Sucking Performance of Babies with Cleft Conditions

Parental Stress, Infant Feeding and Well-being in Families Affected by Cleft Lip and/or Cleft Palate: The Impact of Early Follow-up

ObjectiveTo document the impact of early follow-up by specialized cleft nurses (SCNs) provided to families affected by cleft lip and/or palate (CL/P) and the status of parental stress, infant feeding and well-being.DesignProspective inclusion of a control group, which only received standard care, followed by an intervention group that also received early SCN follow-up.SettingThe cleft lip and palate team at Oslo University Hospital, Norway.ParticipantsSeventy families (69 mothers and 57 fathers) distributed into an intervention group (n = 32) and a control group (n = 38).InterventionSCNs provided a consultation at the maternity ward and a follow-up conversation by phone or face-to-face at scheduled times for six months.Outcome measuresParental Stress Index (PSI), Perceived Stress Scale (PSS-14), feeding questionnaire, survey of infant diets, weight percentiles.ResultsThe mothers reported higher stress scores than the fathers, but in the control group only in the PSI parent domain at T2 and T3 (P = .007, P = .018). Infants in the intervention group used pacifiers less frequently than in the control group (55.2% vs. 81.1%, P = .023). Otherwise, no significant differences were found between the groups. Overall, the infants received less breast milk than norms.ConclusionContextual strategies for early follow-up of families affected by clefts need to be developed, with an emphasis on involving fathers and those parents reporting elevated stress and/or feeding difficulties. There is a need for diagnosis-specific guidelines about the use of pacifiers as well as collaboration between the health professionals involved to increase breastmilk feeding.

Examining the Effect of Bottle Angle on Milk Drip Rate Using the Dr. Brown's® Zero-Resistance® Specialty Feeding System

ObjectiveExamine the drip rate from the Dr. Brown's® Zero-Resistance® Specialty Feeding System without compression across 8 nipple levels and 3 angles.DesignCross-sectional.SettingLaboratory.InterventionsThe drip rate of the Dr. Brown's® Zero-Resistance® Specialty Feeding System was assessed with the bottle positioned at 0°, 30°, and 45° angles across 8 bottle nipple levels: Ultra-Preemie™, Preemie Flow™, Level T, Level 1, Level 2, Level 3, Level 4, and Y-Cut.Main Outcome Measure(s)Milk volume in millimeters extracted per minute (mL/min) for each bottle nipple level and angle configuration. A one-way analysis of variance was conducted to compare the milk drip rate across 3 angles for each bottle nipple level.ResultsThe mean drip rate was 0.0 mL/min across all nipple levels when the bottle was positioned at a 0° angle. No milk drip was observed at any angle for the Y-Cut nipple. Milk drip was observed when the bottle angle increased to 30° and 45° for nipple levels Ultra-Preemie™ to Level 4 ranging from 1.3 mL/min up to 19.4 mL/min.ConclusionsMilk freely drips from the Dr. Brown's® Zero-Resistance® Specialty Feeding System when positioned at 30° and 45° angles for nipples Ultra-Preemie™ through Level 4, putting infants at risk for aspiration. Clinicians should recommend caregivers position the Specialty Feeding System at a 0° angle when infants pause to breathe.

Training Mechanisms for Healthcare Providers in Feeding Infants With Cleft Palate

ObjectiveThere is a lack of formal training documented for service providers across disciplines regarding patients with cleft palate, resulting in a variety of informal training mechanisms. The purpose of this study was to characterize the training interdisciplinary providers have received related to feeding infants with cleft palate and generate ideas for future training mechanisms.DesignProspective, mixed methods surveySettingFeeding providers from ACPA approved cleft palate teams in North AmericaParticipantsProviders of varying disciplines that regularly engaged in feeding services for infants with cleft palate and completed the first training-related question within the surveyMain Outcome MeasuresInformation on provider demographics and trainingResultsMost respondents' (56.6%) academic program did not include information regarding feeding infants with cleft palate, which was significantly higher (P < .001) for disciplines outside of speech-language pathology. Of all respondents, 81.6% received on-the-job training while 69.7% attended continuing education to acquire this information; significantly more speech-language pathologists (P < .001) reported attending continuing education than other disciplines. Conventions or conferences (44.7%) and materials (47.4%) from the ACPA were considered very helpful by those who pursued continuing education. Inductive content analysis revealed themes related to collaborating with other professionals, available research to guide practice, and graduate and postgraduate/professional training.ConclusionsInconsistencies in academic training within and across disciplines exist related to feeding infants with cleft palate. There are several opportunities to expand continuing education.

Non-Nutritive Suck and Parent Report of Feeding Skills in Infants Born With Cleft Lip and/or Palate

ObjectiveTo compare non-nutritive sucking (NNS) and caregiver-reported feeding skills in infants with cleft lip and/or palate (CL/P) to a control group of typically developing infants without CL/P. To examine differences in NNS patterns and feeding behavior between cleft phenotypes.DesignProspective, cross-sectional study comparing infants born with CL/P to an age-matched control group with no congenital anomalies.SettingUrban, academic, tertiary care children's hospital and academic department of speech-language pathology.Patients, ParticipantsForty-two infants (21 with CL/P; 21 without CL/P), 6 months of age and younger were included. Infants with syndromes or who underwent cleft repair were excluded.Main Outcome MeasuresA 5min NNS sample was collected from the infant sucking on the lab's custom research pacifier. The infant's caregiver completed the Neonatal Eating Assessment Tool (NeoEAT) bottle-feeding section about their infant's feeding behaviors.ResultsInfants with CL/P demonstrated slower NNS frequency (P = .04) and reduced suck amplitude (P = .04) compared to the control group. Caregivers of infants with CL/P reported a higher incidence of gastrointestinal symptoms (P = .04) and overall feeding difficulties (P = .03) relative to the control group. There were no significant differences between CL/P phenotypes for NNS or caregiver reported outcomes.ConclusionsInfants with CL/P demonstrate differences in NNS physiology and caregiver report measures of feeding compared to age-matched controls. These findings support the need for interventions to optimize sucking and feeding skill development in infants with CL/P.

Lack of Immediate Diagnosis and Appropriate Intervention Leads to Malnutrition in an Infant With Cleft Palate

This case report describes a full-term infant with a cleft palate who experienced malnutrition because of the delayed introduction of a cleft-adapted bottle and identifies potential areas for improvement in clinical practice. The infant's weight for age z-score at birth was 0.05 and dropped to -1.45 by 2 months of age, indicating mild malnutrition. The infant established care with a cleft team and a cleft-adapted bottle was recommended as the primary feeding method. Feeding time subsequently decreased from 60 minutes per feeding to 20 minutes. The infant presented for palate repair at 9 months of age, and his z-score was -0.01, indicating he was no longer malnourished. Cleft-adapted bottles aid in feeding efficiency in infants with cleft palate, which may subsequently impact weight gain. Appropriate weight gain is essential to receive timely cleft palate repair and support healing.

Evaluation of a Digital Home Weight Monitoring Program for Infants With Cleft Palate

OBJECTIVE

Evaluate the effectiveness of a digital home monitoring program for infants with cleft palate with or without cleft lip (CP ± L), compared to monitoring through in-person clinic visits.

