The first person with a baby with a cleft I ever worked with was a Saudi Arabian woman who clearly had the attitude that of course the baby could be breastfed. I assumed then (and now) that that must have been an attitude which came out of a cultural expectation. It made me very curious about what "happens" to infants with this kind of problem in other cultures. It varies. I have read that the word "stigma" which carries the meaning of an outer sign which reveals something about an inner state (i.e. stigmatized) was historically applied to infants with this condition. In some places such infants were abandoned and left to die. Other cultures seem to have no problem with caring for kids with it. Over the years I've cared for a fair amount of infants with clefts, and their mothers -- no matter how dedicated --have always had a tremendously difficult time feeding them. The cleft means the baby can't create negative pressure in the oral cavity --the way to hold the breast in the mouth and the way to create a pressure differential which facilitates the flow of milk from the positive pressure inside the breast into the negative pressure space created inside the baby's mouth. Try sucking on a straw with a hole in it and you'll get the point. Moms have a lot of trouble keeping a good milk supply because often baby can't adequately drain the breast. Baby may also have so much nasal regurgitation and choking that there is aversion to feeding. I think it takes a lot of effort to swallow without drowning for these babes.Remember, the soft palate is a muscle which is vital to swallowing. They tire very quickly and feeds tend to be short. Post-feed pumping and alternate delivery of hind-milk helps their growth a lot. Breast milk is critical to the health of babies with clefts. There is an important new article on breastmilk and reduction of otitis media with middle ear effusion (glue ear) in infants with clefts. These kids have constant respiratory problems. Usually moms have to pump to keep up a supply adequate for growth. Its possible with some to use feeding supplementers and upright nursing esp on a full breast. Others seem unable to get much out at breast and must be fed expressed hm some other way. There was a wonderful poster at the last ILCA conf. which showed a feeding technique of an African doctor who also noted difficulties feeding babies with clefts in his village and regional care hospitals. He cut apart a bottle nipple so that he created in essence a cheap palatal obturator (fake palate) which he then slipped over the top of another bottle teat so that the flap of the cut teat sealed the cleft while the baby bottle fed expressed milk. Obturators have helped babies I've worked with. I refer to a pedi dentist with experience on a cleft palate team. Clefts of the palate often can't be surgically corrected until later due to head growth in the early pp. I think some are now being done as early as 9 mo. but I've not heard of them before then. Lips can be repaired very early, but they don't pose any real difficulties to nursing. There was a case of child neglect tried some years back where a woman was accused of letting her baby die for the sake of her belief that the child (who had a cleft) could breastfeed. My understanding of this tragic incident is that this was the 2nd baby with this birth defect the woman had nursed.(Genetic counseling is impt. as incidence of another infant with same condition rises after the first birth.) The first was a twin, and the normal twin essentially "drove the train" for the weaker sucking twin. Because the well twin stimulated the milk supply, got the let-down started, etc. the other twin grew adequately. Based on the successful first experience, the assumption was made that cleft palate babies could be breastfed. This is not always the whole story and case-by-case assessments must be made for all infants with physical challenges. I monitor this kind of baby very closely. I have had mothers feed hm to their babies until after the surgical repair. Some were then successful moving to unassisted breastfeeding. I'm working with a immigrant Vietnamese family who have a daughter (now 10 mo old) who has the most cavernous cleft I've ever seen -- so large (no palate at all) that the surgical team is wondering if they can successfully close it. With an obturator and months of pumping and haberman feeders and other bottles they kept her on exclusive breastmilk for 6 mo, partial since then. This family was interesting. I got friendly enough with them for the father to confide in me that he didn't know who to believe, and wondered whether it was considered rude in our culture to question the doctor. Apparantly, he worried very much that any inquiries or requests for explanations would be perceived as challenges to the authority of the doctors (and revenge might be taken on his baby girl.). He was also very much more likely to credit the older doctors. He ever so politely let me know that my being a woman had put him in an awkward position. He liked me and tended to think what I said made sense, but felt very conflicted when my opinion was diff. than the doctors. I told him that in our culture people think that asking questions is a sign of intelligence and would gain him respect if done politely. This helped him a lot in navigating the system. Sorry this is so long, but I think people working with infants with cleft need to do a lot of reading in the bfg and in the plastic surgery lit. Barbara Wilson-Clay, BSE, IBCLC Austin, Tx (priv.pract.)