An interesting patient of mine- a 27 week old baby weighing 1 Kg, had incomplete cleft palate. It was really challenging to increase the baby's feeds to acceptable levels- but ultimately the result was good. I tried a few modifications of my own, and was quite happy with the weight gain over the course of hospitalization. While seeking advice from others, I realized that many are experienced with either of the fields- preterms or clefts - but only a few in both. A practical approach towards a combined case is not always as that outlined in the books - one has to tailor-make the feeding regimen for the baby and involve the parents a great deal.
The most critical part of management - viz. that of feeding is often a problem in that doctors are either not well versed in this core aspect, or do not have sufficient time to devote to the baby and parent for training and modifying practices.
I train mothers in 3 methods of feeding - so that she is always prepared to use one method when the other two are ineffective- this also helps her easily 'step-up' or down when required. Emergency measures are also taught to the mothers before leaving the hospital- so that in the event of aspiration or regurgitation, she is competent enough to provide basic and sensible care at the earliest.
During the feeding of the case mentioned here- breast feeding was not a sustainable option during the initial phase, as the baby would get exhausted rapidly, and thus ingested feeds would be less. We tried dropper, 'Paladai feeds', and bottle feeds (with Habermans) at various times, and with success. The baby is now 2 Kgs and going strong. What has your experience been in similar situations- what was the strategy adopted?
Cleft lip with intact palate can often be fed with the same teniques used for healthy babies but cleft palate with or without cleft lip is another matter. Without the palate to seal the nasal pharynx the path of least resistence is for air to be pulled in through the nose. Thus no suction is generated. If the preterm infant has enough brain maturity to swallow a haberman bottle, mead johnson bottle or other squeezable feeding device shoudl be used and will generally be successful as long as the family is properly instructed.It is essential that they know they must squeeze assist the bottle for a neonate especially a preterm infant.
If the infant is not yet swallowing effeciently ng feeding with an oral stimulation program will generally be successful. If there is not oral stimulation it is easy to have preterm infants with cleft develop oral resistence so that is an importnat part of the plan. Speech therapists or occupational therapists with experience in neonatal feeding can provide the interventions.
Very good inputs dear colleagues - one of the problems I see here is that a few physicians merely look at the baby's sucking efforts and assume that feeds will be tolerated well, while in fact- it may just be the opposite. As far as the preterm with cleft defects is concerned- one needs to periodically assess and decide on the mode of feeding.
Have you given any thought to the use of palatal obturators? Alot of the research on cleft palate has come from pediatric dentisty journals. Another technique that has been tried is breastfeeding the infant in the straddle sit position. The infant is held in a full sitting position with legs spread and straddling the mother's thigh with the head very slightly tilted backward. The mother pushes the breast into the baby's mouth as far as possible sealing off the cleft palate. The breasts are massaged prior to beginning the feeding or use of a breast pump to begin the milk flow. The mother also places her fingers under the baby's jaw and firmly pushes up and down to simulate sucking movements which the baby picks up quickly. At the same time the mother can use an SNS system to make the work somewhat easier for the baby. The SNS device hold a bottle of milk around the mother's neck (hangs like a necklace) with some "angel-hair pasta" size silastic tube which she tapes to her nipple. The milk will automatic flow when the baby makes any attempt to suck. If you these techniques together it may be helpful. I was able to use these with a baby with both cleft lip and palate and had the infant back up to birth weight by 9 days post birth. The mother used her thumb or breast tissue to occlude the cleft lip.
Feeding a 27 weeker with cleft palate is challenging for two reasons. The first reason being prematurity itself and second, the cleft. Suck- swallow coordination is not mature in these preterms and offering direct breast feeds is not the best option. Gavage feeding of expressed breast milk using long stemmed paladai or tube feeds would be beneficial. As for further feeding beyond 34 weeks in small anterior clefts, breast feeding itself can be effective. The mother should be able to pull a long teat out of her breast so that a part of the breast tissue obliterates the cleft.
Very true Venkatesh- exhaustion of a SGA preterm during breast feeding is very problematic indeed.
I reviewed the bay 2 days back, and happy to note that weight gain is a satisfactory 30 grams per day. The baby now prefers mother's milk and expressed milk is now being given through habermans special bottle which is designed for pre-termers with cleft palate. Baby seems to be adjusting to it well.
A few episodes of nasal congestion in the baby causing feeding difficulties was reported by the mother, but responded well to the advice of application of saline nasal drops 10 minutes prior to feeds.
This baby has indeed been one of my greatest teachers!
Mr. Suresh:
Your comment about making sure the nasal passages are unobstructed prior to any type of feeding is right on the mark. Infants with clefts can regurgitate frequently resulting in partial obstruction of the nares from milk residue. This is technique is very important for them as well as any child attempting to breastfeed with blocked passages (e.g. nasal congestion from colds)
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