DESIGN

Retrospective cohort study.

SETTING

One metropolitan pediatric hospital.

PATIENTS

Eight-eight infants with CP ± L: 41 infants received digital home monitoring and 47 infants were monitored solely through in-person visits.

INTERVENTIONS

Beginning in September 2022, all infants with CP ± L were enrolled in a digital home monitoring program, in which caregivers weighed their child weekly at home and submitted those weights, along with subjective evaluations of their child's feeding, using a secure website. Submissions were monitored by the cleft team nurse coordinator.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of malnutrition at 4 months of age. The secondary outcome was the average number of in-person clinic visits during the first 4 months of life.

RESULTS

There was not a significant difference (P = .764) in the incidence of malnutrition between infants monitored in-person compared to infants in the home monitoring program (13% vs 17%). Infants in the home monitoring program had fewer in-person visits with speech-language pathology (5.4 vs 3.9; P < .001). Across groups, malnutrition was associated with Child Protective Services involvement (P = .001) and presence of a syndrome (P = .014).

CONCLUSIONS

The digital home monitoring program did not decrease the incidence of malnutrition, but it did reduce the number of speech-language pathology in-person visits. The program appears to distinguish infants who are gaining weight appropriately from those with feeding challenges, but it does not fully address the multifactorial contributors to malnutrition.

Nutrition and diet in children with orofacial clefts in Africa: a scoping review

BACKGROUND AND AIM

The burden of orofacial clefts (OFCs) has declined globally except in sub-Saharan Africa, with a great disease burden in North Africa. Children with OFCs have a high risk of malnutrition, and African countries have some of the highest malnutrition rates. This scoping review assessed the status of research on OFCs and nutrition and feeding among children living in African countries.

METHODS

We followed the Joanna Briggs Institute guidelines for conducting scoping reviews. We searched eleven databases for articles on malnutrition and feeding among children with OFCs living in African countries. No restriction was done by type of study or publication date. Books, book chapters, and reviews were excluded. Only publications in English language were included. We extracted information about the publication year, study design, setting, location, participants' age, data collection methods, international collaboration, and funding. We classified articles into studies assessing (1) the impact of nutritional deficiencies during pregnancy on OFCs, (2) the impact of OFCs on malnutrition, (3) feeding problems in children with OFCs, and (4) the impact of nutritional status on OFCs repair outcomes. We calculated frequencies and used bar charts and a map.

RESULTS

Out of 208 search results, 36 were duplicates, and 25 eventually fit the inclusion criteria, with 52% retrieved from Google Scholar. About 80% of the studies were from four countries: Nigeria, South Africa, Ghana, and Uganda; 72% were hospital-based and 52% were cross-sectional. The most frequent data collection method was clinical examination and questionnaires. Most studies focused on feeding problems in children with OFCs (44%) and the impact of OFCs on malnutrition (32%). International collaboration was observed in six studies, with one study showing South-South collaboration. Only two studies were funded.

CONCLUSIONS

There is a predominance of under-funded descriptive research not indexed by international databases. Minimal research has been directed to population-level OFC preventive programs in primary healthcare settings and assessing interventions supporting children with OFCs. A research agenda is needed to prioritize research needs and secure funds to support South-South collaboration to address the nutrition and feeding-related problems associated with OFCs.

The oral behavior screener: a brief caregiver-completed measure of oral behaviors

INTRODUCTION

To date, there are no caregiver-reported screening measures of oral behaviors related to feeding. The goal of this study was to develop such a measure.

METHOD

Caregivers of 803 children referred to a feeding clinic and 188 comparison children reported their children's frequency of nine oral behaviors. These data were used to develop an Oral Behavior Screener (OBS). Both the psychometrics of the OBS and the relations between the OBS and child demographics were examined.

RESULTS

As expected, the clinical sample demonstrated more deficits in oral behaviors than the comparison sample. We also found special needs status and age were linked to the OBS summary score.

DISCUSSION

The OBS is a brief screener that can be used by clinicians to examine the need for further assessment, possible targets for intervention, oral behaviors often associated with feeding problems.

Breastfeeding and Cleft Lip and Palate: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the association between cleft lip and/or cleft palate (CL/P) and breastfeeding (BF).

DESIGN

A systematic review and meta-analysis were performed based on studies published in PubMed, Scopus, Web of Science, Cochrane Library, LILACS, BBO, and Embase databases, and in the gray literature. The search occurred in September 2021 and was updated in March 2022. Observational studies evaluating the association between BF and CL/P were included. Risk of bias was analyzed using the Newcastle-Ottawa Scale. A random-effects meta-analysis was conducted. Certainty of evidence was evaluated using the GRADE approach.

MAIN OUTCOME MEASURE(S)

Frequency of BF in relation to the presence or absence of CL/P, as well as to the type of CL/P. The association between cleft type and BF challenges was also evaluated.

RESULTS

From a total of 6863 studies identified, 29 were included in the qualitative review. Risk of bias was moderate and high in most studies (n = 26). There was a significant association between the presence of CL/P and absence of BF (OR = 18.08; 95% CI 7.09-46.09). Individuals with cleft palate with or without cleft lip (CP ± L) had a significantly lower frequency of BF (OR = 5.93; 95% CI 4.30-8.16) and a significantly higher frequency of BF challenges (OR = 13.55; 95% CI 4.91-37.43) compared to individuals with CL. Certainty of the evidence was low or very low in all analyses.

CONCLUSION

The presence of clefts, especially those with palate involvement, is associated with higher chances of absence of BF.

Presurgical Reduction of the Cleft Palate: Serendipitous Benefit of the Stanford Orthodontic Airway Plate Treatment (SOAP) for Infants with Robin Sequence

OBJECTIVE

Narrowing of the palatal cleft is often observed in infants with Robin sequence (RS) treated with the Stanford Orthodontic Airway Plate treatment (SOAP) even though SOAP is utilized primarily to establish airway patency. The current study quantified dimensional changes of the cleft palate (CP) in infants with RS treated with SOAP.

DESIGN

A retrospective chart review.

PATIENTS

Infants with RS and CP who completed SOAP and had maxillary arch models at both pre- and post-treatment time points at a single tertiary referral hospital between September 2019 and July 2023.

SETTING AND OUTCOME MEASURE

Maxillary arch models were measured and analyzed using Bivariate statistical analysis.

RESULTS

Seventeen infants were included in the study. The median age (min, max) was 6.7 weeks (1.1, 21.9) at pre-treatment and 26.6 weeks (18.7, 37.0) at post-treatment. The median Obstructive Apnea Hypopnea Index was 36.2 events/hour (8.1, 103.1) at pre-treatment and 4.1 events/hour (1.9, 8.6) at post-treatment. The pre-treatment width of CP decreased by an average (± standard diviation) of 6.37 mm (± 3.55, p < 0.001) at post-treatment. The ratio of the posterior cleft width to the total maxillary arch width decreased from 40% (± 9.1) at pre-treatment to 22% (± 11) at post-treatment (p < 0.001).

CONCLUSION

The dimensions of CP reduced significantly during SOAP in infants with RS and CP treated for their severe upper airway obstruction. The findings highlight a potential benefit of SOAP that may contribute favorably to the palate repair surgery.

