Feeding intervention in cleft lip and palate babies: a practical approach to feeding efficiency and weight gain

Breastfeeding and Cleft Lip and Palate: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the association between cleft lip and/or cleft palate (CL/P) and breastfeeding (BF).

DESIGN

A systematic review and meta-analysis were performed based on studies published in PubMed, Scopus, Web of Science, Cochrane Library, LILACS, BBO, and Embase databases, and in the gray literature. The search occurred in September 2021 and was updated in March 2022. Observational studies evaluating the association between BF and CL/P were included. Risk of bias was analyzed using the Newcastle-Ottawa Scale. A random-effects meta-analysis was conducted. Certainty of evidence was evaluated using the GRADE approach.

MAIN OUTCOME MEASURE(S)

Frequency of BF in relation to the presence or absence of CL/P, as well as to the type of CL/P. The association between cleft type and BF challenges was also evaluated.

RESULTS

From a total of 6863 studies identified, 29 were included in the qualitative review. Risk of bias was moderate and high in most studies (n = 26). There was a significant association between the presence of CL/P and absence of BF (OR = 18.08; 95% CI 7.09-46.09). Individuals with cleft palate with or without cleft lip (CP ± L) had a significantly lower frequency of BF (OR = 5.93; 95% CI 4.30-8.16) and a significantly higher frequency of BF challenges (OR = 13.55; 95% CI 4.91-37.43) compared to individuals with CL. Certainty of the evidence was low or very low in all analyses.

CONCLUSION

The presence of clefts, especially those with palate involvement, is associated with higher chances of absence of BF.

Lack of Immediate Diagnosis and Appropriate Intervention Leads to Malnutrition in an Infant With Cleft Palate

This case report describes a full-term infant with a cleft palate who experienced malnutrition because of the delayed introduction of a cleft-adapted bottle and identifies potential areas for improvement in clinical practice. The infant's weight for age z-score at birth was 0.05 and dropped to -1.45 by 2 months of age, indicating mild malnutrition. The infant established care with a cleft team and a cleft-adapted bottle was recommended as the primary feeding method. Feeding time subsequently decreased from 60 minutes per feeding to 20 minutes. The infant presented for palate repair at 9 months of age, and his z-score was -0.01, indicating he was no longer malnourished. Cleft-adapted bottles aid in feeding efficiency in infants with cleft palate, which may subsequently impact weight gain. Appropriate weight gain is essential to receive timely cleft palate repair and support healing.

Feeding Management and Palate Repair Timing in Infants with Cleft Palate with and without Pierre Robin Sequence: A Multisite Study

OBJECTIVES

Compare the feeding management practices in infants with cleft palate with and without Pierre Robin sequence (PRS) and determine if specific feeding difficulties or interventions predict delayed palate repair.

DESIGN

Retrospective cross-sectional study.

SETTING

Seventeen cleft palate teams contributed data.

PATIENTS

414 infants were included in this study: 268 infants with cleft palate only and 146 infants with cleft palate and PRS.

PROCEDURES

Data were collected via parent interview and electronic health records.

MAIN OUTCOME MEASURES

Outcomes for the primary objective included categorical data for: history of poor growth, feeding therapy, milk fortification, use of enteral feeding, and feeding difficulties. The outcome for the secondary objective was age in months at primary palate repair.

RESULTS

Infants with PRS had a significantly higher prevalence of feeding difficulties (81% versus 61%) and poor growth (29% versus 15%) compared to infants with cleft palate only. Infants with PRS received all feeding interventions-including feeding therapy, milk fortification, and enteral feeding-at a significantly higher frequency. Infants with PRS underwent primary palate repair at a mean age of 13.55 months (SD = 3.29) which was significantly (P < .00001) later than infants with cleft palate only who underwent palate repair at a mean age of 12.05 months (SD = 2.36). Predictors of delayed palate repair included diagnosis of PRS as well as Hispanic ethnicity and a history of poor growth.

CONCLUSIONS

These findings can be used to establish clinical directives focused on providing early, multimodal feeding interventions to promote optimal growth and timely palate repair for infants with PRS.

