F ee ding M anagem ent in

I n f a n t s w i t h Cr a n i o f a c i a l
Anomalies
Jill M. Merrow, MA, CCC-SLP

KEYWORDS
 Cleft  Craniofacial  Feeding management  Dysphagia  Breastfeeding
 Fiberoptic endoscopic evaluation of swallowing  Modified barium swallow study
 Video swallow study

KEY POINTS
 Feeding and swallowing abilities in infants born with craniofacial anomalies show great variability.
 Difficulties with feeding mechanics in infants with cleft lip and/or palate include limited labial seal
and stability of the nipple within the oral cavity, suboptimal intraoral pressure, suction, and milk
transfer.
 Feeding difficulties with cleft lip and/or palate can be more complicated in the presence of an asso-
ciated syndrome or sequence.
 Common feeding goals for infants with craniofacial anomalies include improvement of milk flow to
meet caloric intake requirements, prevention of excessive air intake, minimalization of nasal regur-
gitation, and attainment of physiologic stability accomplished through various management
strategies.
 Instrumental assessment via fiberoptic endoscopic evaluation of swallowing and/or modified
barium swallow study can be used when appropriate to gain further objective data regarding swal-
low function and to devise strategies to promote safe feeding and swallowing.

Video content accompanies this article at http://www.facialplastic.theclinics.com.

INTRODUCTION fetal ultrasound have been found to be both

informative and anxiety-reducing to the par-
Feeding abilities in all children gain prompt ents.1,2 Specifically, Davalbhatka and Hall3
attention and demand vigilance from parents (2000), reported that antenatal counseling
immediately after birth. Whether receiving a pre- prepared parents for the birth of an infant
natal diagnosis of a craniofacial anomaly by fetal with a cleft in 85% of respondents; 89% of par-
ultrasound or receiving the diagnosis at birth, the ents felt they benefitted from knowing the
anxiety and worry can be overwhelming. The diagnosis ahead of time. Although feeding and
sooner that caregivers are educated regarding swallowing issues persist beyond infancy, this
feeding management, the sooner they feel section focuses on typical development of
empowered to adequately feed their infant. Re- infant feeding and swallowing skills, feeding dif-
facialplastic.theclinics.com

ferrals to cleft and craniofacial teams for prena- ficulties and their causes, evaluation, and
tal consultations after identification of a cleft on management.

Disclosure: The author has nothing to disclose.

State University of New York (SUNY) Upstate Medical Center, 750 East Adams Street, Syracuse, NY 13210, USA
E-mail address: [email protected]

Facial Plast Surg Clin N Am 24 (2016) 437–444

http://dx.doi.org/10.1016/j.fsc.2016.06.004
1064-7406/16/Ó 2016 Elsevier Inc. All rights reserved.
438 Merrow

Typical Feeding and Swallowing Development Swallowing Swallowing, or deglutition, is not a