Comparison of two Specialized Cleft Palate Feeders

OBJECTIVE

To evaluate feeding efficiency and weight gain in infants with cleft palate fed using 1 of the 2 specialty feeders.

DESIGN

Retrospective cohort study.

SETTING

Cleft palate clinic in a tertiary pediatric hospital.

PARTICIPANTS

Infants with cleft palate (with or without cleft lip) fed using the Medela SpecialNeeds® Feeder (n = 39) or the Dr. Brown's® Specialty Feeding System (n = 16) and who had documented feeding and growth data available from the time of initial assessment in the first month of life and at subsequent follow-up between 2 and 4 months.

PRIMARY OUTCOME MEASURE

Feeding velocity (mL/min).

SECONDARY OUTCOMES MEASURES

Calorie velocity (kcal/min), weight gain, and complications associated with poor feeding.

RESULTS

No statistically significant differences in feeding or calorie velocities were identified between infants with cleft palate fed with the Medela SpecialNeeds® feeder and those fed with the Dr. Brown's® feeder. Mean weight z-scores by month did not differ significantly between the 2 bottle groups at the time of initial assessment (P = .84) and follow-up (P = .20). Mean weight z-scores by month for the infants included in this study fell below the 50th percentile. The proportion of infants who developed otitis media, reflux requiring treatment, or who required hospital admission for nasogastric (NG) feeds did not differ significantly between the 2 groups.

CONCLUSIONS

Despite being adequately powered for the primary outcome, no significant differences were identified between infants fed with the Medela or the Dr. Brown's feeders in terms of feeding velocity, calorie velocity, weight gain, or complications.

A Retrospective and Prospective Cohort Study Comparing Pediatric Patients With Cleft Lip and Palate From the United States and Guatemala

Orofacial clefts (OFC) remain among the most prevalent congenital abnormalities worldwide. In the United States in 2010 to 2014, 16.2 of 10,000 live births are born with OFC compared with 23.6 of 10,000 in Alta Verapaz, Guatemala in 2012. Demographics and cleft severity scores were retrospectively gathered from 514 patients with isolated OFC at the Children's Hospital of Philadelphia scheduled for surgery from 2012 to 2019 and from 115 patients seen during surgical mission trips to Guatemala City from 2017 to 2020. Risk factors were also gathered prospectively from Guatemalan families. The Guatemalan cohort had a significantly lower prevalence of cleft palate only compared with the US cohort, which may be a result of greater cleft severity in the population or poor screening and subsequent increased mortality of untreated cleft palate. Of those with lip involvement, Guatemalan patients were significantly more likely to have complete cleft lip, associated cleft palate, and right-sided and bilateral clefts, demonstrating an increased severity of Guatemalan cleft phenotype. Primary palate and lip repair for the Guatemalan cohort occurred at a significantly older age than that of the US cohort, placing Guatemalan patients at increased risk for long-term complications such as communication difficulties. Potential OFC risk factors identified in the Guatemalan cohort included maternal cooking-fire and agricultural chemical exposure, poor prenatal vitamin intake, poverty, and risk factors related to primarily corn-based diets. OFC patients who primarily rely on surgical missions for cleft care would likely benefit from more comprehensive screening and investigation into risk factors for more severe OFC phenotypes.

The relation between clinically diagnosed and parent-reported feeding difficulties in children with and without clefts

A cleft lip and/or palate (CL/P) is one of the most common craniofacial malformations, occurring worldwide in about one in 600-1000 newborn infants. CL/P is known to influence the feeding process negatively, causing feeding difficulties in 25-73% of all children with CL/P. Because there is a risk for serious complications in these children regarding feeding difficulties, there is often a need for intensive medical counseling and treatment. At this moment, adequate diagnosis and measurement remain a challenge and often lead to a delayed referral for professional help. Since parents play a big part in reporting feeding difficulties, it is important to help objectify parents' experiences, as well as the use of a frontline screening instrument for routine check-ups during medical appointments. The aim of this study is to investigate the relationship between parent perspective and standardized observation by medical professionals on feeding difficulties in 60 children with and without clefts at the age of 17 months. We focus on the information from parents and health professionals by comparing the Observation List Spoon Feeding and the Schedule for Oral Motor Assessment with the validated Dutch translation of the Montreal Children's Hospital Feeding Scale.  Conclusion: There is a need for timely and adequate diagnosis and referral when it comes to feeding difficulties in children with CL/P. This study underscores the importance of combining both parental observations and measurements of oral motor skills by healthcare professionals to enable this. What is Known: • Early identification of feeding difficulties can prevent adversely affected growth and development. • Clefts increase the probability of feeding difficulties; however, the diagnostic trajectory is unclear. • The Observation List Spoon Feeding (OSF) and Schedule for Oral Motor Assessment (SOMA) are validated to measure oral motor skills. The Montreal Children's Hospital Feeding Scale Dutch version (MCH-FSD) has been validated for the parental perception of infant feeding difficulties. What is New: • Parents of children with CL/P experience relatively few feeding problems in their child on average. • Oral motor skills for spoon feeding are associated with oral motor skills for solid foods in children with CL/P. • The extent of the cleft is associated with experiencing more feeding difficulties in children with CL/P.

Eating and swallowing disorders in children with cleft lip and/or palate

Introduction. Cleft lip and palate are complex congenital anomalies of the orofacial system of children. Feeding and swallowing problems occur with varying degrees in children with cleft lip and/or palate. Aim. The aim of this paper was to review the literature and available evidence regarding the types of eating and swallowing disorders that can be identified in children with cleft lip and/or palate, as well as a description and types of compensatory strategies and interventions to alleviate difficulties. Methods. Insight into the relevant literature was performed by specialized search engines on the internet and insight into the electronic database. Results. The extent of the cleft is related to the severity of eating and swallowing disorders, so the most common problems are decreased oral sensitivity, cough, choking, nasal regurgitation, difficulty in sucking, laryngotracheal aspiration due to inadequate airway protection during swallowing, which may result in pneumonia and lung damage. Feeding and swallowing difficulty is also a source of stress for parents. Conclusion. Choking, coughing, nasal regurgitation, laryngotracheal aspiration, excessive air intake can lead to dehydration, malnutrition, but also the need for alternative feeding methods Therefore, it is of great importance to identify the problems of feeding and swallowing in a timely manner, along with modifications of the feeding method.

Feeding considerations for infants with craniofacial malformations

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.

Caracterización de la alimentación en bebés chilenos con fisura de paladar entre 0 y 6 meses

Los bebés con fisura de paladar manifiestan problemas en las dinámicas de succión, debido a la comunicación entre la cavidad nasal y oral. El objetivo del estudio fue caracterizar y comparar antecedentes generales y de alimentación en bebés de entre 0 y 6 meses portadores de fisura post-foramen (FPF) y trans-foramen (FTF). Se revisaron registros de atenciones de 36 bebés portadores de FPF y FTF de un hospital público de Chile. Se compararon los datos obtenidos entre los tipos de fisura FPF y FTF usando el software estadístico R. Los días de alimentación por lactancia materna directa fueron en promedio 13.5 días en bebés con FPF y 16.6 días en bebés con FTF. Se constató desnutrición en el 72.7% de los bebés con FPF y 40% de los bebés con FTF. La fórmula láctea y el uso de biberón se presentó más del 96% de los participantes. La extracción de leche materna alcanzó los 25.2 días en FPF y 48.1 días en FTF. La indicación de métodos de extracción de leche materna, tipo de fórmula y tipo de utensilio para la alimentación fue entregada en su mayoría por un profesional. Se observó que el tiempo de lactancia materna directa fue inferior a otros centros nacionales e internacionales. En tanto, el utensilio más usado fue el biberón y las indicaciones para alimentar fueron otorgadas mayormente por profesionales. Se concluye que no existen diferencias significativas al comparar la alimentación entre ambos tipos de fisura.