MicroNAPS: A Novel Classification for Infants with Micrognathia, Robin Sequence, and Tongue-based Airway Obstruction

Background

Robin sequence (RS) describes a heterogeneous population with micrognathia, glossoptosis, and upper airway obstruction (UAO). Workup, treatment, outcomes assessment, and research inclusion are widely variable. Despite several classifications and algorithms, none is broadly endorsed. The objective of this investigation was to develop and trial a novel classification system designed to enhance clinical communication, treatment planning, prognostication, and research.

Methods

This is a retrospective cross-sectional study. A classification system was developed with five elements: micrognathia, nutrition, airway, palate, syndrome/comorbidities (MicroNAPS). Definitions and a framework for "stage" assignment (R0-R4) were constructed. Stage "tongue-based airway obstruction" (TBAO) was defined for infants with glossoptosis and UAO without micrognathia. MicroNAPS was applied to 100 infants with at least 1-year follow-up. Clinical course, treatment, airway, and feeding characteristics were assessed. Descriptive and analytic statistics were calculated and a P value less than 0.05 was considered significant.

Results

Of the 100 infants, 53 were male. Mean follow-up was 5.0 ± 3.6 years. R1 demonstrated feeding-predominant mild RS for which UAO was managed nonoperatively but gastrostomy tubes were prevalent. R2 was characterized by airway-predominant moderate RS, typically managed with mandibular distraction or tongue-lip adhesion, with few gastrostomy tubes and short lengths-of-stay. R3 denoted severe RS, with similar UAO treatment to R2, but with more surgical feeding tubes and longer admissions. R4 represented a complex phenotype with 33% tracheostomies, protracted hospitalizations, and delayed palatoplasty. R0 ("at risk") and TBAO groups displayed the most variability.

Conclusions

MicroNAPS is easy to use and associated with relevant disease characteristics. We propose its adoption in clinical and research settings.

Neurodevelopmental trajectories in children with cleft lip and palate: A longitudinal study based on the Japan Environment and Children's Study

Cleft lip and/or palate (CL/P), the most prevalent congenital anomaly, is understood to negatively affect a wide range of child development. Since the concept remains controversial, because most published work is from cross-sectional studies, we examined the neurodevelopmental trajectories in participants with CL/P through a longitudinal comparison with the general population during early childhood using data from a nationwide birth cohort study in Japan. The linear mixed models for each domain of the Ages and Stages Questionnaire, third edition (ASQ-3), were used to detect differences in standardised mean scores between groups. The ASQ-3 is a general neurodevelopmental screening tool comprising communication, gross motor, fine motor, problem-solving, and personal-social domains. Participants' neurodevelopment was determined semi-annually from 6 to 36 months of age. The trajectories of standardised mean scores in each domain showed several significant differences between the control and CL/P groups, with the maximum difference at 24 months of age in the communication domain. Indeed, CL/P was associated with significantly lower scores in the communication (coefficient: -3.31, 95% CI: -5.09 to -1.14), problem-solving (coefficient: -3.13, 95% CI: -5.07 to -1.18), and personal-social domains (coefficient: -1.99, 95% CI: -3.87 to -0.11). Trajectories of ASQ-3 scores suggest neurodevelopmental delays in children with CL/P.

A Systematic Review of Feeding Interventions for Infants with Cleft Palate

OBJECTIVE

Various devices and techniques have been proposed to reduce feeding difficulties experienced by infants with cleft palate. The aim of this review is to identify and assess the scope and quality of evidence for these interventions.

METHODS

A systematic review of published literature evaluating feeding interventions for infants with cleft palate (with or without cleft lip) from database inception to 2021 was conducted using Preferred Reporting Items for Systematic Reviews guidelines. Quality appraisal of included studies was conducted using a methodological index for nonrandomized studies, Cochrane, or a measurement tool to assess systematic reviews 2 instruments, according to study type.

RESULTS

Fourteen studies met inclusion criteria, with the majority (71%) of studies consisting of second-level evidence. Included interventions were specialty bottles (21%), alternative feeding delivery systems (14%), obturators (14%), and educational programs (14%). Specialty bottles and palatal obturators did not appear to offer any substantial growth advantages compared to traditional bottles or no intervention, respectively. Designated education programs for the mothers of infants with clefts had a positive impact on infant growth.

CONCLUSIONS

Overall evidence evaluating feeding interventions for infants with cleft palate was moderate to low. While it does not appear that specialized feeding delivery systems or palatal obturators significantly improve growth in infants with clefts compared to children without cleft conditions, education programs do appear to be beneficial.

