|Year : 2023 | Volume
| Issue : 1 | Page : 14-25
Feeding interventions among cleft lip/palate infants: A systematic review and meta-synthesis
Manjubala Dash1, Devi Prasad Mohapatra2, Kulumina Dash3, Sasmita Nayak4
1 Department of Obstetrics and Gynecology Nursing, MTPG and RIHS, Puducherry, India
2 Department of Plastic Surgery, JIPMER, Puducherry, India
3 Department of Public Health, KIIT School of Public Health, Kalinga Institute of Industrial Technology Deemed to be University, Bhubaneswar, Odisha, India
4 Department of Community Health Nursing, KIMS, KIIT Deemed to be University, Bhubaneswar, Odisha, India
|Date of Submission||26-Nov-2022|
|Date of Acceptance||14-Dec-2022|
|Date of Web Publication||14-Mar-2023|
Dr. Devi Prasad Mohapatra
Professor && Head, Dept of Plastic Surgery, JIPMER, Puducherry
Source of Support: None, Conflict of Interest: None
Cleft lip and palate (CLP) affect about one baby of every 700 newborn due to alterations in the normal development of the primary and/or secondary palate. The prevalence of clefts in India is between 27,000 and 33,000/year. Searches were undertaken in PubMed, Cochrane database, Web of Science, Scopus, and Google Scholar databases, for primary research studies that report on feeding interventions/feeding techniques/feeding methods, challenges faced by mother/care taker/health personnel as they include most of the publications in this area. Papers were independently reviewed by two authors and Thomas et al's assessment criteria checklist (2003) was used to assess the methodological quality. This systematic review was registered in PROSPERO under number CRD42020208437. The review included 25 studies: 21 quantitative, 2 qualitative, and two mixed methods study, involving 1564 infants and children (age ranging from 1 week to 5 years old) and 790 mothers of Infants with CLP from 13 countries. While comparing the efficacy of the three feeding techniques such as paladai fed, bottle fed, and spoon fed in improving the weight gain pattern the result showed mean weight gain among paladai feeding was better than the bottle or spoon-feeding. Common feeding problems observed were nasal regurgitation, vomiting, and choking, etc. Infants with cleft palate had some major challenges such as aspiration, choking, and inadequate growth. Beyond the esthetic and psychologic implications of the presence of orofacial clefts, the feeding of the child is usually the next concern of the parents and caregivers, a factor which can result in considerable stress to the mother. A prompt diagnosis, especially of a CP, and visit by the cleft team immediately after the birth so that the family can be supported and taught the skills of feeding, is essential.
Keywords: Cleft lip/cleft palate, feeding interventions, infants
|How to cite this article:|
Dash M, Mohapatra DP, Dash K, Nayak S. Feeding interventions among cleft lip/palate infants: A systematic review and meta-synthesis. J Cleft Lip Palate Craniofac Anomal 2023;10:14-25
|How to cite this URL:|
Dash M, Mohapatra DP, Dash K, Nayak S. Feeding interventions among cleft lip/palate infants: A systematic review and meta-synthesis. J Cleft Lip Palate Craniofac Anomal [serial online] 2023 [cited 2023 Mar 30];10:14-25. Available from: https://www.jclpca.org/text.asp?2023/10/1/14/371645
| Background of the Review|| |
Cleft lip and palate (CLP) are common birth defects that affect the lip, palate, or both, and are caused by errors in the embryonic facial fusion process. It affects around one out of every 700 newborns due to abnormalities in the main and/or secondary palate development. The Indian subcontinent remains one of the world's most populated regions, with a birth prevalence of clefts somewhere between 27,000 and 33,000 clefts per year. Feeding these babies is a huge concern for parents, and there is evidence that children with a cleft have delay in growth than children without a cleft. Lip repair is recommended between the ages of 3 and 6 months, and palate repair between the ages of 9 and 12 months and to safely obtain anesthetics he or she must have adequate weight gain with no health complications.
Feeding recommendations after cleft lip repair can be very different that ranges from immediate return to breastfeeding (BF)/bottle feeding to suction abstinence for up to 6 weeks. This divergence is much greater after palatoplasty, and some centers have adopted protocols prohibiting the use of bottles and nipples for a duration of 30 days. Darzi et al. found in a prospective randomized trial that early postoperative breast feeding after cleft lip repair is healthy, results in more weight gain at 6 weeks after surgery and is more cost effective than spoon feeding. Even though breast feeding a baby with a cleft palate may be difficult, the mother may express her milk and give it to the baby via a bottle.