"Mine did not breastfeed", mothers' experiences in breastfeeding children aged 0 to 24 months with oral clefts in Uganda

BACKGROUND

Appropriate breastfeeding is vital for infant and young child nutrition. Annually, oral clefts affect 0.73 per 1000 children in Uganda. Despite this low incidence, children with a cleft face breastfeeding difficulty which affect their nutrition status. In addition, knowledge on maternal experiences with breastfeeding and support is limited. We explored maternal perceptions, experiences with breastfeeding and support received for their children 0 to 24 months with a cleft attending Comprehensive Rehabilitative Services of Uganda (CoRSU) Hospital.

METHODS

This cross-sectional study combined quantitative and qualitative methods. We consecutively recruited 32 mothers of children with a cleft aged 0 to 24 months attending CoRSU hospital between April and May 2018. A structured questionnaire collected data on breastfeeding practices and device use (n = 32). To gain a broad understanding of mothers' perceptions and experiences with breastfeeding and support received, we conducted two Focus Group Discussions (in each, n = 5), and 15 In Depth Interviews. Descriptive statistics were analyzed using SPSS software. Qualitative data were analyzed thematically.

RESULTS

Of the 32 children with a cleft, 23(72%) had ever breastfed, 14(44%) were currently breastfeeding, and among those under 6 months, 7(35%) exclusively breastfed. Of 25 mothers interviewed in IDIs and FGDs, 17(68%; IDIs = 8/15, FGD1 = 5/5 and FGD2 = 4/5) reported the child's failure to latch and suckle as barriers to breastfeeding. All ten mothers who used the soft squeezable bottle reported improved feeding. Nineteen (76%) mothers experienced anxiety and 14(56%), social stigma. Family members, communities and hospitals supported mothers with feeding guidance, money, child's feeds and psycho-social counselling. Appropriate feeding and psycho-social support were only available at a specialized hospital which delayed access.

CONCLUSIONS

Breastfeeding practices were sub-optimal. Mothers experienced breastfeeding difficulties, anxiety and social stigma. Although delayed, feeding, social and psycho-social support helped mothers cope. Routine health care for mothers and their children with a cleft should include timely support.

Infant-Driven Feeding Systems: Do They "Normalize" the Feeding Experience of Infants With Cleft Palate?

OBJECTIVE

To examine feeding skills of infants with cleft palate with or without cleft lip (CP±L) using infant-driven feeding systems compared to healthy controls on standard bottles.

DESIGN

Cross-sectional cohort.

SETTING

Large pediatric academic medical center in the Midwestern United States.

PARTICIPANTS

Infants with CP±L (n = 15) using the Dr. Brown's Specialty Feeding System and typically developing infants without CP±L (n = 15) using the Dr. Brown's Natural Flow Original or Options bottles.

MAIN OUTCOME MEASURE(S)

Bottle-feeding proficiency, duration, milk transfer, and signs of feeding difficulty.

RESULTS

Five-minute feeding proficiency differed significantly between groups with the control group taking 45% of the feed compared to 16% for the CP±L group on level 1 (P < .001) and 30% on level 2 (P < .001) nipples. Proportion of milk transfer was 96% ± 7% for controls and 75% ± 24% for the CP±L group (P = .013). Feeding duration (minutes) differed between the control group (13 ± 3) and the CP±L groups on each nipple level (level 1: 29 ± 16; P = .003; level 2: 32 ± 11; P = .001). Milk transfer rate (mL/min) was 9 ± 3 for control infants compared to 3 ± 1 for infants with CP±L on level 1 (P < .001) and 5 ± 1 on level 2 (P = .007). Coughing occurred in 40% of infants with CP±L and 27% of controls.

CONCLUSIONS

Even when using specialty bottles, infants with CP±L differ from noncleft infants in feeding proficiency, duration, and overall intake.

Prenatal Ultrasound Measurement of Fetal Stomach Size Is Predictive of Postnatal Development of GERD in Isolated Cleft Lip and/or Palate

OBJECTIVE

To determine whether prenatal ultrasound measurement of fetal stomach size, as a surrogate marker of fetal swallowing, is predictive of postnatal development of gastroesophageal reflux disease (GERD) in cases of isolated cleft lip and/or palate (CL/P).

DESIGN

This is a retrospective case-control study. The outcome of interest is postnatal diagnosis of GERD in isolated CL/P. The exposure of interest is prenatal stomach size measurement by ultrasound.

SETTING

The study population was selected from an academic, tertiary care center between 2003 and 2011.

PATIENTS/PARTICIPANTS

Cases were neonates undergoing CL/P repair during the study period. Cases with other known structural or chromosomal abnormalities were excluded. Controls were contemporary, nondiabetic neonates that matched gestational age (within one week) to cases. Each case measurement was matched ∼1:2 with control measurement.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The primary outcome was difference in mean prenatal ultrasound measurement of fetal stomach size between cases and controls. We hypothesized that patients with postnatal development of GERD would have smaller mean fetal stomach size.

RESULTS

There were 32 cases including 19 patients with unilateral cleft lip and palate, 8 with unilateral cleft lip, and 4 with bilateral cleft lip and palate. Cases were noted to have smaller mean anterior-posterior and transverse fetal stomach measurements as compared to controls. This was statistically significant from 16 to 21 weeks, 25 to 27 weeks, and 28 to 36 weeks (P < .01 for all).

CONCLUSIONS

Prenatal ultrasound measurement of fetal stomach size as a surrogate marker of fetal swallowing is predictive of postnatal development of GERD in isolated CL/P.

Feeding and Growth in Infants With Cleft Lip and/or Palate: Relationships With Maternal Distress

OBJECTIVE

To examine relationships between early feeding and growth and maternal distress in infants with and without cleft lip and/or palate (CL/P).

DESIGN

Cross-sectional.

SETTING

Pediatric academic medical center in the Midwestern United States.

PARTICIPANTS

Mothers of infants 1 to 12 weeks old with CL/P (n = 30) and without CL/P (control group, n = 30) were recruited at craniofacial clinic or pediatrician appointments.

MAIN OUTCOME MEASURE(S)

Maternal responses on the Feeding/Swallowing Impact Survey (FS-IS), Parenting Stress Index, Fourth Edition, Short Form (PSI-4-SF), and Edinburgh Postnatal Depression Scale. Infant feeding history and growth measurements were obtained.