Clinical Practice Guidelines on the Treatment of Patients with Cleft Lip, Alveolus, and Palate: An Executive Summary

Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent.

Prenatal Ultrasound Measurement of Fetal Stomach Size Is Predictive of Postnatal Development of GERD in Isolated Cleft Lip and/or Palate

OBJECTIVE

To determine whether prenatal ultrasound measurement of fetal stomach size, as a surrogate marker of fetal swallowing, is predictive of postnatal development of gastroesophageal reflux disease (GERD) in cases of isolated cleft lip and/or palate (CL/P).

DESIGN

This is a retrospective case-control study. The outcome of interest is postnatal diagnosis of GERD in isolated CL/P. The exposure of interest is prenatal stomach size measurement by ultrasound.

SETTING

The study population was selected from an academic, tertiary care center between 2003 and 2011.

PATIENTS/PARTICIPANTS

Cases were neonates undergoing CL/P repair during the study period. Cases with other known structural or chromosomal abnormalities were excluded. Controls were contemporary, nondiabetic neonates that matched gestational age (within one week) to cases. Each case measurement was matched ∼1:2 with control measurement.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The primary outcome was difference in mean prenatal ultrasound measurement of fetal stomach size between cases and controls. We hypothesized that patients with postnatal development of GERD would have smaller mean fetal stomach size.

RESULTS

There were 32 cases including 19 patients with unilateral cleft lip and palate, 8 with unilateral cleft lip, and 4 with bilateral cleft lip and palate. Cases were noted to have smaller mean anterior-posterior and transverse fetal stomach measurements as compared to controls. This was statistically significant from 16 to 21 weeks, 25 to 27 weeks, and 28 to 36 weeks (P < .01 for all).

CONCLUSIONS

Prenatal ultrasound measurement of fetal stomach size as a surrogate marker of fetal swallowing is predictive of postnatal development of GERD in isolated CL/P.

Breastfeeding Practices Among Mothers of Children With Orofacial Clefts in an African Cohort

OBJECTIVE

To carry out a survey of breastfeeding practices and related challenges among mothers with orofacial cleft babies attending the cleft clinic of a tertiary health institution.

METHODOLOGY

This was a cross-sectional descriptive study using an interviewer-administered questionnaire. Sample population was all mothers of babies aged between 1 and 18 months with nonsyndromic orofacial clefts attending the cleft clinic of a tertiary health institution in Nigeria.

RESULT

A total of 65 mothers participated in the study. Initiation of breastfeeding was reported by the majority (83%, n = 54) of the mothers, and only 18.5% (n = 10) of this proportion continued exclusive breastfeeding. Inability of the babies to suck was reported by 46% (n = 30) of the mothers as being the most important challenge in breastfeeding. There was a significant correlation between the type of cleft and challenge in breastfeeding (Fisher exact P = .001). Sixty-three percent (n = 41) of the mothers reported they received no counseling on overcoming challenges associated with feeding their babies with a cleft at the facility where they delivered. Sixty-nine percent (n = 45) reported they first received nutritional information from the cleft clinic at presentation. The most adopted substitute for breastfeeding was the use of regular feeding bottles (n = 24, 43.6%).

CONCLUSION

Rate of initiation of breastfeeding for children with orofacial clefts in this African cohort is higher than reported in other populations despite the low level of nutritional counseling of the mothers after delivery.

Assessment of Nutrition and Feeding Interventions in Turkish Infants with Cleft Lip and/or Palate

PURPOSE

The present study aimed to highlight the feeding challenges of infants with cleft lip and/or palate (CLP) that caregivers encounter and analyze the alternative interventions they perform based on their experiences in the preoperative period.

DESIGN AND METHODS

Parents of 200 infants with CLP were asked to complete our questionnaire. The prenatal feeding preparations, preoperative processes, and feeding challenges and modifications to overcome these difficulties were evaluated.

RESULTS

One-third of the caregivers stated that they had received feeding education prenatally. Sixty-five percent of the parents stated that they were not successful in breastfeeding. 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. Parents also reported that 59.5% of the infants with cleft had stayed in the intensive care units following birth. Moreover, 42% of the infants were initially fed by nasogastric or orogastric tube. Out of the 166 infants with cleft palate, 31.9% used palatal obturators.

CONCLUSIONS

We have reviewed the various feeding difficulties of the infants with clefts and highlighted the results of the interventions performed to overcome these difficulties for better nutrition and growth.

