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 Table of Contents  
REVIEW ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 69-73

Nutritional needs of cleft lip and palate child


Consultant Paediatrician, Child Care Clinic, Prachi Residency, Baner Road, Pune, Maharashtra, India

Date of Submission24-Sep-2021
Date of Acceptance22-Oct-2021
Date of Web Publication01-Jan-2022

Correspondence Address:
Dr. Meera Singhal
F-702, Prakrtii, Balewadi, Baner, Pune - 411 045, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_36_21

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  Abstract 


Children with cleft lip and palate often suffer from nutritional deficiencies and subsequent growth problems, both of which are largely attributed to feeding difficulties due to the structural defect as well as the numerous surgical procedures that they undergo. The aim of this review article is to assess the nutritional needs of such children and to emphasize the role of nutrition in their long-term growth and development along with parental education on nutrition and various alternative feeding practices as an important aspect in the management of cleft lip and palate which may otherwise be overlooked. For this review, various articles on cleft lip and palate from plastic surgery to dental surgery journals were studied and more articles were based on subsequent bibliographic reviews of the above. It was concluded that to achieve optimal health in these children, the dietary changes required per day were minuscule. Rather, it is the delivery method of breast milk or formula which often needs to be changed to reduce effort and resultant caloric loss by the newborn, indirectly boosting the caloric intake and resultant weight gain and growth.

Keywords: Cleft lip palate, dietary changes, feeding problems, growth, nutritional needs


How to cite this article:
Singhal M. Nutritional needs of cleft lip and palate child. J Cleft Lip Palate Craniofac Anomal 2022;9:69-73

How to cite this URL:
Singhal M. Nutritional needs of cleft lip and palate child. J Cleft Lip Palate Craniofac Anomal [serial online] 2022 [cited 2022 Jan 25];9:69-73. Available from: https://www.jclpca.org/text.asp?2022/9/1/69/333650




  Introduction Top


Inadequate nutrition has largely been blamed for the growth problems of children with cleft lip and palate and palate.[1] Nutritional deficits can be attributed to the numerous surgeries that they undergo and feeding challenges due to the oral defect leading to insufficient nutrient intake. This, in turn, results in reduced growth rate, decreased healing of lip or palate scars, as well as teeth decay. They are likely to be lacking in macronutrients (energy, protein, fats and carbohydrates) as well as micronutrients (calcium, iron, phosphorous).[2] Therefore, overcoming nutritional inadequacies and providing nutrition information to parents is critical in combating feeding issues and ensuring that their infants receive proper nourishment.

The aim of this review article is to assess the nutritional needs of children with cleft lip and palate and to emphasize the role of nutrition in long-term growth and development of such children along with proper parental education on nutrition and various feeding practices as an important aspect in the management of cleft lip and palate which may otherwise be overlooked.


  Oral-Motor Deficits in Children With Cleft Lip and/or Palate Top


The early phase of an infant's life is marked by rapid proliferation of tissues and organ systems leading to exponential growth and development. The development of more complicated movements is enabled by a progressive attainment of diverse motor and cognitive skills. Infants with a cleft lip or palate are more likely to have developmental abnormalities, including motor skill deficits and oral motor deficits.[3] Hence, to thrive and grow well, a newborn with a cleft typically requires changes in feeding habits to meet nutritional requirements.

It is vital for successful feeding to have a coordinated velopharyngeal function. Expressing milk from breast or bottle necessitates the creation of a vacuum in the oral cavity. For this, the soft palate's ability to rise up and close off the nasopharynx from the oropharynx and the infant's ability to create a lip seal around the nipple are crucial. In case of a cleft palate, both the above functions are defective; hence, the capacity to create an oral suction is impaired; this is the main aspect that may interfere with feeding.[4] In this case, infants are rarely able to generate enough negative pressure to obtain sufficient milk with the same effort and time as their healthy counterparts, hence unable to meet their nutritional needs and at the same time expending more energy and burning more calories during feeding efforts.

An infant with isolated cleft lip can usually create enough negative pressure to allow for bottle or breastfeeding on a regular basis. Cleft palate newborns, on the other hand, have aberrant muscle attachments and nasal-oral cavity connection. Creating negative pressure and suction within the oral cavity is thus problematic in them due to this abnormal anatomy, despite having a normal sucking-swallowing reflex. Frequent regurgitation of milk through the nose, excessive air intake that necessitates frequent burping, and choking all further hamper the feeding process.[5],[6] Feeding takes much longer and exhausts both the baby and the mother. Modified feeding strategies can help to alleviate this issue.