RESULTS

Having an infant with CL/P revealed greater impact on maternal health-related quality of life due to feeding problems (F = 4.83, P = .03). Mothers of infants with CL/P reported average range Total Stress scores on the PSI-4-SF, which were higher than controls (F = 4.12, P = .05). Edinburgh Postnatal Depression Scale scores did not differ between groups. Compared to controls, infants with cleft palate had lower percentiles for weight (t = 4.13, P = .04) and length (t = 2.93, P = .01). Higher FS-IS scores were associated with longer feeding duration (r = 0.32, P = .01) and lower weight (r = -0.31, P = .02) and length (r = -0.32, P = .02).

CONCLUSIONS

Despite receiving early team care and feeding interventions, mothers of infants with CL/P reported higher stress and more challenges with feeding and growth. Future studies should examine targeted psychosocial interventions to improve feeding and growth outcomes in infants with CL/P.

Duration of Surgery, Ventilation, and Length of Hospital Stay Do Not Affect Breastfeeding in Newborns After Early Cleft Lip Repair

OBJECTIVE

There are minimal data available on nutrition after early repair of cleft lip and the factors influencing initiation of breastfeeding. This study assessed the impact of the length of surgery, length of ventilation support, and duration of hospital stay on breastfeeding rates after early cleft lip surgery.

DESIGN

This is a prospective observational cohort study comparing 2 hospitals providing early surgical repair of facial clefts from January 2014 to December 2016. Both hospitals are designated as Baby-Friendly Hospitals. Demographic and anthropometric data from mothers and newborns were recorded.

SETTING

Tertiary neonatal and pediatric surgery center.

PATIENTS

Hospital A: 61 newborns, Hospital B: 157 newborns.

INTERVENTIONS

Early (day 5 to 14) cheiloplasty in newborns with cleft lip or cleft lip and palate.

MAIN OUTCOME MEASURES

Influence of duration of hospital stay, length of operation, and artificial ventilation on the rate of breastfeeding.

RESULTS

Significantly, more newborns were breastfed following early surgical repair of an isolated cleft lip compared to those with both cleft lip and palate, in both hospitals (hospital A 82% vs 0%, P = .0001, hospital B 66% vs 5%, P = .0001). Duration of hospital stay, length of operation, and duration of artificial ventilation did not significantly affect the rate of breastfeeding.

CONCLUSIONS

The factors associated with early cleft lip repair (length of operation, length of ventilation support, and duration of hospital stay) do not affect breastfeeding rate.

Single-visit Feeding Obturator Fabrication in Infants with Cleft Lip and Palate: A Case Series and Narrative Review of Literature

Cleft lip and palate (CLP) is one of the most common craniofacial anomaly affecting newborns. In the early years of life to survive baby requires nutrition from the mother. Lip seal of infant is affected because of cleft palate and thereby feeding is greatly compromised. As there is communication between nasal cavity and oral cavity there are more chances of aspiration of milk into the lungs. The main role of pedodontist is to fabricate a palatal obturator which facilitates feeding. In this article we have discussed fabrication of feeding obturator in single visit in infants with cleft palate.

Breast Milk Feeding Practices and Barriers and Supports Experienced by Mother–Infant Dyads With Cleft Lip and/or Palate

Objective:

To examine trends in breast milk provision and to characterize the breast milk feeding practices experienced by mother–infant dyads with cleft lip and/or palate (CL/P) in a large US sample.

Design:

Cross-sectional study.

Methods:

An online survey was distributed through cleft-related social media sites in the United States and in a single cleft lip and palate clinic. Statistical analyses included Kruskal-Wallis H tests and post hoc Mann-Whitney tests to examine group differences based on cleft type and prenatal versus postnatal cleft diagnosis. Linear regression was used to estimate associations between obtained variables.

Participants:

One hundred fifty biological mothers of infants (8-14 months of age) with CL/P (15% cleft lip, 29% cleft palate, 56% cleft lip and palate).

Results:

Forty-six percent of mothers of infants with CL/P provided breast milk to their infant for at least 6 months. Five percent of infants ever fed at breast, and 43% received pumped breast milk via bottle. The most commonly reported supports included lactation consultants, nurses, feeding therapists, and online support groups. Feeding therapy was received by 48% of infants.

Conclusions:

A lower percentage of mothers of infants with CL/P reported providing breast milk compared to national estimates of the general population of infants without clefting. Results suggested there are multiple barriers, as well as numerous medical and psychosocial supports that facilitated breast milk feeding success. Implications for care are discussed.

ABM Clinical Protocol #17: Guidelines for Breastfeeding Infants with Cleft Lip, Cleft Palate, or Cleft Lip and Palate-Revised 2019

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Cleft Lip and Palate

Orofacial clefts are common congenital malformations with genetic and environmental risk factors. In the perinatal period, feeding and nutrition can be a challenge and the need for specialized feeders is common. Lip taping and nasoalveolar molding are early interventions that can be used to preoperatively modify cleft defects to enhance surgical outcomes. Multiple techniques are available for repair of orofacial clefts and choice of technique depends on cleft extent and surgeon preference. After definitive repair, children remain at increased risk for middle ear disease, velopharyngeal dysfunction, and malocclusion and require ongoing follow-up with a multidisciplinary team.

A Retrospective Study Identifying Breast Milk Feeding Disparities in Infants with Cleft Palate

BACKGROUND

Breast milk represents the optimal substrate for all infants, including those with a cleft palate for whom growth may be compromised.

OBJECTIVES

Frequency of breast milk feeding at the breast and per feeder (bottle, cup, enteral tube) in infants with cleft palate was determined and compared with rates reported by the Centers for Disease Control and Prevention. A secondary aim was to review growth status of the infants.

DESIGN

This study represents a 5-year retrospective review using the electronic medical record.

PARTICIPANTS AND SETTING

Patients were ≤12 months old at the time of the initial, presurgical encounter after a diagnosis of cleft palate had been made and were treated at one of two pediatric cleft palate and craniofacial centers in Ohio between September 30, 2010, and September 30, 2015.

MAIN OUTCOME MEASURES

Outcomes measured were breast milk use, reported by mothers and documented in patients' electronic medical records, chronological body weight, as well as weight for length and weight-for-age z scores and percentiles.

STATISTICAL ANALYSES PERFORMED

Descriptive statistics included median with interquartile range and frequency with percentages. World Health Organization z scores were estimated using the Centers for Disease Control and Prevention programs for weight, weight for length, and weight for age at first visit. Comparisons of infants treated at the two hospitals were done using the Wilcoxon rank-sum test or the χ2 test.

RESULTS

Breast milk consumption (26 infants were breastfed and 84 received human breast milk administered with a device) was 29.5%, markedly below the 2016 Centers for Disease Control and Prevention national statistics for ever receiving breast milk (81%). Anthropometric findings included z scores of -0.95 and -0.42 for weight for age and weight for length, respectively.

CONCLUSIONS

Infants with cleft palate were seldom breastfed, nor was breast milk frequently used. In addition, median weight-for-age and weight-for-length z scores suggest that growth of infants with cleft palate was below normative standards.

Fabrication of a Feeding Obturator for Infants

Large clefts in the lip and palate are common congenital anomalies. If the cleft palate is large enough, conventional feeding techniques may not provide proper nutrition for the infant. Feeding obturators will aid in the ability of the infant to attain suction and help the infant to feed adequately. It is necessary for the infant to have sustained weight gain prior to surgery to correct the cleft lip and/or palate. Fabrication of an infant feeding obturator is a simple technique using materials found in every dental office. An impression is made using modeling plastic impression compound. This impression is relined using irreversible hydrocolloid, and the resulting cast is used to enable a vacuum-formed obturator to be fabricated. The vacuum-formed obturator is smoothed and adjusted in the infant's mouth to ensure closure of the palate but allows pace posteriorly to allow normal breathing. The resulting obturator is well retained in the infant's mouth, allowing feeding.