PRACTICE IMPLICATIONS

In the light of our findings, further studies should be conducted and additional educational programs should be implemented for both healthcare providers and parents to increase families' awareness regarding cleft feeding, prevent unnecessary and improper feeding interventions in infants with clefts, and alleviate the burden of feeding difficulties for both parents and infants.

Association of cleft lip and palate on mother-to-infant bonding: a cross-sectional study in the Japan Environment and Children's Study (JECS)

BACKGROUND

Cleft lip and/or palate is among the most prevalent congenital birth defects, and negatively affects maternal psychological status and may consequently result in higher prevalence of child maltreatment. However, the association of childbirths of infants with cleft lip and/or palate with maternal emotional involvement still remains unclear. We examined the association between childbirths of infants with cleft lip and/or palate and mother-to-infant bonding, using data from the Japan Environment and Children's Study, a nationwide birth cohort study.

METHODS

A cross-sectional study using the jecs-an-20,180,131 dataset was performed. A total 104,065 fetuses in 15 regional centres in Japan were enrolled after obtaining informed written consent. The Mother-to-Infant Bonding Scale, a self-report scale consisting of 10 items, was used to evaluate maternal bonding at one year after childbirth. Finally, the participants consisted of 79,140 mother-infant pairs, of which 211 mothers of infants with cleft lip and/or palate were included in our analyses. Multivariable logistic regression analysis using multiple imputation for missing data was performed to calculate the odds ratio and 95% confidence interval in the estimation of the association between bonding disorders and childbirths with cleft lip and/or palate.

RESULTS

No increased risk of bonding disorders was observed among all the mothers of infants with cleft lip and/or palate (odds ratio [95% confidence interval]; 0.97 [0.63-1.48], p = 0.880), however, advanced maternal age or multiple parity may adversely affect the associations between bonding disorders and cleft lip and/or palate, respectively. After stratification with a combination of maternal age and parity, a significant association of cleft lip and/or palate with bonding disorders was found only among advanced-age multiparae (odds ratio [95% confidence interval] = 2.51 [1.17-5.37], p = 0.018), but it was weakened after additional adjustment for maternal depression.

CONCLUSIONS

Childbirths of infants with cleft lip and/or palate may increase the risk of bonding disorders among advanced-age multiparae, possibly through maternal depression. This finding provides valuable information for the provision of multidisciplinary cleft care.

A Pilot Study of Mothers' Breastfeeding Experiences in Infants With Cleft Lip and/or Palate

BACKGROUND

Despite the recognized importance of human milk (HM) use, breastfeeding is often discouraged for infants with cleft lip and/or palate because of their anatomical abnormalities. Poor weight gain may require formula for calorie supplementation. Stresses associated with caring for infants with cleft lip/palate may decrease rates of HM provision to these infants.

PURPOSE

This study investigates the experiences of mothers of infants with cleft lip/palate (CL/P) to determine choices and factors associated with providing HM to their infants.

METHODS

A retrospective telephone survey was administered to a cohort of mothers of infants with CL/P.

RESULTS

Fifty mothers agreed to participate in the survey. Most (78%) initiated use of HM for a median duration of 4 months, 32% provided HM for 6 months or more, and 79% exclusively expressed their HM. Poor supply was the most frequent challenge to providing HM and led to cessation in 46% of the mothers. Formula was used to supplement for poor supply or poor infant weight gain in 90% of the mothers. The best predictors of a mother's use of HM were child not in day care, genetic diagnosis, and gestational age at birth. Only 36% of mothers reported individual encouragement to provide HM, and 18% reported they were specifically discouraged from providing HM for their infants.

IMPLICATIONS FOR PRACTICE

Although initiation rates were high, there are opportunities to improve support for mothers to increase duration of HM provision in children with CL/P.

IMPLICATIONS FOR RESEARCH

This study establishes a baseline for future prospective studies looking at the impact of active encouragement and provision of lactation support within the cleft team setting.

Differences in Weight Loss and Recovery After Cleft Lip and Palate Repair

OBJECTIVE

To determine the degree of weight loss, time to regain lost weight, and impact on postoperative outcomes after primary cleft lip (CL) and cleft palate (CP) repair.

DESIGN

Single institution retrospective.

PATIENTS

Two hundred seven patients who underwent primary CL and/or CP repair procedures.

