Infants with clefts require very careful follow up and their parents 
require lots of special teaching.

Infants with cleft lips may breastfeed fine, since orbicularis oris (the 
round muscle around the lips that may be disrupted by a cleft lip) does 
not have to be very active during breastfeeding, as the tongue provides 
the primary seal to the breast. Cleft lip is a much greater issue for 
bottlefeeding, where EMG (electromyelogram = muscle activation) studies 
show that orbicularis oris is much more active than it should be 
(remember, breastfeeding is NORMAL feeding). Also, the soft breast 
generally fills a cleft lip well, preventing loss of suction in the 
mouth. If there is still a gap, mom can use the soft pad side of a 
finger or thumb to block it.

Cleft palates are far more damaging to the infant's ability to feed 
normally, since breastfeeding relies on negative pressure to move milk. 
Of course, some infants figure out how to use compression, but many 
infants with significant clefts transfer very little milk. One group of 
researchers in Japan found that the use of a palatal obturator with a 
projection at the back to replace the soft palate (Hotz type plate) 
improved milk transfer at the breast.

Very small clefts may be occluded by the breast, and the infant may do 
better, but there is pessimism about a cleft palate affected infant's 
ability to breastfeed. Of course they can feed at the breast with a 
positive pressure supplementer (syringe and tube, with mom pressing on 
the syringe as the baby sucks). Sucking at the breast helps to provide 
more normal forces on the palate for growth and expansion. The cleft 
area may also be too sharp for mom to tolerate breastfeeding, or she may 
have no problem.

The final issue is swallowing. The fetus practices swallowing amniotic 
fluid. Cleft affected infants swallow differently, in a way that makes 
aspiration more likely after birth. Most cleft affected infants I've 
seen swallowed very poorly, and were being overwhelmed with flow by the 
people feeding them, who may or may not have been correctly following 
the feeding techniques they were taught. Giving the baby more control 
(Haberman or Pigeon feeder rather than a squeeze feeder without a 
nipple), making sure the boluses are small enough (Haberman allows the 
smallest bolus), and trying to provide some normal tongue movements by 
having the nipple in the mouth far enough so the baby grooves the tongue 
(I don't know that there's a bottle that will stimulate grooving well in 
a baby with a large cleft, babies habitually keep the tongue tip in the 
cleft, and the tongue movements don't develop properly).

So yes, I'd say that mothers planning to bf cleft affected infants need 
tons of extra assistance and teaching!
Catherine Watson Genna, IBCLC  NYC

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