Infants with cleft palate or cleft lip and palate (CP/CLP) have specific feeding needs based upon unique anatomy and swallow physiology. Poor or absent inner oral pressure and compensatory muscle movements affect all phases—oral, pharyngeal, and esophageal—of swallowing, and in some cases, increase risk of aspiration.
These babies expend a significant amount of energy in the act of feeding. They demonstrate an average rate of 109.26 sucks per minute compared to infants without clefts who averaged 75.07 sucks per minute. Increased energy expenditure might lead to fatigue. Under these conditions, infants experience challenges in maintaining respiratory coordination and airway protection in the pharyngeal phase.
When feeding an infant with cleft palate consider the following:
Infants with CP/CLP tend to swallow more air when feeding. Therefore, it’s important to release this air by burping as the infant consumes each ounce. Frequent burping helps the infant avoid feeling falsely sated, and reduces spitting up, reflux, and gas pain.
Infants with CP/CLP under-use their geniohyoid and mylohyoid muscles during the oral phase and have reduced tongue movement, resulting in an extended pharyngeal phase. SLPs might notice an audible swallow, mild pharyngeal wetness, and throat clearing as common feeding characteristics in infants with CP/CLP. These signs make sense when we consider these compensatory swallow patterns.
Infants should feed in a relaxed state, but those with CP/CLP often feel stress while feeding. Look for stress cues during feeding including a furrowed brow, wide eyes, redness around brow/eyelids, tension in the legs/arms, and/or clenched fists often held high near the face.
We also need to watch carefully for signs of aspiration during feeding. These include significant pharyngeal wetness, gagging, coughing, chest congestion, vomiting, watery eyes, and excessive nasal congestion or regurgitation not mitigated with bottle changes. In these cases, SLPs perform a modified barium or videofluoroscopic swallow study.
A word of caution regarding thickened feedings for infants with cleft palate:
Common strategies to increase the viscosity of breast milk or formula in infants with typical anatomy might cause more issues for infants with CP/CLP. Poor oral pressures and compensatory swallow patterns mean they often get a small amount of residue of thin liquids along the posterior tongue and pharynx, which you can see during a swallow study.
Thickened liquids can be more difficult to clear and might create pharyngeal residue, increasing risk of aspiration. I strongly recommend thickened liquids be assessed under fluoroscopic examination. In some cases, temporary tube feeding provides a safer alternative to thickened liquids in infants with CP/CLP. For infants needing thickened liquids for gastroesophageal reflux management, your team might want to consider an anti-regurgitation formula.
Thickened liquids can also alter the mechanics of the specialty feeder bottles and increase feeding times, leading to fatigue and decreasing the intake volumes needed for hydration and weight gain.
Allyson Goodwyn-Craine, MS, CCC-SLP, BCS-S, has more than 30 years of clinical experience feeding infants with cleft palate and cleft lip and palate. She is an adjunct professor at Portland State University, and also provides outpatient pediatric feeding services and works as part of the NICU rehabilitation team at Sunnyside Medical Center. Goodwyn-Craine is an affiliate of ASHA Special Interest Groups 5, Craniofacial and Velopharyngeal Disorders; and 13, Swallowing and Swallowing Disorders (Dysphagia). Allyson@FeedingSpeechPaths.com