RESULTS

One hundred thirty primary CL repairs (isolated CL = 59; cleft lip and palate [CLP] = 71) and 140 primary CP repairs (isolated CP = 72; CLP = 69): At the first postoperative visit, 21.54% of CL and 57.14% of CP repair patients had not returned to their immediate preoperative weights ( P < .0001). Maximum weight loss after CL repair was 0.44 kg (mean = 0.15 kg; standard deviation [SD]: 0.11) and for CP repair was 0.85 kg (mean = 0.31 kg; SD: 0.21; P = .002). Maximum percentage body weight loss was 6.11% after CL repair (mean = 2.08%; SD: 1.56) and 9.2% after CP repair (mean = 3.10%; SD: 2.13; P = .02). If not returned to preoperative weight by first postoperative visit, CP repair took significantly longer. Median time to return to preoperative weight was CL = 14.08 days (interquartile range [IQR]: 7.26) and CP = 25.37 days (IQR: 21.07; P < .0001). Patients undergoing CP repair with slowed weight recovery had a 22.5% rate of unintentional fistula/partial dehiscence compared to 10.0% of those who recovered quickly ( P = .052).

CONCLUSIONS

Primary CP repair involves significantly higher risk and degree of postoperative weight loss and slower rates of weight recovery when compared with primary CL repair. Postoperative weight loss is associated with increased risk of complications with palatal healing. Cleft palate repair patients should be monitored closely for weight recovery and considered for nutritional interventions to support improved postoperative outcomes.

A single visit feeding plate for 3 months old cleft palate infant . A case report

Infants with cleft palate (CP) suffer from several difficulties, one of them is feeding, which prevent infant from maintaining adequate nutrition. Usage of feeding plate, special bottles and nipples has been described to overcome this problem. This article describes steps of constructing a single visit feeding plate for a CP infant. The main objective was to provide an infant with a properly functioning feeding prosthesis and to reduce parents’ anxiety originated from multiple dental visits. We can conclude that our feeding plate was successfully achieving the planned objectives.

Breast Milk Feeding Rates in Patients with Cleft Lip and Palate at a North American Craniofacial Center

Objective

Our study goal was to evaluate the rates of breast milk feeding among patients with oral clefts at a large North American Craniofacial Center.

Methods

Parents of patients with oral clefts born from 2000 to 2012 and treated at our center were interviewed regarding cleft diagnosis, counseling received for feeding, and feeding habits.

Results

Data were obtained from parents of 110 patients with oral clefts. Eighty-four percent of parents received counseling for feeding a child with a cleft. Sixty-seven percent of patients received breast milk for some period of time with a mean duration of 5.3 months (range 0.25 to 18 months). When used, breast milk constituted the majority of the diet with a mean percentage of 75%. Breast milk feeding rates increased successively over the 13-year study period. The most common method of providing breast milk was the Haberman feeder at 75% with other specialty cleft bottles composing an additional 11%. Parents who received counseling were more likely to give breast milk to their infant ( P = .02). Duration of NasoAlveolar Molding prior to cleft lip repair did not affect breast milk feeding length ( P = .72). Relative to patients with cleft lip and palate, patients with isolated cleft lip had a breast milk feeding odds ratio of 1.71.

Conclusion

We present breast milk feeding in the North American cleft population. Although still lower than the noncleft population, breast milk feeding with regards to initiation rate, length of time, and proportion of total diet is significantly higher than previously reported.

Reporting of Randomized Controlled Trials in Cleft Lip and Palate: A 10-Year Review

Objectives

Reviews of the quality of reporting of randomized controlled trials (RCTs) have recently been conducted in different surgical specialties. In this review of RCTs relating to cleft lip, cleft palate, and cleft lip and palate (CL/P), we investigate the quality of reporting against the Consolidated Standards of Reporting Trials (CONSORT) checklist.

Design

A systematic review of CL/P RCTs published from 2004 to 2013, with the included articles scored against the CONSORT checklist.

Patients, Participants

The literature search identified 174 articles. Studies were selected for participants with CL/P who were involved in an RCT with prospective data collection and reported in a full journal article. A total of 6352 participants were included from 65 CUP RCTs during the study period.

Main Outcome Measures

The methodological quality of RCTs was assessed using the CONSORT checklist and Jadad scale.