Reid published a study of feeding procedures for children with cleft palate in 2004 that looked at 55 articles and found that there were a variety of interventions for infants with isolated cleft conditions, including early feeding and nutrition education, as well as assisted feeding approaches. She also stated that there was a scarcity of evidence that was graded as either moderate or strong prevailed, underscoring the need for ongoing scientific evaluation of feeding interventions used with infants who have cleft palate.
Based on the available literature, this systematic review aims to explore and describe studies comparing feeding methods for children with different types of cleft lip/palate in the pre-and postoperative periods, aiming to train parents and professionals for the often-difficult task of feeding children with CLP.
To identify feeding interventions used for feeding in children with cleft lip and cleft palate
- To identify feeding interventions used for infants having unoperated cleft lip, palate or both
- To identify feeding Interventions used for infants in the postoperative period following surgery of cleft lip, palate, or both
- To determine the challenges faced by health professionals (doctors and nurses) while educating the parents/caretakers regarding feeding techniques for children with cleft.
| Materials and Methods|| |
The systematic review complies with the PRISMA guidelines.
Search strategy and selection criteria
The literature search was carried out from September 30, 2021 to April 30, 2022. The search was performed in the PubMed, Cochrane database of Systematic Reviews, Web of Science, Scopus, EBSCO, ProQuest and Google Scholar databases, for primary research studies that report on feeding interventions/feeding techniques/feeding methods, challenges faced by Mother/caretaker/health personnel. The search strategy consisted use of the following terms (MeSH):
cleft palate AND infant feeding,
cleft palate AND feeding efficiency,
cleft palate AND bottle-feeding,
cleft palate AND breast-feeding,
cleft palate AND feeding obturators
cleft palate AND feeding after palatoplasty
palatoplasty and feeding
cleft palate AND infant feeding AND Challenges
cleft palate AND infant feeding AND Education
This systematic review was conducted according to the PRISMA Statement and registered at PROSPERO (http://www.crd.york.ac.uk/PROSPERO/) under number CRD42020208437.
A manual search was performed in the references of the selected articles to identify other possible studies to integrate into the review.
This systematic review included all research studies published in the English language that reported on the feeding interventions, feeding strategies, feeding methods, challenges faced by parents/mothers/health personnel to feed these cleft babies.
The PICo (P-Population, I-Interest, and Co-Context) approach was used to break down the specific objectives and underpin the search strategy.
Population (P): The terms to identify Population (P) was to include the infants with cleft lip, cleft palate, cleft lip & Palate (e.g., 'Infant' OR 'Infants' AND/OR 'cleft lip' AND/OR 'Cleft Palate')
Interest (I): Terms to identify the Interest (I) was related to identify the feeding Interventions (e.g., “Intervention or Interventions” OR “Method or Methods”) for cleft babies.
Context (Co): The context in this systematic review was the challenges faced by parents/care takers/health personnels. Terms to identify the Context (Co) was to include challenges in feeding the infants with cleft (e.g., “challenge” OR “challenges” OR “barrier” OR “barriers”).
Search terms were combined using the Boolean operand 'AND' (for example ' cleft palate AND infant feeding AND Challenges) using the key words 'Feeding Techniques, 'Cleft Lip or cleft Palate', 'Parents or care takers', 'challenges', 'difficulties' etc.
We included all quantitative, qualitative, and mixed methods studies published in the English language that reported on the feeding techniques for cleft babies and challenges faced by mothers or care takers.
Non-English language studies were excluded. Studies reporting on mother's awareness regarding the feeding techniques (despite their recognized importance), were excluded in order to focus on the said objectives for this paper.
Retrieved papers was reviewed independently by two independent authors by title and abstract and then by full text. Two authors had to agree for the included papers, and any disagreements were discussed and solved by the corresponding author of this review.
Assessment of methodological quality of included studies
A modified version of Thomas et al.'s (2003) 12-point quality assessment criteria checklist was used to assess the methodological quality of included studies because it facilitated the assessment of quantitative, qualitative, and mixed methods studies. Each criterion on the tool was scored '1' if the criterion was met, or '0' if not met. Studies were assessed and scored under three categories, and the total scores were categorised as 'weak' (Scores 0 to 6), 'moderate' (Scores 7 to 9) OR 'strong' (Scores 10 to 12) methodological quality. A decision was made a priori to exclude studies that scored '6' or less. All four authors independently assessed the methodological quality of included papers and confirmed the final score and each paper's inclusion for data extraction.
Data extraction was done in Excel (Microsoft Inc.) to report a full description of each study, including year of publication, first author's name, type of study, population, feeding methods, assessed parameters and findings by the author, etc.
