Breastfeeding is possible for these babies but may require the assistance of a lactation specialist. Infants with cleft lip are usually more successful with breastfeeding than the infant with cleft palate or a cleft lip and cleft palate. Mothers who wish to breastfeed to gain all the benefits from breastfeeding should be supported. Skill 14-1 describes mechanical feeding methods that may be used for infants with both cleft lip and cleft palate. After the infant has established a feeding routine, the infant should be able to complete the feeding in 18 to 30 minutes. An infant who requires a longer feeding period could be working too hard and expending too many calories. This would not promote growth, which is a goal for these infants. It is important for the nurse and the caregiver to remain flexible and patient in feeding these infants. It may require trying several different systems and techniques before the best one is found (Figure 14-2).

Skill 14-1

Oral Feeding for Infants with Cleft Lip or Cleft Palate

Equipment	Description
Soft, thin-walled nipple (preemie nipple)	•Compresses easily; readily available
NUK orthodontic nipple	•Large surface for compression
Cross-cut nipple	•Allows easy flow of milk with compression
Ross Cleft Palate Nurser	•For infants with weak suck; has soft tubelike nipple that delivers past the cleft
Mead Johnson Cleft Palate Nurser	•Soft, long cross-cut nipple; soft bottle for squeezing and monitoring milk flow; can use cross-cut or NUK nipples with this system
Haberman Feeder	•Large, squeezable nipple with a slit cut; has one-way valve to reduce amount of air ingested; two nipple lengths available: regular and short
Pigeon Cleft Palate Nurser	•Larger, more bulbous Y-cut nipple; firm on top with soft bottom; has air valve to prevent collapse and air flow; has flow setting in bottle collar
Asepto syringe, rubber tip	•Readily available; places milk beyond cleft

Method

1. Use a nipple or feeding system that provides a controllable flow rate and is energy-efficient for the infant.

2. Hold infant in upright position to assist in reducing the amount of nasal regurgitation.

3. Use a pillow for additional support for infant to assist with longer feeding times.

4. Keep chin tucked because neck extension inhibits swallowing.

5. If regurgitation occurs (milk coming out through the nose), stop feeding and allow infant to cough/sneeze to clear nasal airway.

6. Place nipple on top of tongue. Nipple insertion may push tongue to the back of mouth.

7. Burp the infant frequently because of increased air ingestion.

8. Monitor for distress and fatigue during feeding.

9. Limit feeding time to approximately 30 minutes to avoid fatigue.

10. Follow feeding with sterile water to clean any trapped food in the cleft.

11. Clean mouth and nose.

Adapted from Cleft Palate Foundation. (2002). Feeding an infant with a cleft. Chapel Hill, NC: Author.

Postoperative Care

Postoperative nursing goals for a child with cleft lip/palate repair include (1) preventing the child from excessive crying, which could cause tension on the suture line, (2) careful positioning (never on the abdomen) to avoid injury to the operative site, (3) cleaning the suture line to prevent crusts from forming, which could cause scarring, (4) applying restraints to prevent injury to the operative site and using a butterfly strip or a Logan bow (bar) (to reduce tension on the suture line), and (5) cuddling and other forms of affection to provide for the infant’s emotional needs. This last is of particular importance because the infant is unable to obtain the usual satisfactions from sucking.

Suture line care may involve application of an antibacterial ointment, depending on the surgeon’s instruction. Cotton-tipped applicators should be avoided to prevent injuring the surgical site. The surgical site may be rinsed with sterile saline solution. The infant receives feedings by special feeder until the wound is completely healed (from 1 to 2 weeks).

Cleft Palate

A cleft palate is more serious than a cleft lip. It forms a passageway between the nasopharynx and the nose, which not only complicates feeding but easily leads to infections of the respiratory tract and middle ear and is generally responsible for speech difficulties in later life. Unlike cleft lip, cleft palate is more common in girls than in boys.

Treatment

Most surgeons prefer to operate between 7 to 15 months of age, so that speech patterns are not affected. Even with the advances in surgical techniques, many centers are electing to repair the cleft palate during these times (Campbell et al., 2010). There are several approaches to repair depending on the severity of the defect. While a single surgery may be all that is necessary, future surgical interventions may be required as the child grows.

The management of the child with a cleft lip and cleft palate requires expert teamwork over a long period of time. The emotional problems that sometimes occur with this condition may require more extensive attention than the repair itself. A child born with a facial deformity encounters many problems. It is difficult to be unattractive when society places such importance on good looks. The parent’s first reaction to a disfigured newborn infant may be one of shock, hurt, disappointment, and guilt. Some parents may regard the deformity as a result of their inadequacies. It should be strongly stressed that they are not responsible for causing the defect. They may desire to hide the child from relatives and friends. Feedings are difficult. As the child grows, irregular tooth eruptions, drooling, delayed speech, and intermittent hospitalizations and frequent clinic appointments can be frustrating. The developing child senses the feelings of the parents and acquires either a positive or a negative self-attitude.

In large cities, special cleft palate clinics are available where several specialists can work together in convenient consultation. The parents should be informed of the resources available in the state in which they live. Financial assistance is usually indicated because of the length of treatment required.

Postoperative Management and Nursing Care

Fluids are best taken by a cup, although an Asepto syringe with a rubber tip (gravity feeder) may be used (Figure 14-3). Hot foods and liquids should be avoided to prevent injury to the surgical site. All objects should be kept out of the mouth. This includes straws, tongue blades, spoons, forks, and pacifiers. A wide-bodied spoon may be used if the food is fed from the side of the spoon and does not come in contact with the roof of the mouth. The diet progresses from a clear to a full liquid diet. The older child may go home on a soft diet (nothing harder than mashed potatoes).

FIGURE 14-3 After a cleft lip repair, a syringe with a rubber tip is used for feeding to prevent trauma to the incision.

Oral Hygiene.

The mouth is kept clean at all times. Feedings should be followed by a little water. The doctor may prescribe a mild antiseptic mouthwash.

Restraints.

Elbow restraints are generally sufficient for a young child. They should be removed under supervision one at a time periodically to prevent constriction of circulation and to allow normal movement. It is important to prevent the child from placing fingers or objects in the mouth. Discuss with the older child to keep the tongue away from the sore part of the mouth.

Speech.

Children who have had extensive repairs or have associated deafness will need the help of a speech therapist. Others simply require a minimum of help from their parents.

Diversion.

The goal is for the child to cry as little as possible. Play should be quiet, particularly in the immediate postoperative period. Read to the child or help the child color.

Complications.

Otitis media and dental problems may accompany this condition. The parent should seek medical attention at the first signs of earache. Children with cleft palate are at high risk for developing hearing loss and should be closely followed (Kaster et al., 2008). Because of the involvement of the palate, development of teeth may be involved and the orthodontist may be involved until adulthood.

Gastroschisis and Omphalocele

These two defects allow abdominal contents to herniate outside the abdominal cavity (Figure 14-4). The gastroschisis usually occurs to the right of the umbilical cord. It is usually a small defect and involves only the bowel. It does not have a sac covering the defect. An omphalocele is a herniation of the gut into the umbilical cord. It is generally a large defect involving the bowel, liver, spleen, bladder, uterus, or ovaries. It is contained in a translucent sac with amniotic fluid. Improvement with survival rates has been helped by prenatal detection and cesarean delivery in a medical facility able to handle the care of this infant.