Results

The mean CONSORT score was 15.8, and the mean Jadad score was 3.3. There was a significant positive correlation between the CONSORT and Jadad score ( P < .0001, ρ = .47). The only significant correlation showed that with an increasing number of authors, both the CONSORT and the Jadad score increased.

Conclusion

This analysis has shown that that there are deficiencies in the transparent reporting of factors such as randomization implementation, blinding, and participant flow. Interventions, outcomes, and the interpretation of results are well presented. We would recommend that RCTs are conceived and undertaken using the CONSORT checklist and reported in a clear and reproducible manner.

Cup feeding versus other forms of supplemental enteral feeding for newborn infants unable to fully breastfeed

BACKGROUND

Breast milk provides optimal nutrition for term and preterm infants, and the ideal way for infants to receive breast milk is through suckling at the breast. Unfortunately, this may not always be possible for medical or physiological reasons such as being born sick or preterm and as a result requiring supplemental feeding. Currently, there are various ways in which infants can receive supplemental feeds. Traditionally in neonatal and maternity units, bottles and nasogastric tubes have been used; however, cup feeding is becoming increasingly popular as a means of offering supplemental feeds in an attempt to improve breastfeeding rates. There is no consistency to guide the choice of method for supplemental feeding.

OBJECTIVES

To determine the effects of cup feeding versus other forms of supplemental enteral feeding on weight gain and achievement of successful breastfeeding in term and preterm infants who are unable to fully breastfeed.

SEARCH METHODS

We used the standard search strategy of the Cochrane Neonatal Review group to search the Cochrane Central Register of Controlled Trials (CENTRAL 2016, Issue 1), MEDLINE via PubMed (1966 to 31 January 2016), Embase (1980 to 31 January 2016), and CINAHL (1982 to 31 January 2016). We also searched clinical trials' databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials and quasi-randomised trials.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials comparing cup feeding to other forms of enteral feeding for the supplementation of term and preterm infants.

DATA COLLECTION AND ANALYSIS

Data collection and analysis was performed in accordance with the methods of Cochrane Neonatal. We used the GRADE approach to assess the quality of evidence.The review authors independently conducted quality assessments and data extraction for included trials. Outcomes reported from these studies were: weight gain; proportion not breastfeeding at hospital discharge; proportion not feeding at three months of age; proportion not feeding at six months of age; proportion not fully feeding at hospital discharge; proportion not fully breastfeeding at three months of age; proportion not fully breastfeeding at six months of age; average time per feed (minutes); length of stay; and physiological events of instability such as bradycardia, apnoea, and low oxygen saturation. For continuous variables such as weight gain, mean differences and 95% confidence intervals (CIs) were reported. For categorical outcomes such as mortality, the relative risks (RR) and 95% CIs were reported.

MAIN RESULTS

The experimental intervention was cup feeding and the control intervention was bottle feeding in all five studies included in this review. One study reported weight gain as g/kg/day and there was no statistically significant difference between the two groups (MD -0.60, 95% CI -3.21 to 2.01); while a second study reported weight gain in the first seven days as grams/day and also showed no statistically significant difference between the two groups (MD -0.10, 95% CI -0.36 to 0.16). There was substantial variation in results for the majority of breastfeeding outcomes, except for not breastfeeding at three months (three studies) (typical RR 0.83, 95% CI 0.71 to 0.97) which favoured cup feeding. Where there was moderate heterogeneity meta-analysis was performed: not breastfeeding at six months (two studies) (typical RR 0.83, 95% CI 0.72 to 0.95); not fully breastfeeding at hospital discharge (four studies) (typical RR 0.61, 95% CI 0.52 to 0.71).Two studies reported average time to feed which showed no difference between the two groups. Two studies assessed length of hospital stay and there was considerable variation in results and in the direction of effect. Only one study has reported gestational age at discharge, which showed no difference between the two groups (MD -0.10, 95% CI -0.54 to 0.34).