synonymous term to pair with feeding. Swallowing
In a healthy, typically developing newborn, feeding
is a complex process of both volitional and reflex-
is reflexive. The rooting reflex encourages the
ive behaviors involving the action of coordinated,
newborn to find the nipple and the suck reflex to sequential motor movements from the mouth to
pull milk from the nipple. Milk is extracted from
the esophagus. Hence, there are 4 stages to swal-
the nipple by both positive and negative pressure,
lowing that are generally accepted: the oral prepa-
otherwise known as compression and suction. ratory phase, the oral phase, the pharyngeal
Milk extraction results from the coordinated move-
phase, and the esophageal phase. The oral prepa-
ments of the following oral structures.
ratory phase involves the suckling or sucking,
Jaw biting, and chewing actions that bring the food
The supportive structure of the jaw moves in a ver- into the mouth and form the bolus. The oral phase
tical dimension. Its inferior movement assists with consists of bolus transit to the oropharynx by the
creating suction. tongue. The pharyngeal phase involves the closure
of the nasopharyngeal port, anterior and vertical
Lips excursion of the larynx, inverse movement of the
The lips assist with the anterior seal around the epiglottis, vocal fold closure at midline and relaxa-
nipple and support stabilization of the nipple within tion of the upper esophageal sphincter (UES), and
the oral cavity. inverse movement of the epiglottis with coverage
of but not a tight seal for the laryngeal vestibule.
Tongue The pharyngeal muscle constriction triggers
The tongue tip compresses the nipple. The poste- pharyngeal peristalsis. As the bolus moves from
rior aspect of the tongue seals the oral cavity the hypopharynx through the open UES, the
against the soft palate. When the tongue drops, esophageal phase begins. The involuntary peri-
it enlarges the oral cavity creating suction. The staltic action of the esophagus propels the bolus
tongue also forms a midline groove for the transfer through the relaxed lower esophageal sphincter
of the liquid bolus from the mouth to the to allow the bolus to enter the stomach.
oropharynx.
Progression Reaching oral sensorimotor mile-
Cheeks stones allows the typically developing infant to
The cheeks provide stability. The greater the fat progress to solid foods. According to Arvedson
pads, the greater the stability. and Brodsky4 (2002), spoon-feeding skills emerge
between 4 to 6 months of age. At about 6 months,
Hard palate munching with vertical jaw movements emerges.
The hard palate assists the tongue with nipple Infants become ready for thicker textures. Rotary
compression and stability. jaw action begins at about 7 months and is refined
by 12 months of age. New textures should be
Soft palate gradually introduced in order for the child to gain
The soft palate assists the tongue in closing off the competence in chewing ability and to prevent
oral cavity posteriorly. During the swallow, it rises choking.
to seal off the nasal cavity, prevent nasal regurgita-
tion and create suction. Feeding Difficulties: the Mechanics
Parents of infants with clefts often make the
Sucking These oral movements coordinate with following observations regarding limited feeding
respiration and swallowing to produce a suck- ability: “My baby isn’t sucking well. My baby
swallow-breathe sequence ideally in a 1:1 suck- doesn’t want to feed. He pushes the nipple out
swallow ratio. Suckling is the first phase of the of his mouth. My baby is lazy. My baby isn’t swal-
suck to emerge. The tongue moves in an lowing correctly. It comes out of his nose. My baby
anterior-to-posterior dimension and, according to is always hungry. My baby acts hungry but then
Arvedson and Brodsky4 (2002), “liquid is drawn falls asleep as soon as he starts feeding.” These
into the mouth through a rhythmic licking action symptoms are often influenced by the mechanical
of the tongue, combined with pronounced opening issues that emerge due to the cleft lip and/
and closing of the jaw. Lips are loosely approxi- or palate. In simple terms, the lip latches to the
mated.” This pattern changes by the sixth month nipple and the palate maintains the latch. Given
of life with onset of differentiation between the lip and palatal deficiencies, the latch and its main-
jaw, tongue, and lips, including increased lip tenance are adversely affected. The type and
closure and more vertical excursion of the tongue. severity of the cleft directly influence the intensity
 Feeding Management in Infants with Craniofacial Anomalies 439

of the modifications needed for feeding success. breathing while feeding given that infants are obli-
Clefts are classified as unilateral or bilateral and gate nasal breathers. With a small cleft of the soft
complete versus incomplete. Peterson-Falzone palate, the tongue often occludes the cleft for at
and colleagues5 (2001) remind us that “clefts least part of the transition from suck to swallow,
vary in three other dimensions: anterior to poste- thereby reducing effect on negative pressure gen-
rior, width and ‘depth.’” These dimensions are eration. With a submucous cleft palate, there may
important when deciding on the most efficacious be mild reduction in negative pressure due to the
nipple placement within the mouth. Infants with dysfunction of the velopharyngeal valve. Nutritive
cleft lip and palate innately exhibit a sucking reflex breastfeeding is most likely possible with a small
similar to typically developing infants; however, cleft of the soft palate or submucous cleft palate;
they have limited ability to create suction efficiently however, nutritive breastfeeding is rarely success-
and consistently. ful in an infant with a large cleft palate.

