Feeding an Infant with a Cleft Lip or Palate

Babies born with cleft lip and/or palate need to feed efficiently to grow and thrive. If a baby has a cleft lip only and not a cleft palate, he/she should be able to use a standard bottle/nipple or breastfeed successfully. Babies born with a cleft lip and palate or cleft palate only will likely require use of a specialty bottle system to allow for efficient extraction of expressed breast milk or formula. Babies with cleft palate are at risk for poor weight gain without use of a specialty bottle system. Rare success has been documented with breastfeeding of infants with cleft of the soft and/or hard palate.

Le Leche League International cautions, “Except in rare cases, a baby with a cleft palate cannot get all the milk he needs by breastfeeding alone. An opening in the palate makes it impossible for the baby to seal off his mouth and make the suction typically used to keep the breast (or bottle) in place and pull the nipple to the back of his mouth. Over time, lactation consultants have found that feeding exclusively at the breast is a difficult goal for all but a few babies with uncorrected cleft palates."

At UPMC Children’s Hospital of Pittsburgh’s Cleft-Craniofacial Center, a speech-language pathologist will evaluate your baby's feeding and swallowing skills at an initial visit. At that time, a specialty bottle may be trialed if not being used already, and special feeding techniques may be discussed with the baby's parents. We will work with you to promote feeding success and reduce stress surrounding your baby's feeding.

General Feeding Suggestions for Success

Start with a calm environment in a comfortable chair.
Feed your baby in a semi-upright position. Support your baby, allowing for neutral/stable positioning of the head and neck.
In general, your baby should be ready to feed:
- Every two to three hours as a newborn.
- Every three to four hours as they get a little older.
Use a specialty bottle recommended by the Cleft-Craniofacial speech-language pathologist (feeding specialist).
Babies should be able to consume their goal amount of formula or expressed breast milk within 30 minutes without any signs or symptoms of aspiration (coughing, choking, congestion, wet vocal quality, etc.). If feedings last longer than 30 minutes, your baby is likely burning too much energy to allow for good weight gain and growth.
If your baby has a unilateral (one-sided) cleft lip and palate, it is sometimes helpful to position the nipple on the “non-cleft" side to help with better compression of the nipple and improved extraction of milk.
Burp your baby at least halfway through a feeding and when the feeding is finished. Babies with a cleft palate tend to take in more air while feeding. Watch for cues that your baby needs to burp (pulling away from nipple, squirming, body stiffening, general signs of discomfort, etc.).
It is normal for a baby with a cleft palate or cleft lip and palate to have some milk come out through their nose or for the baby to have nasal congestion during feeding.

Specialty Bottle Types

The bottles listed below are available for you at our Center. Please see the description for each bottle system to learn about each. Our speech pathologists will make a recommendation for which bottle and nipple system will work best for your child based on type of cleft they have. These recommendations are based on our clinical use and experience here at UPMC Children's Hospital.

Features:

Y-cut nipple allows for adequate flow of milk.
One-way valve allows for extraction of milk upon compression of the nipple.
Large and small nipple choices.

Instructions:

Fill bottle with goal volume of liquid. Place white one-way valve flat (heart) side up toward the nipple in the base of the nipple. Place the nipple + valve in the ring and secure onto the bottle.
Squeeze the nipple and flip the bottle over. Gently release pressure on nipple to allow it to fill up with liquid.
Position baby semi-upright for feeding.
Orient the notch (air vent) on the nipple with your baby's nose.
If the large nipple seems too fast or overwhelming, reduce the flow by switching to the smaller nipple or by tightening the nipple ring.
Feedings should take no longer than 30 minutes.

Precautions:

If your baby begins exhibiting signs and symptoms of aspiration such as: congestion in the chest, coughing, gagging, choking, wet/noisy breathing, or a wet/gurgly vocal quality with feeding, please contact your Cleft-Craniofacial team.


Bottle	Y-cut nipple with air vent	Valve (heart side up)

Valve in nipple heart side up	Nipple ring

Features:

Used frequently with babies born with Pierre Robin sequence and cleft palate only but can also be used with babies who have cleft lip and palate.
Has three flow rates (slow, moderate, and fast) with corresponding lines on the nipple that are oriented with the nose.
Parent provides pressure on the nipple while infant is actively feeding to allow for adequate extraction.
One-way valve allows for extraction of milk upon compression of the nipple.

Instructions:

Fill bottle with goal volume of liquid. Place one-way valve on top of the bottle with the white side facing up toward the nipple. Place the nipple on top and secure the ring tightly.
Squeeze the nipple and flip the bottle over. Gently release pressure on nipple to allow it to fill up with liquid.
Position baby semi-upright for feeding.
Orient the flow line on the nipple recommended by your Cleft Team's speech-language pathologist (SLP) with baby's nose. Once she latches or begins munching, provide constant pressure on the nipple with your fingers. Your SLP will help you determine how much pressure is adequate and safe for your baby.
Stop providing pressure during breathing breaks or if baby becomes overwhelmed (wide eyes, coughing, pulling away from the nipple, etc.).
If recommended flow and pressure seem too fast or overwhelming, reduce the flow and/or pressure, while still making sure that baby is able to extract enough milk.
Feedings should take no longer than 30 minutes.

Precautions:


Nipple with flow lines	Valve (white side up)	Nipple & valve in ring

Bottle	Valve (white side up)	Valve on top of bottle

Bottle assembled

Features:

Frequently used system.
Multiple flow rates for nipples ranging from “Ultra Premie” to “Level 4 - Fast Flow.” The most appropriate nipple flow rate should be assessed by the speech pathologist.
One-way valve allows for extraction of milk upon compression of the nipple.

Instructions:

Fill bottle with goal volume of liquid. Place blue one-way valve flat side up toward the nipple in the base of the nipple. Position the blue vent insert into the bottle and then place the nipple + valve in the ring and secure onto the bottle.
Squeeze the nipple and flip the bottle over. Gently release pressure on nipple to allow it to fill up with liquid.
Position baby semi-upright for feeding.
Utilize level nipple that is recommended by your Cleft-Craniofacial Team's speech-language pathologist (SLP).
Feedings should take no longer than 30 minutes.

Precautions:


Bottle	Valve (flat side up)	Nipple in ring

Nipple & valve in ring	Blue vent insert	Blue vent insert in bottle

Bottle assembled

Features:

Used less frequently.
Typically recommended for babies who require thickened formula with oatmeal cereal due to:

Swallowing dysfunction.
Aspiration of thin formula.
Breast milk observed upon modified barium swallow study.

Squeezable bottle with a crosscut nipple which can be switched to other nipple types.

Instructions:

Fill bottle with goal volume of liquid.
Place the crosscut nipple (or other nipple that is recommended by your Cleft Team) onto the bottle, orienting it into a + position with the baby's nose.
Position baby semi-upright for feeding.
Gently pressurize the bottle by squeezing it as the infant is sucking. Amount of pressure needed for extraction may vary and be dependent on how thick the liquid is (if using this bottle for thickened liquids).
Feedings should take no longer than 30 minutes.

Precautions:

If your baby begins exhibiting signs and symptoms of aspiration such as: congestion in the chest, coughing, gagging, choking, wet/noisy respirations, or a wet/gurgly vocal quality with feeding, please contact your Cleft-Craniofacial team.

Contact the Cleft-Craniofacial Center at UPMC Children's Hospital of Pittsburgh

Please do not hesitate to contact the Cleft-Craniofacial Center with questions about your baby's feeding or to schedule an appointment.

412-692-8650