AUTHORS' CONCLUSIONS

As the majority of infants in the included studies are preterm infants, no recommendations can be made for cup feeding term infants due to the lack of evidence in this population.From the studies of preterm infants, cup feeding may have some benefits for late preterm infants and on breastfeeding rates up to six months of age. Self-reported breastfeeding status and compliance to supplemental interventions may over-report exclusivity and compliance, as societal expectations of breastfeeding and not wishing to disappoint healthcare professionals may influence responses at interview and on questionnaires.The results for length of stay are mixed, with the study involving lower gestational age preterm infants finding that those fed by cup spent approximately 10 days longer in hospital, whereas the study involving preterm infants at a higher gestational age, who did not commence cup feeding until 35 weeks' gestation, did not have a longer length of stay, with both groups staying on average 26 days. This finding may have been influenced by gestational age at birth and gestational age at commencement of cup feeding, and their mothers' visits; (a large number of mothers of these late preterm infants lived regionally from the hospital and could visit at least twice per week).Compliance to the intervention of cup feeding remains a challenge. The two largest studies have both reported non-compliance, with one study analysing data by intention to treat and the other excluding those infants from the analysis. This may have influenced the findings of the trial. Non-compliance issues need consideration before further large randomised controlled trials are undertaken as this influences power of the study and therefore the statistical results. In addition larger studies with better-quality (especially blinded) outcome assessment with 100% follow-up are needed.

Feeding methods for children with cleft lip and/or palate: a systematic review

INTRODUCTION

Feeding difficulties in children with cleft lip and palate (CLP) are frequent and appear at birth due to impairment of sucking and swallowing functions. The use of appropriate feeding methods for the different types of cleft and the period of the child's life is of utmost importance for their full development.

OBJECTIVE

Review studies comparing feeding methods for children with CLP, pre- and postoperatively.

METHODS

The search covered the period between January 1990 and August 2015 in the PubMed, LILACS, SciELO, and Google Scholar databases using the terms: cleft lip or cleft palate and feeding methods or breastfeeding or swallowing disorders and their synonyms. This systematic review was recorded in PROSPERO under number CRD42014015011. Publications that compared feeding methods and published in Portuguese, English, and Spanish were included in the review. Studies with associated syndromes, orthopedic methods, or comparing surgical techniques were not included.

RESULTS

The three reviewed studies on the period prior to surgical repair showed better feeding performance with three different methods: squeezable bottle, syringe, and paladai bottle. Only one study addressed the postoperative period of cleft lip and/or palate repair, with positive results for the feeding method with suction. Likewise, the post-lip repair studies showed better results with suction methods. After palatoplasty, two studies showed better performance with alternative feeding routes, one study with suction method, and one study that compared methods with no suction showed better results with spoon.

CONCLUSION

The studies show that prior to surgical repair, the use of alternative methods can be beneficial. In the postoperative period following lip repair, methods with suction are more beneficial. However, in the postoperative period of palatoplasty, there are divergences of opinion regarding the most appropriate feeding methods.

Initial Nutritional Assessment of Infants With Cleft Lip and/or Palate: Interventions and Return to Birth Weight

OBJECTIVE

To assess and quantify cleft team practices with regard to nutritional support in the neonatal period Design :  Retrospective review.

SETTING

Tertiary pediatric hospital.

PATIENTS

One hundred consecutive newborn patients with a diagnosis of cleft lip and/or cleft palate between 2009 and 2012.

MAIN OUTCOME MEASURES

Birth weight, cleft type, initial cleft team weight measurements, initial feeding practices, recommended nutritional interventions, and follow-up nutritional assessments.

RESULTS

All patients in the study were evaluated by a registered dietitian and an occupational feeding therapist. Average birth weight and average age at the first cleft team visit were similar for each cleft type: cleft lip (CL), cleft lip and palate (CLP), and cleft palate (CP). The calculated age (in days) for return to birth weight was significantly different between cleft types: CL = 13.58 days, CLP = 15.88 days, and CP = 21.93 days. Exclusive use of breast milk was 50% for patients with CL, 30.3% for patients with CLP, and 21.4% for patients with CP. Detailed nutritional interventions were made for 31 patients at the first visit: two with CL, 14 with CLP, and 15 with CP.

CONCLUSIONS

Distinct differences were seen in neonatal weight gain between cleft types. There was significantly greater total weight gain for patients with CL at their first visit and significantly slower return to birth weight for patients with isolated CP. Patients with CL required far fewer interventions at the initial assessment and were more likely to be provided breast milk exclusively or in combination with formula. Infants with CP were far less likely to receive any breast milk. Patients with CLP and CP required frequent nutritional interventions.