Cleft lip Cleft lip and palate

Cleft lip causes a limited labial seal around the The combination of cleft lip and palate will result in
nipple of the breast or bottle that may decrease the aforementioned feeding issues but likely to a
negative pressure to a minor degree and greater degree. Nutritive breastfeeding is rarely
contribute to limited stability of the nipple within successful in an infant with complete cleft lip and
the oral cavity. These issues are usually very mild palate.
with cleft lip only. The nipple of the breast or bottle Poor longitudinal feeding outcomes may include
will often fill the space of the cleft to create a seal general fatigue with limited alertness and interac-
and stability of the nipple. Nutritive breastfeeding tion, refusal behaviors, limited urinary and fecal
is typically preserved in this population. output, and limited weight gain. These unfortunate
circumstances may negatively affect infant and
Cleft lip and alveolus caregiver interaction over time. Masarei and col-
With significant involvement of the alveolus, it be- leagues6 (2007) compared feeding skills in infants
comes more difficult for the infant to anchor the with unrepaired clefts to healthy infants without
nipple between supporting structures to achieve clefts. All comparisons were statistically significant
a good latch and seal of the oral cavity (ie, lips, in demonstrating the decreased sucking efficiency
tongue, primary palate) and may limit negative in infants with unrepaired isolated cleft palate and
pressure generation. The infant has less ability to unilateral cleft lip and palate. The infants with unre-
compress the nipple in a vertical plane (ie, tongue paired clefts demonstrated shorter lengths of indi-
and primary palate). Infants often show a greater vidual sucks and shorter lengths of sucking bursts
extent of vertical jaw excursion to improve (number of suck-swallow sequences) while rate of
compression contributing to fatigue. Nutritive sucking, suck-swallow ratio, and positive pressure
breastfeeding is typically achieved given assis- generation were greater (Table 1).
tance with milk delivery. Reid and colleagues7 (2007) examined the suc-
Cleft palate tion capabilities of 40 2-week-old infants with
With compromise of the hard palate comes clefts. All 8 infants with cleft lip demonstrated suc-
decreased stability of the nipple within the oral tion. One out of 10 infants with cleft lip and palate
cavity and decreased compression of the nipple. demonstrated suction. Thirteen out of 22 infants
These infants are more reliant on suction for milk with cleft palate demonstrated suction. Of the 13
extraction. With compromise of the soft palate infants, 10 had clefts of the soft palate only
comes decreased intraoral pressure, decreased and only 3 maintained regular pressure changes
suction, and limited milk transfer. This results in over time. The investigators found significant
decreased sucking efficiency and lengthy feeding between-group differences, concluding that in-
times with limited intake. Excessive air intake oc- fants with cleft lip or minor clefts of the soft palate
curs due to the poor seal between the oral and were more likely to generate normal levels of
nasal cavities. As the tongue drops in preparation suction and compression than infants with larger
for the swallow, air is pulled into the oropharynx clefts.
and hypopharynx from the nasal cavity. This can
Special Populations
lead to aerophagia, a false sense of satiation,
excessive spit up, and emesis. This also provides Pierre Robin sequence
a conduit for milk to propel from the mouth into Sucking in infants with Pierre Robin sequence
the nasopharyngeal region, otherwise known as is negatively affected by the limitations in posi-
nasal regurgitation, before or during the swallow. tive pressure generation given the maxillary-
This leads to nasal congestion and trouble mandibular discrepancy of the micrognathia, the
440 Merrow