  Infant Nutritional Requirements Top


As long as no other systemic abnormalities are present, a newborn born with a cleft has similar nutritional requirements as those without. The fundamental concern for all newborns in the early months of life is to maintain appropriate dietary intake. This is irrespective of whether they are normal or have any structural defects like a cleft lip/palate. The outcome of future surgeries and specialized care for the infant can be jeopardized if it does not develop and thrive early on.

Maintaining sufficient dietary is a challenge in infants with cleft due to common feeding issues like nasal regurgitation, ineffective sucking, frequent air intake and burping and consequent longer feeding time. This is of paramount importance to build their immunity and to allow adequate weight gain so that they can tolerate stress of surgical interventions and to speed up the healing process thereafter. The intake process, rather than absolute nutritional changes, is the most important aspect that requires modification for newborns with cleft palates.


  Challenges of Breastfeeding in Infants With Clefts Top


Breastfeeding infants with cleft lip and/or palate is fraught with controversy. Certain groups are sure that any infant may be appropriately breastfed irrespective of the type of cleft in them. The advantages of breast milk for babies have been well recognized.[7] Breastfeeding indirectly has some protective action against otitis media in children, according to several studies.[8] Similar protection has been documented in children with cleft palates.[9] One of the complicating elements that can occasionally reverse the efficiency of breast milk in protecting against otitis media is  Eustachian tube More Details function, which is common in children affected with cleft palates. Due to this disability, young infants with cleft are in fact more prone to get ear infections. Yet, the protection offered by breast milk to prevent ear infections cannot be overlooked and holds an important place in the overall management of these children. Aniansson et al.[10] recommended that children with cleft palates be fed breast milk for a longer period of time because early cessation increases the risk of otitis media in them.

Infants with isolated cleft lip can commonly breastfeed if the breastfeeding position is adjusted in such a way that the intact part of the alveolus and lip makes a good seal with the breast tissue. However, breastfeeding is challenging for most newborns who have a cleft palate (including the soft palate), and they need interventions for the same. Yet, it is important to encourage their mothers to breastfeed. However, unrealistic encouragement might lead to emotions of inadequacy and failure in the mother, if at a later stage of life, additional bottle feeds are recommended for poor growth. Hence, a balanced approach is needed.


  Early Feeding Modifications Top


Babies' capacity to deal with the different types of clefts varies, but simple alterations can help them get enough nutrients to gain weight. Various treatments have been described and applied effectively by craniofacial surgeons and institutions over the years. Several centers have proposed the creation and deployment of a feeding obturator to physically limit the oral cavity's continuity with the nasal cavity.[11] The purpose of the obturator is to help the infant establish enough negative pressure to allow proper milk sucking from the breast or nipple, as well as to reduce regurgitation through the nasal cavity. It produces a firm platform for the baby to press against and obtain milk from the nipple. Feeding is made easier and feeding time is considerably reduced, nasal regurgitation and choking is minimized, and the tongue is also prevented from entering the defect.[6],[7] Therefore, a feeding plate restores the basic functions of mastication, deglutition, and speech production till the defect can be surgically fixed.[12] Other approaches are based on making swallowing as the primary contributor in the feeding mechanism rather than active sucking by the baby. This can be accomplished by using modified feeding bottles or teats to supply milk directly to the posterior part of the oropharynx [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Squeezable bottles may be preferable to use for feeding babies with cleft lip and/or palate rather than rigid ones.[13] Furthermore, the caregiver is often advised to feed the baby in less than half an hour so that the infant does not waste extra calories during feeds. It is crucial to keep a close eye on the weight and growth of the infant, particularly in the early months.
Figure 1: Medela Special Needs (Haberman) Feeder (https://www.medela.com/breastfeeding-professionals/products/feeding/special-needs-feeder). Milk flow can be adjusted to suit baby's ability with a soft variable-flow nipple. Specially designed pump action one-way valve closes when baby wants to pause

Click here to view
Figure 2: Mead Johnson Nutrition-Cleft Lip/Palate Nurser (https://www.enfamil.com/products/cleft-lip-palate-nurser/). A soft, squeezable bottle that helps the flow of milk and can be fitted with any standard teat. For use in cleft palate babies

Click here to view
Figure 3: Pigeon Feeder with long nipple for cleft palate (https://www.pigeon-in.com/product/feeder-wlong-nipple-for-cleft-palate/). The cross-cut nipple has a thick and a thin side, with a one-way valve that prevents excessive air intake and allows milk to flow only when nipple is compressed