Two researchers initially and two other researchers subsequently, independently reviewed the titles and abstracts of all selected articles to assess whether the studies would be eligible for inclusion in the review. The selected articles were read in full to confirm eligibility and to extract data. Disagreements were resolved by discussion with corresponding author of this manuscript. When abstracts did not provide sufficient information, the full text of the article was read for the assessment. The review included 25 studies: 21 quantitative, 2 qualitative, and two mixed methods study, involving 1564 infants and children (age ranging from 1 week to 5 years old) and 790 mothers of infants with CLP from 13 countries.
Nine studies reviewed from 2006 to 2020 on the period prior to surgical repair showed better feeding performance with four different methods like paladai (feeding cup) feeding, cup with spoon feeding, Syringe-feeding and bottle feeding along with direct BF, etc. While comparing the efficacy of the three feeding techniques like paladai fed, bottle fed and spoon fed in improving the weight gain pattern the result showed mean weight gain among paladai feeding was better than the bottle or spoon-feeding. Common feeding problems observed were nasal regurgitation, vomiting, and choking, etc.
Five studies reviewed from 2005 to 2011 regarding post-operative feeding practices after palatoplasty, had two studies showing better performance with spoon feeding, cup feeding and bottle feeding after surgery. One study highlighted the role of infant orthopedics (IO) in improving feeding velocity.
Eleven studies from 2006 to 2020 were reviewed regarding challenges or difficulties faced by the mother/parents/caretakers. Of these eight studies showed that mothers of children with diagnosis of CLP significantly reported high stress level and challenges in BF than those with diagnosis of cleft lip only. Infants with cleft palate had some major challenges such as aspiration, choking, and inadequate growth. Further it was observed that lower percentage of mothers of infants with CL/P providing breast milk. Two studies highlighted that prior information, education, and support is needed for mothers regarding feeding techniques.
| Results and Discussion|| |
The search strategy performed to select the studies included in this review is shown in [Figure 1]. The initial search identified 253 articles as potentially eligible. After evaluating the title and abstract, 65 articles were selected, and total of 188 studies were excluded as they did not meet the study objectives and due to duplication, case reports, etc. A full reading of the 65 remaining studies was performed, and of these, 59 studies were retrieved full text to integrate into the systematic review. Each full text paper was independently reviewed, and a total of 31 studies were excluded because they did not report on feeding techniques or challenges faced by mothers. Further three studies were excluded during the quality assessment as the studies did not meet the criteria. Finally, 25 studies were included.
The infant born with a cleft has similar nutritional requirements as other infants born without a cleft as long as no other systemic issues are involved. Maintaining nutrition is the priority and finding a feeding technique as close to normal as possible is second. The most notable problems are insufficient suction, excessive air intake, choking, nasal regurgitation, fatigue, inadequate milk intake, failure to gain weight, and excessive time required to feed. The inability to feed satisfactorily can lead to maternal stress and anxiety and thus lead to poor mother and infant bonding.
The main characteristics of the feeding methods of the included studies were alternative feeding routes (nasogastric tube), feeding methods that required suction (bottle and BF), feeding methods without suction (cup, spoon, syringe, and paladai). The parameters evaluated in the studies were ingested food acceptance and volume, feeding performance, time and complications during feeding, growth and nutritional gain, etc.
Characteristics of nine studies regarding different feeding methods and physical growth parameters, and also feeding difficulties are shown in [Table 1]. Sucking parameters such as suction and compression during bottle feeding were assessed. Feeding ability, oral motor function, and feeding efficiency were assessed at 2 weeks, 3 months, and 14 months of age. The result showed that babies with smaller clefts (i.e., CL or minor soft palate clefts) were more likely to generate the normal levels of suction and compression compared to their counterparts with larger clefts. Poor feeding skills are relatively common in newborns with cleft palate and CLP. The prevalence of poor feeding reduced to 19% at 3 months of age and 15% at 14 months of age. Oral motor dysfunction and sequelae (particularly nasal regurgitation) were more commonly observed in babies with poor feeding skills, irrespective of comorbidity, Infants with nonsyndromic complete unilateral CLP or a cleft of the soft and at least two-thirds of the hard palate had less efficient sucking patterns than their noncleft peers,,
|Table 1: Studies identifying feeding methods in the preoperative period among cleft lip and palate babies|
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A study conducted by Martin and Greatrex-White, 2014 with different feeding methods like direct breast feeding, breast feeding with expressed breast milk, formula milk, and use of bottles like Squeezable bottle type (Mead Johnson bottle [complete with teat], Softplas bottle [with NUK orthodontic teat], Haberman feeder [with squeezable teat], Rosti bottle [and scoop], etc.,) and teats for feeding and weight velocity, feeding behavior, and maternal self-esteem were assessed. Babies with isolated clefts of the hard and soft palate experienced greater feeding problems and suffered the biggest weight losses. This remained significant independently of the type of bottle/teat used. Poor weight gain was also associated with a mother's low perception of herself and her child and her tendency toward depression. Further, children with CLP were 12 times more likely to be bottle-fed than children with CL (odds ratio = 12.21; confidence interval = 4.09–36.45). The prevalence of harmful oral habits (HOH) was 37%. Eighty-seven percent (87%) of parents stated that HOH could lead to serious complications of tooth misalignment.
