prese…

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Breastfeeding is understood as the most beneficial dietary substance for newborns by most healthcare providers. Some craniofacial anomalies may not have issues with breastfeeding, such as cleft lip and cleft lip alveolus. However, other craniofacial anomalies may have more difficulty breastfeeding efficiently due to physical properties. If a caregiver wishes to attempt breastfeeding it is recommended that they seek out a lactation consultant, as well as monitor the infant's weight gain. Infants with craniofacial anomalies may not gain, or even lose weight if feeding becomes too difficult by breastfeeding.

Reference: Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Advantages:
- Controls the flow rate and can vary it throughout feeding.
- Feeder is able to manually assist with bolus extraction by squeezing if the infant does not have a strong suck.
- Other nipples can fit on this bottle

This is a soft bottle that is easily squeezed and also has a long, soft, crosscut nipple. This helps the infant to conserve energy and reduce calorie expenditure during feeding. This nurser comes with a specialized nipple, but other nipples can be used with this flexible bottle.

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Advantages:
- Wide base that is easier for infants with cleft lip and alveolus

This style of 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–breathe sequence. The wide base of this nipple may provide infants with cleft lip and alveolus because they may conform to the cleft and reduce air leakage while sucking.

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Infants with craniofacial anomalies are at risk for excessive air intake through feeding. To combat this issue, feeders may need to burp more frequently to stop over air intake. Generally, burping every ounce is recommended to prevent any discomfort.
Reference: Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Infants with a cleft palate often experience nasal regurgitation. Feeders should monitor the infant, and stop and allow time for the infant to cough or sneeze to clear out the nasal passage. Feeders should also ensure the infant is an an upright position throughout feeding if nasal regurgitation occurs frequently throughout feedings. This allow the liquid to flow downward with the use of gravity. Slow flow nipples can also be used to help with nasal regurgitation.

Reference: Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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An obturator is a prosthetic appliance that can be used by infants with cleft palate to aid 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 blocks the tongue from resting inside the cleft and provides a solid surface so that the tongue can compress the nipple against the plate for sucking.

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Reference: Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Terms Related to Dysmorphology and Craniofacial Anomalies 

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Terms Related to Dysmorphology and Craniofacial Anomalies 

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Reference: Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Terms Related to Dsymorphology and Craniofacial Anomalies 

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Terms Related to Dsymorphology and Craniofacial Anomalies 

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Reference: Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Visual representation of semi-upright feeding position

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Visual representation of semi-upright feeding position

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Some infants may require chin support to aid in proper labial seal. Proper labial seal is important to aid in adequate pressure to suck, as well as to prevent loss of material. To provide chin support feeders should place a finger under the infant's chin then apply firm pressure throughout the feeding.

References: Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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How to feed a baby with craniofacial anomalies that require cheek support

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How to feed a baby with craniofacial anomalies that require cheek support

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Hold the baby at semi-upright angle using fingers to apply firm pressure to increase seal.

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Some infants may require cheek support to aid in proper labial seal. Proper labial seal is important to aid in adequate pressure to suck, as well as to prevent loss of material. To provide cheek support feeders should place their hands under the infant's chin with the thumb on one cheek and the middle finger on the other. The feeder should then apply firm pressure, while using the index finger to hold the bottle in place.

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This video exhibits techniques to utilize while feeding infants with craniofacial anomalies. 

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This video exhibits techniques to utilize while feeding infants with craniofacial anomalies. 

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Bottle Feeding Your Baby with Cleft Lip/Palate

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Cleft Lip: Cleft lip is defined as a congenital malformation that occurs in utero during the first trimester of pregnancy and involves a fissure of the lip and sometimes the alveolus
-It can be unilateral or bilateral
-It can cause difficulty with feeding and swallowing, specifically with forming a seal around the nipple and creating suction to extract the liquids.

Cleft Palate: Cleft palate is defined as "a congenital malformation that occurs in utero during the first trimester of pregnancy and involves a fissure in the soft palate and sometimes the hard palate" (Kummer, 2014)
The baby may have:
-Nasopharyngeal reflux if there is incomplete velopharyngeal closure during swallowing
-Inability to create negative pressure for efficient sucking
-Disorganization of sucking, swallowing, and respiration during feeding may result in compromised airway protection

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Unilateral Cleft Lip, Bilateral Cleft Lip, Normal Palate

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Unilateral Cleft Lip, Bilateral Cleft Lip, Normal Palate

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Macrostomia refers to an excessively large mouth opening. This is particularly common with hemifacial microsomia, where one corner of the mouth can extend into the cheek, making the mouth opening on that particular side large and distorted in appearance Macrostomia does not cause speech problems

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Microagnathia means small mandible
-Restricted range of jaw motion during sucking
-Placement of tongue prevents nipple from making contact with the tongue body for central grooving around the nipple and efficient sucking

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Macroglossia means large tongue
Feeding can be difficult secondary to airway obstructions, lack of seal around the nipple to extract liquids, and difficulty with movement of the tongue for bolus propulsion

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Advantages:
- No suck response is required (feeder can squeeze)
- Infant can bite down to extract liquids as well
- Feeder has control of volume and amount of milk being presented
- Amount of milk the baby takes can be easily tracked and controlled
- It has three flow rates: slow, medium, and fast

Hold the feeder horizontally with a slight angle upward on the bottom of the bottle. Angle the feeder so the air that remains rises to the end of the bottle. Begin the flow of milk by gently squeezing the two pads on either side of the reservoir. Use the tip of the reservoir to stimulate the baby to open his or her mouth. Lay the rim of the reservoir on the baby's lower lip. Tip the feeder so that the milk in the reservoir is fed to the baby.

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Advantages:
- Infant can be active feeder and have control over extraction of milk
- Fits on standard bottle
- Infant does not have to suck to extract liquid; infant bites down on nipple and the one way valve does the work. The "heart" on the valve always faces the infant

The nipple has a firm side that goes toward the roof of the mouth and a softer side that goes on the tongue. Works by compression only and no squeezing is needed. A small noted at the base of the nipple serves as an air vent. This notch should be uppermost under the baby's nose when feeding.

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Advantages:
- Controls the flow rate and can vary it throughout feeding.
- Feeder is able to manually assist with bolus extraction by squeezing if the infant does not have a strong suck.

As the baby begins to suck, squeeze the bottle when the baby is sucking with a firm steady pressure. Squeeze when the baby utilizes a suck response and do not squeeze if it appears that the baby is pausing for a breath. Typically, it takes a minute to get into a good rhythm between feeder and infant.

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Kummer, A. W. (2020). Cleft palate and craniofacial conditions: A comprehensive guide to clinical management (Fourth edition). Jones & Bartlett Learning.

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Advantages:
- Infant can be active feeder and have control over extraction of milk
- Fits on standard Dr. Brown Bottle
- Infant does not have to suck extract liquids; infant bites down on nipple and one way valve does the work

Allows an infant to express a bolus with lingual movements during sucking attempts without requiring a manual bolus expression from the caregiver. The Dr. Brown's infant Paced Feeding Valve is inserted into any level Dr. Brown's standard silicone nipple to create a "compression" nipple and when used in combination with the Dr. Brown's bottle system, assist the infant in self-regulation during oral feedings.

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•Cheek support

•Chin support

•Positioning

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Typical Issues Craniofacial Anomalies Usually Face 

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Typical Issues Craniofacial Anomalies Usually Face 

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•Spillage

•Improper Seal

•Aspiration due to poor coordination