Dear Lactnetters
I am posting this in the hope I may get some further ideas.  Last evening in
the Special Care Nursery I work in a baby was admitted with a midline cleft
of the soft palate.  Born yesterday morning, having difficulty with
breastfeeding and noted to be making "clicking" sound.  Assessed by
postnatal staff as not breastfeeding effectively found to have cleft palae.
Doctor notified and given finger feed.  Apparently had a dusky episode
associated with small mucously vomit and finger feed and transferred to the
Special Care Nursery.  I looked after baby for first time this morning.

Mother keen to breast feed.  I got baby sitting in upright position, good
gape and mouth around areola but obviously had great difficulty creating any
suction.  Made "clicking" noise and frequently needed to be re-positioned at
breast, didn't appear to elongate nipple.  Mum has small firmish nipples so
I feel probably will never get to the stage that they will stretch and
elongate far enough to cover the cleft.  A suck assesment  with gloved
finger demonstrated baby could generate a small amount of suction.  Baby
tired after about 20 minute breast feed and I topped up via an OG.
Aspiration of tube demonstrated a minimal amount of colostrum transfer so
there is some hope of eventual success.  Had discussion with mother regards
the need for expression following breast feeds to build up a good supply.
At the moment she is hand expressing (very small amounts < 1 ml--so at this
stage baby needs to be supplemented with formula--no milk banks here is
Australia) and will use the pump when milk comes in.  When milk comes in
plan to use breast compression techniques to help facilitate transfer.

2nd feed on my shift  was a similiar story, baby tried very hard and we
decided to top baby up using a cleft palate teat (similiar mechanics to a
Haberman) which worked very well, milk was tranferred by compression of teat
and slowly took full quota top up.  Our plan of action is for mother to
demand feed baby at breast and then bottle feed expressed colostrum (with
added formula if necessary )until milk comes in then we will work from
there.  Again baby is held almost upright for bottle feed and this seemed to
work well.  There have been no further vomits or dusky episodes.

In the past, although I have had mothers successfully express and bottle
feed EBM,  I have never seen a mother successfully fully breast feed with a
cleft palate.  I would be grateful for any ideas or comments on how we have
managed this case so far.  Mum is not insured and within the public hospital
system very early surgery for cleft palate doesn't seem to be an option
Marian Rigney (RN)



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