Cleft Lip and Palate

By Barbara Wilson-Clay
 
Clefts of the lip and palate are birth defects that occur early in pregnancy, sometimes even before a woman knows she is pregnant. No one knows exactly what causes clefts. Some evidence suggests that environmental factors may combine with genetic factors to increase the risk of cleft defects. For example, studies have identified excessive maternal intake of Vitamin A, cigarette smoking, and alcohol consumption during the first trimester with increased risk of clefts defects.
 
Clefts form during fetal development when the sides of the upper lip or the roof of the mouth (the palate) fail to grow together. An isolated cleft lip may not significantly affect feeding. Some infants may have an isolated cleft of the hard or soft palates. Palate clefts pose significant feeding challenges. Sometimes a complete cleft forms. In such cases, the nose, upper lip, hard and soft palates all are affected. Cleft defects run in families. Once a couple gives birth to an infant with a cleft, genetic counseling helps assess risk factors for future children.
 
The good news is that cleft defects are correctable with surgery. Most major cities have a cleft palate team that includes plastic surgeons, speech pathologists, a children’s dentist, and other specialists who are trained to support the baby and the family. The timing of surgical repair varies. Traditionally, repair of the lip takes place when the baby is 3-6 months old, with palate surgery scheduled at 9-18 months. Some surgical teams now repair the lip during the first month after birth, and the palate around 3 months. A number of websites address craniofacial issues and offer parents a wealth of information.

Parents want to know if breastfeeding is possible for infants with cleft defects. This varies. A cleft of the lip is not usually a problem for breastfeeding. A mother can use her finger tip or draw up some of her breast tissue to close the gap in the lip to help the baby create a seal. Feeding is more challenging when infants have a cleft of the palate. Because of the hole in the roof of the mouth, the baby can’t seal the oral cavity or create suction. To complicate things, food can enter the nasal cavity through the cleft. Sometimes a soft plastic device called an obturator can be fitted by a member of the cleft palate team. The device covers the cleft to form an artificial intact palate. Such devices help some infants with cleft palate breastfeed, at least partially. While all infants benefit from direct sucking at the breast, infants with cleft palate typically tire before obtaining full feedings. They require supplemental feeds, ideally with their mother’s pumped milk.

Human milk contains anti-inflammatory properties that prevent irritation of the exposed nasal tissue. Infants with clefts of the palate who are formula-fed have chronic respiratory and ear infections because of irritation from the foreign proteins in formula. Babies who drink only mother’s milk are healthier, have fewer respiratory infections, and have stronger immune systems. This often means that they can tolerate surgery earlier. Babies may breastfeed immediately following repair for cleft lip, although some infants refuse until more recovered from surgery. 

Infants with cleft defects often require special help with feeding. Medela offers several products to assist parents in making sure their baby has the protection of exclusive human milk feeds. The SpecialNeedsFeeder is a special bottle that doesn’t require suction in order for the milk to flow. The baby ‘milks’ this nipple with the tongue and jaws. Rental grade electric pumps protect the milk supply and provide breast milk supplements for the baby. The SNS™ can be used to encourage the baby to keep trying at the breast. Remember, as the baby grows stronger, breastfeeding ability will improve. If your baby has a cleft defect, contact an IBCLC in your area who can help you with milk supply, latch, and other feeding concerns.

 
 
References:
 
Darzi M, Chowdri N, Bhat M. Breastfeeding or spoon feeding after cleft lip repair: a prospective, randomized study. Br J Plast Surg 1996; 49(1):24-26.
 
Goldman A,  Thorpe L,  Goldblum R. Anti-inflammatory properties of human milk. Acta Paediatrica Scandia 1986; 75:689-693.
 
Garcez L, Giugliani E. Population-based study on the practice of breastfeeding in children born with cleft lip and palate. Cleft Palate Craniofac J 2005; 42(6):687-93.
 
Kogo M, Okada G. Ishii S, et al. Breastfeeding for cleft lip and palate patients, using the Hotz-type plate. Cleft Palate Craniofac J 1997; 34(4):351-353.
 
Lorente C, Cordier S, Goujard J, et al. Tobacco and alcohol use during pregnancy and risk of oral clefts. Occupational Exposure and Congenital Malformation Working Group, Am J Public Health 2000; 90(3):415-419.
 
Merritt L. Part 2. Physical assessment of the infant with cleft lip and/or palate. Adv Neonatal Care 2005; 5(3):125-134.
 
Olsen B, Vach W, Knudsen VK, et al. Oral clefts and life style factors – a case cohort study based on prospective Danish data. Eur J Epidemiol 2007, 22(3):173-181.
 
Paradise J, Elster B,  Tan L. Evidence in infants with cleft palate that breast milk protects against otitis media. Pediatrics 1994; 94(6):853-859.
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