Further studies conducted by Ravi et al. comparing the efficacy of the three feeding techniques such as paladai fed, bottle fed, and spoon fed, in improving the weight gain pattern of children. The result depicted that mean weight gain among paladai feeding was better than the bottle or spoon-feeding. Chandrasekhar et al., 2015 conducted a study on cup with spoon feeding highlighting that cup with spoon feeding had significant difference in growth pattern and fewer comorbidities. Common feeding problems observed were nasal regurgitation, vomiting, and choking, etc.
Ize-Iyamu and Saheeb, compared syringe-fed and cup-and-spoon-fed groups with normal breast or bottle-fed babies and their weight gain from birth to 6, 10, and 14 weeks. The result showed that syringe-fed CLP babies fed breast milk had a significant difference in weight gain (0.7 and 0.8 kg) compared with cup-and-spoon-fed babies (0.4 kg), at 10 and 14 weeks, respectively.
Rikimaru Sasaki et al. examined the fitting of Hotz's plates in infants for bottle feeding with a focus on tongue movements during sucking. The results showed that tongue movements during bottle feeding were larger in CLP infants without Hotz's plates than in CLP infants with Hotz's plates and healthy infants. When Hotz's plates were fitted, movements were stable and close to those of healthy infants, indicates that fitting Hotz's plates is useful.
It is important to note that, burping of children is advised to parents as they are prone to aerophagy that results in early cessation of feed by the baby while the mother believes the baby has had enough feed. This is also a frequent cause of lack of weight gain. Among the instructions given by Indian cleft surgeons/cleft care professionals to mothers regarding feeding, paladai feeding and frequent burping are consistently advised. Mothers are counseled to understand that a baby with cleft palate requires almost thrice the time for feeding compared to a baby without cleft palate and frequent burping to compensate for aerophagy.
Characterization of five studies [Table 2] comparing methods of feeding in the postoperative period of surgical repair of cleft lip and/or palate, isolated lip repair, or lip associated or not associated with palate., Prahl et al. conducted a study on IO and its impact on bottle feeding velocity (mL/min) at intake, during 3, 6, 15, and 24 weeks (T0 to T24); as well as assessed growth parameters such as weight-for-age, length-for-age, and weight-for-length. Researchers observed that feeding velocity increased with time from 2.9 to 13.2 mL/min in the IO2 group and from 2.6 to 13.8 mL/min in the IO1 group; there was no significant differences were found between groups. Further weight-for-age, length-for-age, and weight-for-length (z scores) did not differ significantly between groups. Whereas a study conducted by Masarei et al. to investigate presurgical orthopedics (PSO) to facilitate feeding in infants with CLP, reported that PSO did not improve feeding efficiency before palate repair at 3 months of age or following palate repair at 12 months of age. Similarly, the hypotheses, that PSO facilitates more efficient feeding by acting as an obturator and providing an opposing surface prior to repair of the palate was not supported.
|Table 2: Studies identifying methods of feeding in the postoperative period among cleft lip and/or palate, isolated lip repair, or lip associated or not associated with palate|
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Kim et al. compared bottle with the usual nipple and feeding with a spoon, cup, or syringe. Amount of oral intake for the first 6 days (from the day of surgery), and relative weight gain at 1 and 2 months were compared. They found that bottle-feeding had no adverse effect on the early postoperative course after palatoplasty including complication rate, oral intake, and weight gain. Similarly, Trettene et al. compared the best technique-a cup or a spoon for feeding children immediately after palatoplasty to understand food escaping and coughing during feeding. They reported that spoon to administer food after palatoplasty is better than using a cup.
Further, De Vries et al. studied the prevalence of feeding difficulties, rates of NG tube feeding, and effect of palatoplasty on feeding difficulties reported that feeding difficulties were reported in 67% (n = 60) of all cases. NG feeding was given in 32% (n = 28) of all children. Forty-nine children (54%) had associated malformations. Children with CPO are at high risk of developing feeding difficulties. NG feeding is often necessary. Improvement of feeding difficulties after surgery supports the importance of the soft palate closure in relation to sucking patterns and feeding skills.
