Dear Susan,

I'm not an IBCLC yet either (a couple of years to go yet - so you're closer than me). But I have breastfed a baby with a cleft lip and palate and have worked with other families for some years now. 

>I don't recall babies with cleft palates being more at risk of aspiration with breastfeeding than bottle feeding. I am looking for evidence based research/ information on the risks of  breastfeeding vs bottle feeding  with cleft palates

I would love to have the same information. But perhaps it hasn't been studied because there isn't a great risk of aspiration? From informal conversations I have had with doctors, they have assumed that only those infants with neurological difficulties would be at risk of aspiration.

I have known many families through cleft support groups and through conference presentations that I have given and in the six years since my daughter was born I have only known one baby with aspiration problems - but he has other issues more important than his cleft palate  (the parents don't have a clear diagnosis but he has breathing difficulties, swallowing difficulties and developmental delays and he doesn't take any food by mouth at age two). 

Another boy (unilateral cleft lip and palate) had an isolated case of aspiration and he was many months old when it happened (he was bottle fed).

Doctors here (in Italy) can be a little bit heavy handed and use a nasal gastric tube when they fear aspriation. Obviously, impeding the mother from breastfeeding adds stress to an already complicated breastfeeding situation. Surely the doctors could observe the baby at the breast first, before deciding to bottle feed only?

>I remember from my course work that babies can breastfeed well with a cleft, if not to severe and baby is able to form seal with breast tissue.

I know one mother personally who exclusively breastfed her daughter born with a cleft of the soft palate. As in the case you describe, the cleft was diagnosed only some days after birth. This mother had good breastfeeding information during pregnancy and in the hospital (she also had a cesarean, just to complicate things). She did have to work at keeping up her milk supply (expressing after some feeds), but exclusively breastfed until 3 months, when she stopped for other reasons (the baby was diagnosed with other health problems and she gave up breastfeeding for stress reasons).

But even if the baby can't breastfeed exclusively, then the baby should be given the chance to breastfeed and then work out a strategy for helping baby receive more milk at the breast or how to supplement expressed milk.

Possible strategies are;

-Breast compressions while baby is at breast
-Expressing after feeds to increase supply
-An SNS or Lact-Aid can be used (may need to be modified to help flow)
-Some mothers alternate breast/bottle/breast
-The baby can breastfeed first and then receive some of the bulk of the feed via bottle
-Baby can receive all nutrition via alternate needs and 'comfort suck' whenever possible


There is a chance that the baby will continue breastfeeding/commence breastfeeding after the palate repair (which is frequently around five-six months). It's a delicate time and the mother should be encouraged to seek lacatation support beforehand.

Good luck, and I would love to hear your progress with this case.

Alice Farrow
(studying to be an IBCLC)
Italy

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