Any baby with a cleft palate will have some difficulty establishing feeding.  This is because they cannot form a good vacuum in their mouth needed to extract milk either from the breast or a bottle.

A cleft palate with or without a cleft lip, however small, results in abnormal placement of the soft palate muscles.

In a palate without a cleft, the soft palate lifts to create a vacuum in the mouth when one sucks and swallows (picture “A” – palate at rest, picture  “B” – palate lifted).  Because of the abnormal muscle position in a baby with a cleft, there is limited and ineffective movement of the soft palate.  Baby therefore cannot create a seal at the back of the nose needed to form a vacuum in the mouth to draw in the mother’s breast tissue to breast-feed.

How this affects breastfeeding

Breast tissue needs to be drawn into the baby’s mouth for good attachment and therefore adequate milk removal, especially the fat rich milk at the end of the feed which helps your baby to gain weight.

This problem may be overcome by encouraging you to express your milk at first, teaching you a slightly different technique of attaching your baby to your breast and by stimulating the milk flow by hand expressing during the feed.

Your feeding options

Some babies with a cleft lip and palate are much more difficult to breastfeed successfully than others. Here are some examples:

• A cleft palate that is wide.
• A baby with a cleft palate, a small jaw and a tongue which is set back in the mouth.
• A baby, who has had breathing difficulties at birth, associated with their cleft palate.
• A baby with an extensive bilateral cleft lip and palate.

The mothers who are most successful breast feeding a baby with a cleft are those who have breast fed before, and/or those who are very determined to succeed.

Breast feeding

If you wish to breast feed, it helps if you start to express your milk using a double breast pump (provided by your midwifery unit) as soon as possible following the birth of your baby.  This stimulates the production of your milk.  

It also helps if baby can get a larger than normal mouthful of breast tissue to breast feed. This can be achieved by using an exaggerated attachment technique:
 

1. Start off by holding your baby horizontally with his nose opposite your nipple.  
2. Turn your baby completely on his side to face you and with your free elbow bring his bottom close to your body. Tummy to tummy/chest to chest.
3. Try not to hold his head but support the back of his neck and shoulders between your spread out finger and thumb.
4. His head should fall back gently between the V shape your finger and thumb makes.  This helps to raise his chin off his chest so that he can open his mouth wide, ready for a good attachment.  
5. If feeding across the front, when you look down at your baby, his forehead, shoulder and hip should all be in a straight line. Using your other hand, support your breast underneath with your small finger touching your ribs. Your thumb should rest on the top of your breast usually on the edge of the areola (dark surround of the nipple).

 

Line your nipple with baby's nose so he can smell the milk and open his mouth wide.  Bring your baby to your breast but make sure your baby's bottom lip makes contact with the areola, well away from the base of the nipple.



Your thumb then needs to quickly slide or roll your nipple forward under the roof of your baby's mouth and then be brought back to rest, on top of the areola.



Once this manoeuvre is complete it may be necessary to maintain this breast hold and use your fingers and thumb to gently express milk into his mouth to help him feed more effectively.  
If this is not necessary once he has established a good feeding rhythm, your hand should be slowly released from your breast and brought to rest under him.

The advantages of giving breast milk to your baby with a cleft palate

One of the main added advantages of giving your child breast milk is to protect the exposed delicate tissues of the lining of the nose from milk deposits caused by formula milk.  These deposits can irritate your baby’s nose.   Breast milk also gives added protection against infections at the time of operation and infections that can contribute to “glue ear”, common in babies with a cleft.

Giving breast milk by bottle

You may feel that you would like to give your child breast milk but are worried about succeeding.

As an alternative, you can express your milk using a breast pump and either you or your partner can give your expressed milk by bottle.  Portable electric pumps are quick and efficient to use and can be hired easily.  Your midwife can give you details.  Electric pumps can be set up for single or double pumping.

Single pumping is when you use the pump on one breast at a time.

Double pumping is when you pump both breasts at the same time. It may be especially beneficial if you:

• Use the pump on a long term basis
• Would like to reduce your pumping time (it takes about half the time)
• Do not want to waste milk that leaks from the second breast whilst pumping from the first.
• Are going back to work early and need to build up a good store in the freezer.

Ann expressing her milk using a double electric breast pump

Double pumping both breasts at the same time can take about 10 to15 minutes.  If more milk is required massage and resume pumping for a short time.

As baby needs to create a vacuum in the mouth to bottle feed, it may be necessary to use a soft bottle and learn a technique called ‘assisted feeding’. Your specialist who provides you with bottles will teach this to you, following a formal feeding assessment of the feeding skills of your baby.

Further information and links:

“Feeding your baby with a cleft lip and/or palate – Your Options” by Vanessa Martin and Mandy J.B. Abbett or you can obtain this booklet from the Medela website at www.medela.co.uk

Breastfeeding an infant with cleft lip or palate

Emedicine links:

Cleft palate

Cleft lip

Bilateral Cleft lip repair

Pierre Robin Syndrome

Cleft lip and palate

Articles & research:

Breastmilk and babies with cleft palate and otitis media.

Yes! Infants with clefts can be breastfed.

Breastfeeding and reduced rate of otitis media in cleft babies

Breastfeeding and clefting

Danner SC. Breastfeeding the infant with a cleft defect. NAACOGS Clin Issu Perinat Womens Health Nurs. 1992;3(4):634-9.

Weatherley-White RC, Kuehn DP, Mirrett P, Gilman JI, Weatherley-White CC. Early repair and breast-feeding for infants with cleft lip. Plast Reconstr Surg. 1987 Jun;79(6):879-87.

Organisations:

Cleft Lip and Palate Association of Ireland

Cleft Advocate Your On-Line Source for Education and Inspiration.

Cleft Lip & Palate Association (UK)

Cleftpals: The Cleft Lip and Palate Society (Australia)

SMILES Cleft Lip and Palate Support Group

Wide Smiles Cleft Lip & Palate Resource