Table 1
According to Peterson-Falzone and colleagues5
Sucking differences in infants with clefts (2001), both sides of the face may be involved
but typically one side is more affected than the
Infants with other. Feeding and swallowing difficulties may
Unilateral Cleft result from structural anomalies of the jaw, tongue,
Lip and Palate Infants face, and pharynx, or from neurologic dysfunction
or Isolated without and/or congenital heart defects.
Cleft Palate Clefts
22q deletion syndrome
Length of 8.97 s 13.28 s
sucking
These infants may experience feeding and swal-
bursts lowing problems of multiple causes given the great
variability in phenotypic expression. Airway anom-
Rate of 109.26 75.07
sucking sucks/min sucks/min alies and cardiac defects can negatively affect the
suck-swallow-breathe cycle, induce significant fa-
Length of 0.57 s 0.87 s
individual
tigue, and lead to aspiration from an antegrade
sucks process. Cardiac defects can cause extrinsic
compression of the trachea or of the esophagus,
Positive 71.68% 25.71%
pressure and obstruct the passing of food and liquid.
generation Gastrointestinal tract dysfunction can occur due
Suck-swallow 2.97:1 1.20:1
to hypotonia with reflux, slowed motility, and
ratio structural anomalies. These issues can lead to
limited caloric intake, feeding refusal, poor weight
Data from Masarei AG, Sell D, Habel A, et al. The nature of gain, and failure to thrive. It is important to keep in
feeding in infants with unrepaired cleft lip and/or palate
compared with healthy noncleft infants. Cleft Palate mind the linear growth trajectory predicted for
Craniofac J 2007;44:321–8. these infants and the tendency to exhibit slower
growth than their same-age peers in early
childhood.
misaligned forces of compression by the dental Treacher Collins syndrome
arches, and the lack of contact to the superior sur- These infants often experience poor airway
face of the nipple secondary to the typically wide patency and respiratory difficulties. Tracheot-
U-shaped cleft palate. The tongue often sits omies are frequently required.5 Surgical repair of
retracted in the mouth (glossoptosis) with minimal a cleft palate may lead to greater risk of airway
ability to produce an anterior tongue carriage to compromise. Conservative oral feeding measures
compress the nipple effectively. If the infant is may be needed with supplemental or alternate
able to produce an anterior tongue carriage to enteral feedings to meet nutritional needs but,
secure the nipple, airway patency typically im- certainly, variability is present.
proves. Suction ability depends on the size of the
cleft palate. There is variability in the phenotypic SOCIAL–EMOTIONAL INTERACTIONS
expression of Pierre Robin sequence and there
may be absence of a cleft palate in some cases. The technical aspects of feeding infants with
With less pharyngeal space for airway patency clefts and other craniofacial anomalies are of
and swallowing mechanics due to micrognathia utmost importance to ensure adequate growth;
and glossoptosis, these infants may experience however, attention should also be paid to the
significant chest retractions, nasal flaring, snort- feeding interaction between parent and child.
ing, stertor, and stridor at baseline and while Speltz and colleagues8 (1994) assessed 3-
feeding. These infants tend to pause more month-old infants with clefts and their mothers.
frequently and tolerate only short sucking bursts. The infants were divided into 3 groups: cleft lip
Longer sucking bursts often tax efforts at coordi- and palate; cleft palate only; and healthy, typical
nation and lead to extended swallow apneas, infants. Infants’ temperament and mothers’
gasping, gagging, and possibly aspiration. emotional and attitudinal factors were critiqued.
Furthermore, airway issues may also mask under- Infants in the typical group rated higher than
lying neuromotor dysfunction. both cleft groups on the clarity of cues scale. In-
fants with cleft lip and palate were less likely to
Hemifacial microsomia signal readiness to eat and less likely to display
This broad group of first and second branchial changes in tension at the onset of the feeding
arch malformations results in mandibular hypopla- and shortly thereafter. Both cleft groups were
sia and facial weakness of varying degrees.4 less likely than the typical infants to smile or laugh
 Feeding Management in Infants with Craniofacial Anomalies 441