Breast Milk Feeding Rates in Patients with Cleft Lip and Palate at a North American Craniofacial Center

Objective

Our study goal was to evaluate the rates of breast milk feeding among patients with oral clefts at a large North American Craniofacial Center.

Methods

Parents of patients with oral clefts born from 2000 to 2012 and treated at our center were interviewed regarding cleft diagnosis, counseling received for feeding, and feeding habits.

Results

Data were obtained from parents of 110 patients with oral clefts. Eighty-four percent of parents received counseling for feeding a child with a cleft. Sixty-seven percent of patients received breast milk for some period of time with a mean duration of 5.3 months (range 0.25 to 18 months). When used, breast milk constituted the majority of the diet with a mean percentage of 75%. Breast milk feeding rates increased successively over the 13-year study period. The most common method of providing breast milk was the Haberman feeder at 75% with other specialty cleft bottles composing an additional 11%. Parents who received counseling were more likely to give breast milk to their infant ( P = .02). Duration of NasoAlveolar Molding prior to cleft lip repair did not affect breast milk feeding length ( P = .72). Relative to patients with cleft lip and palate, patients with isolated cleft lip had a breast milk feeding odds ratio of 1.71.

Conclusion

We present breast milk feeding in the North American cleft population. Although still lower than the noncleft population, breast milk feeding with regards to initiation rate, length of time, and proportion of total diet is significantly higher than previously reported.

Suck-Swallow-Breathe Dynamics in Breastfed Infants

Despite the importance of the suck-swallow-breathe reflex during breastfeeding, a large proportion of our understanding is derived from bottle-feeding studies. Given the differences in the delivery of milk during breast and bottle feeding, it is imperative that a more general view of the suck-swallow-breathe and milk removal process during breastfeeding is available. This systematic review aimed to assess the evidence for the mechanism of milk removal during breastfeeding; evaluate how the term infant coordinates sucking, swallowing, breathing (SSwB) and cardiorespiratory patterns; and how these patterns change with maturation during breastfeeding. A literature search of PubMed and MEDLINE was performed to assess the mechanism of milk removal and patterns of sucking, swallowing, breathing, and cardiorespiratory control during breastfeeding in healthy term infants. Seventeen studies were selected and a narrative synthesis was performed. Nine studies assessing the infant sucking mechanism consistently provided evidence that vacuum is essential to milk removal from the breast. The limited data on swallowing and breathing and cardiorespiratory control showed mixed results. Overall, results highlighted the high variability in breastfeeding studies and suggested that swallowing, breathing, and cardiorespiratory patterns change with maturation, and within a breastfeed. These findings show potential for devising breastfeeding interventions for populations at risk of SSwB problems. However, consistent methods and definitions of breastfeeding parameters are required before interventions can be adequately developed and tested.

Ultrasound Imaging of Breastfeeding--A Window to the Inside: Methodology, Normal Appearances, and Application

Ultrasound imaging has been employed as a noninvasive technique to explore the sucking dynamics of the breastfeeding infant over the past 40 years. Recent improvements in the resolution of ultrasound images have allowed a more detailed description of the tongue movements during sucking, identification of oral structures, and measurements of nipple position and tongue motion. Several different scanning planes can be used and each show sucking from a different perspective. Ultrasound techniques and image anatomy are described in detail in this review and provide the basis for implementation in the objective assessment of breastfeeding.

Presurgical orthopedics by drink plates does not significantly normalize deglutition in infants with cleft lip and palate

OBJECTIVE

To test the null hypothesis of no significant difference between intraoral pressure characteristics in infants with cleft lip and palate (CLP) with or without presurgical orthopedic (PSO) plates (groups CLP and CLP-PSO), compared with noncleft infants.

MATERIALS AND METHODS

Intraoral atmospheric pressure assessments were performed on 17 subjects with preoperative CLP (m/f, 11/6; mean/SD, 4.76/0.92 months) and a matched control group (n = 24; m/f, 15/9; mean/SD, 4.88/0.9 months), for 200 seconds, simultaneously at the vestibulum (vestibular space [VS]) and at the palate (subpalatal space [SPS]), using a prepared pacifier connected to a digital manometer. Areas under the pressure curves (AUC), frequencies, durations, and magnitudes of swallowing peaks and pressure resting plateaus were compared between trial groups and locations (VS, SPS) using a two-factor analysis of variance for repeated measures, Kruskal-Wallis test, and Mann-Whitney U-test (α = .05).

RESULTS

The null hypothesis was rejected: Globally, there were statistically significant differences in intraoral pressure characteristics between groups CLP, CLP-PSO, and control (all P < .01), with significantly higher negative pressures (AUC) in the control subjects compared with those of CLP or CLP-PSO. There were significant effects by the location of pressure recordings (VS, SPS) and their interaction with all treatment groups. Differences between noncleft and CLP subjects were more pronounced in the VS than in the SPS. There was no significant effect by PSO.

CONCLUSION

PSO does not improve deviated swallowing characteristics during suction in CLP infants.

Feeding considerations in infants born with cleft lip and palate

Infants born with the congenital deformity of cleft lip and or palate suffer from varieties of complications since the day 1 of their life. The most important of which is the feeding difficulty which leads to insufficient food intake and thereby causing deleterious effects on their overall development leading to malnutrition and death in some cases. However, research into the anatomical variations of these infants in the region of lip and palate has led to the development of several types of feeders and their modifications which would help them thrive well in the initial days and also for later. Hence, it is worth important to know about them in detail and help these infants and their families psychologically so that the infants do not suffer from feeding difficulties anymore.

Weight, Length, and Body Mass Index Growth of Children Under 2 Years of Age With Cleft Lip and Palate

OBJECTIVE

To study the growth of length-for-age (L/A), weight-for-age (W/A), and body mass index (BMI) of children with cleft lip and palate receiving a normal diet; to establish specific growth curves for children with cleft palate with or without cleft lip (CLP/ICP) who had not undergone palatoplasty and for children with isolated cleft lip (ICL); and to assess if CLP/ICP growth differed from ICL growth and if CLP/ICP and ICL growth differed from growth for typical children.

DESIGN

Prospective and cross-sectional study.

SETTING

Hospital for Rehabilitation of Craniofacial Anomalies, Bauru, São Paulo, Brazil.

MAIN OUTCOME MEASURES

Weight and length of 381 children with cleft lip and palate and who were younger than 2 years were recorded and used to calculate W/A, L/A, and BMI growth curves. The 2006 World Health Organization growth charts were used as a reference for typical children. All children received a normal diet for age.

RESULTS

Children with CLP/ICP had median W/A and BMI growth curves below growth curves for typical children but showed spontaneous recovery starting at approximately 5 months of age, even with nonoperated cleft palate. Children with ICL had growth similar to that of typical children. Children with CLP/ICP, who initially had W/A and BMI values less than those of the ICL group, had W/A and BMI equal to or higher than the ICL group after 9 months of age.