Click here to view
Figure 4: Dr. Brown's Specialty Feeding System (https://www.drbrownsbaby.com/product/dr-browns-original-baby-bottle-specialty-feeding-system-8-oz-240-ml-2-count/). With one-way valve at the base of the nipple to keep the nipple full of milk, it does not require suction

Click here to view



  Postsurgical Feeding Modifications – Following Cleft Lip Closure Top


For a newborn with a cleft lip and/or palate, continuing to provide enough nourishment and maybe changing feeding techniques are issues needing special attention after surgical closure of the defect. The child's dietary needs after surgery are similar to those with other surgical treatments. But here, the method of milk/food delivery is a source of concern since the surgery involves oral cavity. Breastfeeding or bottle-feeding is prohibited by certain surgeons immediately after lip closure due to the potential for postoperative stress on the surgical site.

In a retrospective assessment of 80 children with clefts treated at their hospital, Cohen et al.[14] compared infants who promptly started breast or bottle-feeding after lip repair surgeries to their counterparts who were instead kept on tube and syringe feeding for 7–10 days postoperatively. These researchers found that breast or bottle-feeding postoperatively, if done with due caution, was safe and that no major changes in feeding techniques were required.[14] These suggestions, however, are not commonly embraced. Some facilities still advise against using the nipple or breast for a period of up to 6 weeks after surgery.


  Postsurgical Feeding Modifications – Following Cleft Palate Repair Top


Following cleft palate closure, there are additional variations in feeding behaviors. In 1991, Wellman and Coughlin[15] conducted a survey of 92 cleft palate teams to see how they handled nutritional and surgical instructions before and after surgery for primary cleft palate closure. Most centers did not specify any dietary adjustments, according to the 49 surveys that were returned. Many facilities, on the other hand, had certain rules for postoperative feeding techniques (e.g., feeding by cup/spoon/syringe, feeding only purées or liquids, etc.), and some even indicated that specific foods like citrus or sticky food be avoided for a certain time. Only one of the centers that responded to the study said they used additional nutritional counseling to handle the extra caloric needs, carbohydrates, proteins, and vitamins following surgical procedures. Majority did not prescribe any dietary supplements either.[15] Although development and weight gain in children born with clefts remain a constant concern through the initial phase of life, there are signs that these issues may not persist once the defects have been surgically closed. Lee et al.[16] studied 83 infants aged 0–4 years who had a cleft lip and/or palate. They found that this group, in early infancy, developed slowly but caught up later, reaching the predicted anthropometric parameters at the last follow-up at 25.5 months of age.

However, if there are other associated syndromes impeding development, these worries can last a long time; nevertheless, because majority of children have nonsyndromic clefts, removing the defects should result in normal growth.


  Children With Clefts and Associated Dental Issues Top


It is not surprising that children with cleft lip/palate have a higher risk of dental anomalies such as supernumerary teeth, missing teeth, or deformed teeth, particularly in clefts involving alveolar ridge. Caries and gingivitis are also more common in children with cleft palates.[17] Although several factors are responsible for early childhood caries, two of the most important are early Streptococcus-mutans infection and feeding newborns and toddlers for long hours at night.[18] Infestation with large number of bacteria causing caries and repeated carbohydrate exposures appear to be critical contributors for the occurrence of caries in children with cleft palates. Hence, parents of children born with clefts should be taught and reinforced information about oral hygiene, dietary practices, and sleep hygiene including faulty nighttime feeding practices.[19]


  Education and Counselling of Parents and Caregivers Top


Special educational interventions are required to promote awareness, alleviate various psychological stressors, anxieties, and fears, and improve overall health management among parents of children with clefts. Health education can be imparted through face-to-face interaction via lectures or counselling by the treating doctor or support staff and/ or virtual methods using social media platforms like a dedicated website for the cause, Facebook groups and parent support groups which offer caregivers a forum to exchange information, experiences and develop a sense of companionship and community, thereby alleviating their anxiety to a great extent. However, such groups require close monitoring or supervision by a trained administrator to prevent spreading myths and medical misinformation. Cleft teams in all hospitals should certainly have a clinical psychologist on board to address emotional needs of such parents as the birth of a child with defects including the multitude of surgeries they undergo and the special feeding requirements, all put together, can be quite overwhelming and distressing for most parents.