during feeding. Of interest, the mothers of infants FEEDING EVALUATION

in the cleft groups showed no significant differ-
ence from the mothers of typical infants in their To best manage these feeding issues, thorough
responsiveness to their infants who smiled less; assessment is necessary, including a detailed
however, the mothers of the infants with cleft history, physical examination with baseline
lip and palate showed decreased sensitivity to physiologic assessment, feeding observation,
their infants’ cues. The investigators suggest and stimulability trials. In some instances,
that the lowered maternal sensitivity in this group further evaluation of the swallowing mechanism
was likely due to the additional problems of the is necessary via instrumental testing. This may
cleft lip. In feeder-assisted interactions, infants include a fiberoptic endoscopic evaluation of
exhibited less control of feeding pace and length swallowing (FEES) or modified barium swallow
of feeding. There is valuable suggestion that study (MBSS). Disorders of swallowing can be
training of feeding technique should be combined classified as oral and/or pharyngeal dysphagia,
with attention to the quality of social interaction. and as described by Darrow and Harley10
The prenatal consultation can help parents feel (1998): mechanical, neurologic, or develop-
more comfortable in learning the technical as- mental dysphagia.
pects of feeding, thereby more expeditiously
History
shifting the focus from feeding technique to social
interactions and enjoyment of their infant sooner Detailed history and discussion of current feeding
after birth. practices provide valuable insight into the nature
of the feeding problem. The outline below is helpful
Outcomes and Goals to address the major variables in the feeding
process:
Outcome measures help compare the effective-
ness of feeding skills of the infant born with a  History of the problem: caregiver description
craniofacial anomaly to typically developing in- of the feeding difficulties, signs and symp-
fants while considering other variables in the toms of intolerance, medical restrictions.
feeding process, such as infant–caregiver interac-  Environment: place of feeding, caregivers
tion and milk supply to the infant. Outcomes within involved with feeding, distractions.
the feeding session may include the quantity of  Nutrition: breastmilk, formula (type, calories
intake during the feeding, as well as change in per ounce, supplements trialed), other liquids
physiologic stability from baseline, endurance, or foods offered, intake goals
and tolerance of the food and liquid offered.  Feeding method: breast (discuss milk supply,
Generally, an infant should complete his or her use of manual expression, pumping), bottle
full feeding within 20 to 30 minutes; otherwise, (type, nipple, flow rate), enteral feedings
she or he tends to burn more calories than (type, formula, rate).
consumed. The hospital-based neonatologist,  Feeding efficiency: optimal state for feeding,
community-based pediatrician, or cleft and duration of feedings, frequency of feedings,
craniofacial team may guide the feeding plan sleep and feeding schedule, changes in
with a daily intake goal. The daily intake for an in- feeding from beginning to end of session,
fant with a cleft, daily output, and weight gain changes in feeding from first feedings until
over time (due to significant day-to-day variability) present, physiologic stability.
are quantifiable factors by which to assess the  Other pertinent details: positioning, work of
adequacy of the infant’s intake. If the infant is breathing, burping, presence of nasal regurgi-
reaching feeding goals safely, further evaluation tation and/or emesis, output.
may not be necessary. If an infant has other
diagnosed congenital anomalies (eg, microgna- Observation at rest
thia, cardiac defect, short stature as a phenotypic Observe the infant’s behavior and ability to
characteristic of a diagnosed syndrome), goals communicate his needs, as well as the
and expectations for intake may be altered. The caregiver’s responses to these requests, to
World Health Organization growth charts are rec- gain insight regarding potential issues with child–
ommended by the Center for Disease Control caregiver interaction. Physiologic observations at
and Prevention (CDC) and are supported by the rest include posture and positioning, airway
American Academy of Pediatrics for use from birth patency and respiratory effort (audible and
to 2 years of age. The CDC growth charts are rec- visual observation-stridor, stertor, halted breath-
ommended by the CDC for use with children from ing or apnea, chest retractions, nasal flaring), neu-
2 years of age and older.9 romotor function, airway protection, including
442 Merrow