Characteristics of eleven studies [Table 3] on challenges faced by mothers/care takers of babies with CLP were reviewed. Britton et al. explored feeding practices and challenges that the parents experienced, especially in the first hours and months after birth stated that cleft type had a significant impact on whether the infant was breastfed (P < 0.05), those with a cleft lip being more likely to be breastfed. Parents found it difficult to find the right feeding method for their baby until they were guided by cleft care health professionals and only a few parents managed to establish a regular feeding pattern. They highlighted the importance of Specialist Cleft Nurses in guiding parents and caregivers of children with cleft. Lindberg and Berglund explored “The experience of mothers for feeding CLP babies and how to cope to challenges,” suggested that “mothers of children born with CLP were in need of individual information by healthcare professionals with expertise, at the time of the diagnosis and until the feeding was manageable.” Mothers' personal resources, the fathers, and immediate family were of major importance for the mothers to cope with challenges related to feeding.
|Table 3: Studies on challenges faced by mothers/care takers of babies with cleft lip and palate|
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Gil-da-Silva-Lopes et al. assessed different feeding resources used prior to corrective surgery and found that BF was encouraged among 80% of mothers, feeding tube was used in 21% (29%) families, considered ordinary nipple, was the best option. Snyder and Ruscello explored early feeding experiences of parents with their children reported that majority of parents experienced initial difficulties with feeding their infants. Mothers expressed that there is a need to seek information and assistance from various sources. Similar study conducted by Madhoun et al. regarding breast milk feeding practices experienced by mother–infant dyads presented that a lower percentage of mothers of infants with CL/P reported providing breast milk compared to infants without clefting. There are multiple barriers, as well as various medical and psychosocial supports that facilitated breast milk feeding success. Five percent of infants ever fed at breast, and 43% received pumped breast milk via bottle. Kucukguven et al. evaluated the prenatal feeding preparations, preoperative processes, and feeding challenges and modifications to overcome these difficulties reported that Infants with isolated cleft lip had minor feeding difficulties, whereas the ones with cleft palate had some major challenges such as aspiration, choking, and inadequate growth. Adekunle et al. studied the BF practices and related challenges among mothers reported that “mothers of children with diagnosis of CLP significantly reported challenges in BF than those with diagnosis of cleft lip only (P < 0.001)”. For mothers whose babies were not breastfed exclusively, the most common supplementary mode of feeding adopted was the use of conventional feeding bottles.
A study by Banhara et al. on psychosocial repercussions experienced by caregiving parents stated that mother figure plays the main and determining role in care, reflecting the complexity of care. Madhoun et al. studied maternal stress level, postpartum depression, demographic, feeding, and growth parameters (weight, length, weight-for-length, and head circumference) of children reported that mothers of infants with CL/P had higher stress and more challenges with feeding and growth.
Amstalden-Mendes et al. evaluated the resources used in feeding; and their correlation to the child's weight. They highlighted that educational program for nonspecialized health professionals, as well as regular pediatric follow-up and specialized multi-professional teams, could improve nutritional intake and could move the schedule for surgical procedures forward. Murthy et al. compared specially designed audio-visual module over traditional instructional module to educate the mothers found that there was significant improvement in the knowledge of the mothers from baseline to 6 months. However, the practices indicated that the mothers belonging to the audio-visual module group showed better understating of the condition and earlier adaptation of the BF practices. Correspondingly, the growth parameters also showed significant difference. The custom-made audio-visual module would help the mothers adapt better to the stressful situation following the birth of the infant affected with CLP.
| Conclusion|| |
Beyond the esthetic and psychologic implications of the presence of orofacial clefts, the feeding of the child is usually the next concern of the parents and caregivers, a factor that can result in considerable stress to the mother. A prompt diagnosis, especially of a CP, and a visit by the cleft team immediately after the birth so that the family can be supported and taught the skills of feeding, is essential. It needs to be recognized that parents of children with a CP need as much, if not more, support as parents of children with a CL. The nonvisible nature of a CP can create the deceptive impression that the condition is a minor one. Professionals must give every child with a cleft the opportunity for normal physical and psychological development and every parent the chance to take pride in their child.
MBD initiated the aims and scope of the review. Search strategy support was provided by SN, MBD, DPM, & KD. Methodological support, advice and review were given by DPM. The manuscript was written by MD and edited by DPM, KD, and SN. All authors have read and approved the manuscript for publication.
Consent for publication
All authors have given consent
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]