CONCLUSION

Children with CLP/ICP had impaired W/A and BMI growth with spontaneous recovery starting early in childhood. This study established specific W/A, BMI, and L/A growth curves for children with cleft lip and palate.

Incidence of use of acid suppression medications in infants with oral clefting

OBJECTIVE

Less than 1% of the general pediatric population needs pharmacologic therapy for reflux symptoms; yet, the co-existence of gastroesophageal reflux disease (GERD) with oral clefting remains unclear. The purpose of this retrospective study was to appreciate the difference in the incidence of anti-GERD pharmacotherapy in a sample population of infants with oral clefting compared to the general pediatric population.

MATERIALS AND METHODS

One hundred ninety-six consecutive patients diagnosed with cleft lip only, cleft lip and palate, and isolated cleft palate were analyzed through clinical record review. Demographic and clinical information including but not limited to the type of oral cleft present at birth, reported signs and symptoms of GERD, and anti-GERD medications used were compiled for all subjects. Collected data were analyzed using descriptive statistics.

RESULTS

Sixty-four (33%) of 196 infants with oral clefts had documented signs and symptoms of GERD. Nine percent (18 of 196) of the subjects received anti-GERD medications. The infant subgroup with treated GERD consisted of 11 out of 62 (18%) patients with isolated cleft palate, 5 of 112 (4.5%) with cleft lip and palate, and 2 of 17 (11%) with cleft lip only.

CONCLUSIONS

The incidence of anti-GERD pharmacologic therapy among infants with oral clefts (9%) is significantly higher than among the general pediatric population (<1%). Furthermore, palatal clefts impart a greater risk of GERD symptoms than clefts of the alveolus, lip, or nose. In order to minimize the long-term consequences of GERD, a standardized interdisciplinary clinical protocol is necessary for evaluating infants with oral clefts.

An evaluation of factors influencing feeding in babies with a cleft palate with and without a cleft lip

The objective of this article was to determine the impact of different bottles and teats for feeding babies with a cleft palate (with and without a cleft lip) on weight velocity, feeding behaviour, and maternal self-esteem. A mixed methods study incorporating the use of diaries to record feeding patterns of babies and levels of professional support received was used. Growth was assessed by converting weights into standard deviation scores and using the differences to express weight velocity over a six-week period. Visual analogue scales were used to assess mothers' perceptions of their children and themselves. The Edinburgh Postnatal Depression Score (EPDS) was used to identify maternal depression. The study demonstrated that the most significant effect on weight was determined by cleft type. Babies with isolated clefts of the hard and soft palate experienced greater feeding problems and suffered the biggest weight losses. This remained significant independently of the type of bottle/teat used. Poor weight gain was also associated with a mother's low perception of herself and her child, and her tendency towards depression. The study highlights the importance of the early assessment of babies' feeding skills and regular follow-up and support from trained and experienced nurse specialists.

Role of obturators and other feeding interventions in patients with cleft lip and palate: a review

BACKGROUND

Newborns with cleft palate have a distorted maxillary arch at birth. Depending upon the type of cleft, infants suffer from a variety of problems, many of which are related to feeding difficulties. Feeding these babies is an immediate concern because there is evidence of delayed growth of children with cleft lip and palate (CLCP) compared to normal infants. Many methods have been devised to overcome these problems, including the use of special bottles, nipples, and initial obturator therapy.

REVIEW

A Pub Med search was conducted using the following search terms: feeding interventions in cleft lip and palate, feeding plate/obturator in cleft palate. All the relevant articles were studied and the reference list of selected articles was also studied. Effects of different feeding interventions in infants with cleft palate with special emphasis on obturators, based on descriptive reports, expert opinions, and available data from clinical trials was reviewed.

RESULTS

The combination of search terms generated a list of 74 articles out of which 51 articles were excluded based on analyses of abstracts and full texts. Three additional publications were identified by the manual search. A total of 26 relevant articles were selected which included randomised controlled trials and descriptive studies on feeding interventions and obturators.

CONCLUSION

A single intervention may not fulfil all feeding requirements of infants with CLCP. Combined use of different feeding interventions such as palatal obturator, Haberman feeder, and breast milk pump and lactation education may successfully meet the feeding needs of both mother and child.

Prevalence of feeding disorders in children with cleft palate only: a retrospective study

OBJECTIVES

The purpose of this study in children with cleft palate only (CPO) is to (1) explore the prevalence of feeding problems on a retrospective basis, (2) investigate rates of nasogastric (NG) feeding, (3) examine the prevalence of associated disorders and/or syndromes (AssD/S), (4) investigate if there are certain risk factors associated with feeding difficulties, NG feeding, and failure of breastfeeding, and (5) investigate the effect of palatoplasty on feeding difficulties.

MATERIALS AND METHODS

In total, 90 questionnaires were included in this study. The medical records were reviewed.

RESULTS

Feeding difficulties were reported in 67% (n = 60) of all cases. NG feeding was given in 32% (n = 28) of all children. Forty-nine children (54%) have associated malformations. There is no significant relation for gender, gestational age, and birth weight as risk factors for feeding difficulties, NG feeding, and failure of breastfeeding. The severity of the cleft is significantly related to the prevalence of AssD/S. After palatoplasty, feeding difficulties improved in 79% of the CPO children.

CONCLUSIONS AND CLINICAL RELEVANCE

First, our results clearly indicate that children with CPO are at high risk of developing feeding difficulties (67%); NG feeding is often necessary (32%). Second, our results also indicate that the more severe the cleft, the more likely the chance for AssD/S. Third, the severity of the cleft is significantly related to the prevalence of AssD/S. Fourth, there is no significant relation for gender, gestational age, and birth weight as risk factors for feeding difficulties, NG feeding, and failure of breastfeeding. Fifth, improvement of feeding difficulties after surgery supports the importance of the soft palate closure in relation to sucking patterns and feeding skills.

ABM clinical protocol #18: guidelines for breastfeeding infants with cleft lip, cleft palate, or cleft lip and palate, revised 2013

A central goal of the Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient.

Intraoral pressure patterns during swallowing

Swallowing disturbances are common after neurological disease and oropharyngeal tumor resection. In this case the oral stage is often affected. So far the clinical evaluation of the oral phase is limited. Recently the role of pressure changes during oropharyngeal swallowing has been pointed out, but until now there are not enough data. Thereby 52 healthy adults aged between 20 and 45 years were examined using an oral shield (Silencos^®, Bredent, Senden, Germany) connected to a digital manometer (GDUSB 1000^®, Greisinger electronics, Regenstauf, Germany) able to record pressures in a range of 2,000 to −1,000 mbar at a frequency of 1 kHz. Three swallowing conditions were measured: an active bolus intake (ABI) of water, a passive bolus application of a water-bolus (PWA) and a passive application of a gel-bolus (PGA). We found negative pressures with a median value of −278.9 mbar during ABI, of −24.2 mbar during PWA and of −29.4 mbar during PGA. Significant differences in pressure amplitudes and the pressure pattern were observed depending on the kind of bolus application and its consistency. The used test presents a simple and easy to handle method to assess the oral phase of swallowing.