  Conclusion Top


The growth and development of a child with cleft lip or palate necessitates a great deal of attention, particularly during the growing years, through good nutrition, feeding practices, and hygiene. To achieve optimal health in children with cleft lip and palate, it is critical to implement appropriate nutrition interventions as well as educate caregivers. Typically, only minor dietary changes are required. Rather, it is the delivery method of breast milk or formula that often needs to be changed to reduce effort and resultant caloric loss by the newborn, indirectly boosting the calories consumed to assist weight gain and growth. The goal is to provide the newborn with enough calories before and after any surgical intervention so that he or she can recuperate and grow.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Gopinath VK. Assessment of nutrient intake in cleft lip and palate children after surgical correction. Malays J Med Sci 2013;20:61-6.  Back to cited text no. 1
    
2.
Swamy AS, Santhosh G. Nutritional status of children with cleft lip, cleft palate and knowledge of their mothers at health care centers. Int J Health Sci Res 2018;8:215-24.  Back to cited text no. 2
    
3.
Neiman GS, Savage HE. Development of infants and toddlers with clefts from birth to three years of age. Cleft Palate Craniofac J 1997;34:218-25.  Back to cited text no. 3
    
4.
Golding-Kushner KJ. Therapy Techniques for Cleft Palate Speech and Related Disorders. San Diego (CA): Singular Publishing; 2001.  Back to cited text no. 4
    
5.
Choi BH, Kleinheinz J, Joos U, Komposch G. Sucking efficiency of early orthopaedic plate and teats in infants with cleft lip and palate. Int J Oral Maxillofac Surg 1991;20:167-9.  Back to cited text no. 5
    
6.
Shprintzen RJ. The implications of the diagnosis of Robin sequence. Cleft Palate Craniofac J 1992;29:205-9.  Back to cited text no. 6
    
7.
Oski FA. Infant nutrition, physical growth, breastfeeding, and general nutrition. Curr Opin Pediatr 1994;6:361-4.  Back to cited text no. 7
    
8.
Duncan B, Ey J, Holberg CJ, Wright AL, Martinez FD, Taussig LM. Exclusive breast-feeding for at least 4 months protects against otitis media. Pediatrics 1993;91:867-72.  Back to cited text no. 8
    
9.
Paradise JL, Elster BA, Tan L. Evidence in infants with cleft palate that breast milk protects against otitis media. Pediatrics 1994;94:853-60.  Back to cited text no. 9
    
10.
Aniansson G, Svensson H, Becker M, Ingvarsson L. Otitis media and feeding with breast milk of children with cleft palate. Scand J Plast Reconstr Surg Hand Surg 2002;36:9-15.  Back to cited text no. 10
    
11.
Osuji OO. Preparation of feeding obturators for infants with cleft lip and palate. J Clin Pediatr Dent 1995;19:211-4.  Back to cited text no. 11
    
12.
Goswami M, Jangra B, Bhushan U. Management of feeding problem in a patient with Cleft Lip/Palate. Int J Clin Pediatr Dent 2016;9:143-5.  Back to cited text no. 12
    
13.
Bessell A, Hooper L, Shaw Wc, Reilly S, Reid J, Glenny AM. Feeding interventions for growth and development in infants with cleft lip, cleft palate or cleft lip and palate. Cochrane Database Syst Rev 2011;2011:CD003315.  Back to cited text no. 13
    
14.
Cohen M, Marschall MA, Schafer ME. Immediate unrestricted feeding of infants following cleft lip and palate repair. J Craniofac Surg 1992;3:30-2.  Back to cited text no. 14
    
15.
Wellman CO, Coughlin SM. Preoperative and postoperative nutritional management of the infant with cleft palate. J Pediatr Nurs 1991;6:154-8.  Back to cited text no. 15
    
16.
Lee J, Nunn J, Wright C. Height and weight achievement in cleft lip and palate. Arch Dis Child 1997;76:70-2.  Back to cited text no. 16
    
17.
Yetter JF 3rd. Cleft lip and cleft palate. Am Fam Physician 1992;46:1211-21.  Back to cited text no. 17
    
18.
Tinanoff N, O'Sullivan DM. Early childhood caries: Overview and recent findings. Pediatr Dent 1997;19:12-6.  Back to cited text no. 18
    
19.
Redford-Badwal DA, Mabry K, Frassinelli JD. Impact of cleft lip and/or palate on nutritional health and oral-motor development. Dent Clin N Am 2003;47:305-17.  Back to cited text no. 19
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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  In this article
Abstract
Introduction
Oral-Motor Defic...
Infant Nutrition...
Challenges of Br...
Early Feeding Mo...
Postsurgical Fee...
Postsurgical Fee...
Children With Cl...
Education and Co...
Conclusion
References
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