frequency of spontaneous swallows, presence Fiberoptic Endoscopic Evaluation of

of drooling (anterior and posterior), coughing, Swallowing
phonation (vocal quality, pitch, intensity), vital
A FEES provides the most direct view of the
sign monitoring (oxygen saturation, heart rate
laryngeal structures and observation of laryngeal
and respiratory rate), color, oral examination,
function. Real-time video in color makes exami-
and anthropometric measurements.
nation of the integrity of the mucosa and the
Feeding observation abundance of secretions easily visible (Video 1).
The amount of change in physiologic parameters FEES should be considered initially instead of
with onset of the feeding session and the infant’s the MBSS if it will provide the quality of informa-
tolerance thereof will determine whether the work tion desired to avoid radiation exposure during
of feeding is functional or excessive, requiring MBSS. Furthermore, if transportation to the radi-
modifications. Observations of the typical feeding ology suite or positioning within the videofluoro-
(simulated as best as possible given a likely change scopic space is not possible, FEES should be
from home to a clinical setting) should include considered. Willging and colleagues14 (2001) re-
state, motor control, tactile reflexes and behavioral ported indications for pediatric FEES to include
responses, oral motor movements, suck-swallow- assessment of readiness for oral feedings, to
breathe coordination, and outcomes of the feeding determine if a structural abnormality is present,
(eg, quantity consumed, length of feeding).11 Oral, and to determine if there is need to further
pharyngeal and esophageal phases of swallowing assess airway protection and devise strategies
should be monitored as well. to improve safe swallowing. FEES with the
component of sensory testing has been proven
Stimulability testing a useful tool in the diagnosis and management
Stimulability testing assesses effectiveness of of laryngopharyngeal sensation in children.15
modifications to promote successful feeding out- Recent studies examining the effects of topical
comes. This is performed during the feeding nasal anesthetic on swallowing have shown
evaluation, if possible, following observation of differing results. Kamarunas and colleagues16
the infant with his or her caregiver, in attempt (2013) found no change in comfort, ease of ex-
to immediately alleviate feeding issues for the amination, or quality of view between conditions
family. This involves making milk flow easily to of viscous lidocaine hydrochloride versus gel
meet caloric requirements, preventing excessive Surgilube during FEES. Fife and colleagues17
air intake, minimizing nasal regurgitation, and (2015) found no statistical significance for im-
maintaining physiologic stability through changes pairment of swallowing ability in patients with
in positioning, feeding modality, flow rate, liquid dysphagia given use of aerosolized lidocaine dur-
viscosity, assistance with milk delivery, and other ing FEES; however, “topical nasal anesthesia
strategies (eg, pacing techniques). significantly reduces subjective pain and discom-
fort and improved tolerance during FEES.” O’Dea
Instrumental evaluation
and colleagues18 (2015) reported significant
Despite thorough historical investigation and
lower pain ratings during scope insertion without
complete clinical feeding and swallowing evalua-
significant change in swallow function or residue
tion, an instrumental evaluation may be necessary
between anesthetized and nonanesthetized con-
to further examine unanswered clinical questions.
ditions when using a dose of 0.2 mL of 4% atom-
FEES and MBSS are common instrumental pro-
ized lidocaine during FEES. The investigators
cedures used for objective evaluation of swallow-
suggest that the quantity of anesthetic used
ing. Both tools provide a baseline anatomic and
during the evaluation and the length of the evalu-
physiologic assessment of the swallowing mech-
ation may be variables affecting pain tolerance.
anism, gauge swallowing function for trialed
foods and liquids, and host therapeutic trials
Modified Barium Swallow Study
with use of positional strategies, changes in
food texture and liquid viscosities, as well as The MBSS provides the most comprehensive view
changes in modalities used for presentations of the oropharyngeal swallowing mechanism for
(eg, bottle, cup, spoon). There are conflicting re- examination of the oral, pharyngeal, and esopha-
ports regarding diagnostic agreement between geal stages of swallowing (Video 2). This examina-
FEES and MBSS in children.12,13 There are tion allows for observations not visible with
inherent advantages and disadvantages to both endoscopy (eg, tongue base contact with the pos-
procedures. Each can be used solely or in combi- terior pharyngeal wall that is seen as a whiteout
nation to obtain qualitative information from during FEES, deep laryngeal penetration during
multiple views. the swallow). Consecutive swallows, often seen
 Feeding Management in Infants with Craniofacial Anomalies 443

with infants feeding from a bottle or a neurologi- Occlusion of the cleft palate: Obturators are not
cally impaired child who has difficulty with self- necessary and used infrequently.
pacing, are better evaluated by MBSS; otherwise, Nipple modifications: Wide base and shaft for
the view from the endoscope is obstructed by the better occlusion of the cleft, length depends
repetitive peristaltic movement of the bolus on size of the mouth and cleft, softness for
through the hypopharynx. Globus complaints, easier compression, and variable hole size
possible cricopharyngeal dysfunction, and to adjust the flow rate of milk.
nonspecific complaints are better evaluated by Infant-directed, assisted milk flow by bottle
MBSS.19 If a patient would have poor tolerance (Fig. 1): Use a soft-sided bottle and pliable
of endoscopy or refusal thereof, an MBSS would nipple or a one-way flow valve.
be indicated. A prospective study by Weir and col- Feeder-directed, assisted milk flow by bottle: Use
leagues20 (2011) supported the use of MBSS to a soft-sided bottle and pliable nipple, angle the
identify silent aspiration in children, including nipple to contact a portion of bone for better
those with aspiration lung disease and neurologic positive pressure generation, squeeze the bot-
impairment. MBSS is also a helpful assessment tle when the infant sucks to synchronize posi-
tool when diagnosing functional effects of asym- tive pressure application with the infant’s
metric movement given the lateral, anteroposte- suck-swallow-breathe pattern (see Fig. 1).
rior, and Towne views available. Other: Burp frequently, irrigate the nose only if
needed.
Breastfeeding (if applicable depending on the
FEEDING MANAGEMENT type and severity of the cleft): Nurse through
let down, use manual expression, use assis-
If an infant is showing feeding difficulty, modifica-
ted milk flow at the breast (eg, a supplemental
tions should be trialed during the evaluative ses-
nursing system), and close monitoring of
sion, including the following:
growth.
Positioning of the feeder: Supported position to Breastfeeding (if the infant is not a good candi-
maintain stability throughout the feeding. date for nutritive feeding at the breast): Put
Positioning of the infant: Upright or elevated side the infant to breast briefly either at the onset
lying to minimize the effects of nasal regurgi- of the feeding or after nutritive feeding from
tation and glossoptosis (if applicable). the bottle, encourage infant to breast for
Occlusion of the cleft lip and alveolus: With the skin-to-skin contact and stimulation of milk
breast or a wide nipple. Stabilize the jaw and production, elicit assistance from a lactation
cheeks for better oral closure, being mindful consultant for milk production strategies.
that the infant may rely on oral versus nasal Compensatory strategies for poor feeding: Add
breathing if airway patency issues are present. supplement to the breastmilk, increase caloric