Growth trajectory of children and adolescents with isolated cleft lip and/or palate through the first two decades of life

A wide body of evidence shows that patients with clefts exhibit decreased growth in their early years. Less evidence regarding their growth trajectory, specifically their body mass indices (BMIs), in later years is available. This study analyzes BMIs of patients with isolated clefts and/or palate over time using age-adjusted BMI z-scores based on the CDC 2000 references for height and weight for age. At least two height and weight measurements were obtained during 2-10 years and at least two height and weight measurements were obtained during 10-20 years. Mean BMI z-score for all patients was 0.117. Males had a mean z-score of 0.087 and females a mean of 0.160 (p=0.407). Patients under 10 years of age had a mean z-score of 0.208, while patients older than 10 years had a mean z-score of -0.028 (p=0.223). While significance was not achieved in the statistical analysis, the results suggest that overall, the cleft population maintains a mean BMI that is similar to that of the general population during childhood and adolescence. A larger analysis is warranted to investigate this phenomenon further and to investigate specifically the rate of obesity within this group.

Application of the International Classification of Functioning, Disability, and Health–Children and Youth Version (ICF-CY) to Cleft Lip and Palate

Objective

In recent health policy discussions, the World Health Organization has urged member states to implement the International Classification of Functioning, Disability, and Health: Children and Youth Version in their clinical practice and research. The purpose of this study was to identify codes from the International Classification of Functioning, Disability, and Health: Children and Youth Version relevant for use among children with cleft lip and/or palate, thereby highlighting the potential value of these codes for interprofessional cleft palate-craniofacial teams.

Design

The scope of recent published research in the area of cleft lip and/or palate was reviewed and compared with meaningful terms identified from the International Classification of Functioning, Disability, and Health: Children and Youth Version. In a five-step procedure, a consensus-based list of terms was developed that was linked separately to International Classification of Functioning, Disability, and Health: Children and Youth Version categories and codes. This provided a first draft of a core set for use in the cleft lip and/or palate field.

Conclusions

Adopting International Classification of Functioning, Disability, and Health: Children and Youth Version domains in cleft lip and/or palate may aid experts in identifying appropriate starting points for assessment, counseling, and therapy. When used as a clinical tool, it encourages health care professionals to go beyond treatment and outcome perspectives that are focused solely on the child and to include the children's environment and their familial/societal context. In order to establish improved, evidence-based interdisciplinary treatments for children with cleft lip and/or palate, more studies are needed that seek to identify all the influencing conditions of activities, children's participation, and barriers/facilitators in their environments.

Clinical and Fiberoptic Endoscopic Evaluation of Swallowing in Robin Sequence Treated with Nasopharyngeal Intubation: The Importance of Feeding Facilitating Techniques

Objective

To evaluate oral feeding capacity, the swallowing process, and risk for aspiration, both clinically and during fiberoptic endoscopic evaluation of swallowing, in infants with isolated Robin sequence treated exclusively with nasopharyngeal intubation and feeding facilitating techniques.

Design

Longitudinal and prospective study.

Setting

Hospital de Reabilitação de Anomalias Craniofaciais, University of São Paulo, Bauru, Brazil.

Patients

Eleven infants with isolated Robin sequence, under 2 months of age, treated with nasopharyngeal intubation.

Interventions

Feeding facilitating techniques were applied in all infants throughout the study period. The infants were evaluated clinically and through fiberoptic endoscopic evaluation of swallowing at first, second, and, if necessary, third week of hospitalization (T1, T2, T3). The mean volume of ingested milk was registered during clinical evaluation, and events were registered during feeding.

Results

The respiratory status of all infants was improved after nasopharyngeal intubation; 72% of them presented risk for aspiration during fiberoptic endoscopic evaluation of swallowing at T1. This risk was less frequent when thickened milk was given to the infants and at subsequent evaluations (T2 and T3).

Conclusions

Nasopharyngeal intubation aids in stabilizing the airway in isolated Robin sequence, but it does not relate directly to feeding. The risk for aspiration was present in most of the infants, mainly during the first week of hospitalization, and improved within a few weeks, after the use of feeding facilitating techniques.

Evaluation of growth in patients with isolated cleft lip and/or cleft palate

OBJECTIVE

The purpose of the study was to evaluate the growth of patients with isolated cleft lip (CL), with or without cleft palate (CP), or CP during the first few years of life.

METHODS

A retrospective analysis of data from birth to 5 years for 307 patients with isolated CL/CP or CP alone who were seen in a large craniofacial center between 1980 and 2007 was performed. We analyzed growth patterns and feeding interventions. Anthropometric values were plotted onto 2000 Centers for Disease Control and Prevention charts. Longitudinal analyses were performed to estimate age-related changes and to test whether feeding interventions or early education influenced age-related changes.

RESULTS

Including progressive weight, length, and head circumference values, a total of 1944 data points were available. The most frequent diagnosis was unilateral CL with CP (165 [53.7%] of 307 cases). No patients experienced significant failure to thrive during the study period, although predicted weight and length percentiles for age had initial decreases during the first year of life, with nadirs at 5.2 and 15 months, respectively. These decreases were followed by recovery that started at approximately 12 months for weight and at 20 months for length (P < .0001). Patients who had feeding interventions had a significantly (P = .047) increased gain rate over time for weight for length, compared with those who did not.

CONCLUSIONS

In this population, there were weight and length decreases during the first year of life, which were not clinically significant and were followed by statistically significant recovery. Recovery seemed to be related to successful education and feeding interventions. Head circumference and weight for length started at lower percentiles but showed consistent gain over time.

Avaliação da alimentação em crianças com fissura de lábio e/ou palato atendidas em um hospital de Porto Alegre

OBJETIVO: avaliar a alimentação de crianças fissuradas e descrever suas características; verificar o tipo de alimentação e suas dificuldades alimentares. MÉTODOS: foi um estudo quantitativo, transversal, observacional e descritivo. Participaram 23 pacientes fissurados de zero a nove anos, que realizaram avaliação do sistema estomatognático e cujos responsáveis foram entrevistados. Realizou-se análise estatística descritiva dos dados obtidos na avaliação, assim como análise teórica. RESULTADOS: o tipo de fissura mais encontrada foi a Fissura Transforame Unilateral. Das 23 crianças, duas (8,75%) foram amamentadas exclusivamente. As maiores dificuldades alimentares foram: seis (26,1%) dificuldade para sugar, 10 (43,5%) engasgos, quatro (17,4%) dificuldade para deglutir, três (13,0%) dificuldade para mastigar e 12 (52,2%) tinham refluxo nasal. As alterações das funções do Sistema Estomatognático mais frequentes foram a interposição lingual importante na deglutição e mastigação do tipo mascagem. CONCLUSÃO: a fissura transforame, mesmo sendo mais complexa, não excluiu o aleitamento materno exclusivo; o tipo de alimentação relacionado com a idade dos pacientes apresenta-se de maneira adequada; boa parte dos pacientes ainda usa a mamadeira com bico comum, constituindo um hábito deletério. As maiores dificuldades na alimentação relatadas pelas mães foram engasgos, refluxo nasal e dificuldade de sugar. As crianças que não apresentaram queixas de dificuldade de alimentação eram portadoras, na sua maioria, de fissura pré-forame incisivo.