Fig. 1. Bottles commonly used to

assist with milk delivery during
feeding. From left to right: Ross
bottle with Similac Premature
Nipple & Ring, Dr. Brown’s Specialty
Feeding System, Respironics Pigeon
feeder, Mead Johnson Cleft Lip/
Palate Nurser, Medela’s Special-
Needs feeder with Mini teat, Me-
dela’s SpecialNeeds Feeder. The
second, third, fifth, and sixth sys-
tems include a one-way valve to
promote more controlled, infant-
directed feeding.
444 Merrow

concentration of the formula, provide tempo- 7. Reid J, Reilly S, Kilpatrick N. Sucking performance
rary enteral feedings if necessary. of babies with cleft conditions. Cleft Palate Cranio-
Monitoring: Weight checks with the pediatrician, fac J 2007;44(3):312–20.
follow-up with clinician, referral to other 8. Speltz M, Goodell EW, Endriga MC, et al. Feed-
specialists as needed, hospital admission for ing interactions of infants with unrepaired cleft
failure to thrive or if physiologic stability is lip and/or palate. Infant Behav Dev 1994;17:
significantly compromised. 131–40.
Postoperative Feeding: Recommendations 9. Growth charts. Center for Disease Control and Pre-
based on surgeon’s preferences, practice vention Web site. Page reviewed September 9,
preoperatively. 2010. Available at: http://www.cdc.gov/growth-
charts/index.htm. Accessed February 1, 2016.
SUMMARY 10. Darrow DH, Harley CM. Evaluation of swallowing
disorders in children. Otolaryngol Clin North Am
Feeding and swallowing abilities in infants born 1998;31(3):405–18.
with craniofacial anomalies show great variability. 11. Wolf LS, Glass RP. Feeding and swallowing
Those infants with the same medical diagnosis or disorders in infancy: assessment and manage-
craniofacial anomaly may present very differently ment. San Antonio (TX): Therapy Skill Builders;
in their intrinsic management of food and liquid 1992.
consumption. The instinctual drive to gain nourish- 12. Leder SB, Karas DE. Fiberoptic endoscopic evalua-
ment can become complicated by structural differ- tion of swallowing in the pediatric population. Laryn-
ences, physiologic instability, and environmental goscope 2000;110(7):1132–6.
influences. These factors assessed individually 13. DaSilva AP, Lubianco Neto J, Santoro PP. Compari-
and in combination will assist in producing the son between videofluoroscopy and endoscopic
most favorable feeding outcomes possible with evaluation of swallowing for the diagnosis of
overall goals of providing adequate nutrition and dysphagia in children. Otolaryngol Head Neck
hydration for brain development and growth, and Surg 2010;143:204–9.
facilitating the most positive feeding experience 14. Willging JP, Miller CK, Thompson Link D, et al. Use
for both infant and caregiver. of FEES to assess and manage pediatric patients.
In: Langmore SE, editor. Endoscopic evaluation
SUPPLEMENTARY DATA and treatment of swallowing disorders. New York:
Supplementary data related to this article can Thieme; 2001. p. 213–34.
be found at http://dx.doi.org/10.1016/j.fsc.2016. 15. Link DT, Willging JP, Miller CK, et al. Pediatric laryng-
06.004. opharyngeal sensory testing during flexible endo-
scopic evaluation of swallowing: feasible and
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