Doubts of caregivers of children with cleft lip and palate on postoperative care after cheiloplasty and palatoplasty

Objective To identify the main doubts of caregivers of children with cleft lip and palate on postoperative care after cheiloplasty and palatoplasty. Method Cross-sectional study carried out in a reference hospital, between September and November 2012. The sample was composed of 50 individuals divided in two groups, of which 25 caregivers of children submitted to cheiloplasty, and 25 of children submitted to palatoplasty. The doubts were identified by an interview applied during the preoperative nursing consultation and were then categorized by similarity. Descriptive statistics was used for analysis of the outcomes. Results Concerning cheiloplasty, the doubts were related to feeding (36%), hygiene and healing (24% each), pain and infection (8% each). With regard to palatoplasty, the doubts were related to feeding (48%), hygiene (24%), pain (16%), bleeding (8%) and infection (4%). Conclusion The study evidenced the concern of caregivers in relation to feeding and care of the postoperative wound.

Proteomic Analysis of RBP4/Vitamin A in Children with Cleft Lip and/or Palate

Cleft of the lip and/or palate (CLP) is one of the most common congenital craniofacial defects. Non-syndromic CLP (NSCLP) is a multifactorial disease influenced by the interaction of genetic and environmental factors. However, there are few studies reporting on the developmental or metabolic status of babies with NSCLP after birth. In our study, we sought to identify and evaluate the differential expression of serum protein profiles in NSCLP children and unaffected babies. Thus, a 'shotgun proteomics' approach was first used to analyze the plasma proteome of 13 children with NSCLP and 10 control children, aged 2 to 3.5 years. In total, more than 300 proteins were identified in the serum sample. With gene ontology (GO) analysis, we detected many differentially expressed proteins that could be related to NSCLP, including those involved in lipoprotein metabolism, insulin-like growth-factor-related processes, and so on, especially the proteins involved in retinol transport. Retinol binding protein 4 (RBP4), one protein of the retinol transport category, was significantly decreased in the NSCLP group. Thus, serum vitamin A levels were further determined by high-performance liquid chromatography (HPLC). A significant difference (p < .01) was also found in vitamin A concentrations, consistent with the trend of RBP4. Our results indicated that reduced levels of RBP4 and vitamin A were related to newborns with NSCLP and should thus receive more attention. These results also suggest that vitamin A supplementation might be necessary at an early stage.

Role of obturators and other feeding interventions in patients with cleft lip and palate: a review

BACKGROUND

Newborns with cleft palate have a distorted maxillary arch at birth. Depending upon the type of cleft, infants suffer from a variety of problems, many of which are related to feeding difficulties. Feeding these babies is an immediate concern because there is evidence of delayed growth of children with cleft lip and palate (CLCP) compared to normal infants. Many methods have been devised to overcome these problems, including the use of special bottles, nipples, and initial obturator therapy.

REVIEW

A Pub Med search was conducted using the following search terms: feeding interventions in cleft lip and palate, feeding plate/obturator in cleft palate. All the relevant articles were studied and the reference list of selected articles was also studied. Effects of different feeding interventions in infants with cleft palate with special emphasis on obturators, based on descriptive reports, expert opinions, and available data from clinical trials was reviewed.

RESULTS

The combination of search terms generated a list of 74 articles out of which 51 articles were excluded based on analyses of abstracts and full texts. Three additional publications were identified by the manual search. A total of 26 relevant articles were selected which included randomised controlled trials and descriptive studies on feeding interventions and obturators.

CONCLUSION

A single intervention may not fulfil all feeding requirements of infants with CLCP. Combined use of different feeding interventions such as palatal obturator, Haberman feeder, and breast milk pump and lactation education may successfully meet the feeding needs of both mother and child.

Weight Gain in Children with Cleft Lip and Palate without Use of Palatal Plates

Goals/Background. To evaluate children's growth in the first year of life, who have cleft palate and lip, without the use of palatal plates. Materials/Method. Chart review was conducted, retrospectively, in the Center for Integral Assistance of Cleft Lip and Palate (CAIF), in Brazil, between 2008 and 2009. Results for both genders were compared to the data published by the World Health Organization (WHO) regarding average weight gain in children during their first year of life. Results. Patients with syndromic diagnosis and with cleft classified as preforamen were excluded, resulting in a final number of 112 patients: 56 male and 56 female. Similar patterns were seen comparing the two genders. Although it was observed weight gain below the average until the 11th month in male patients and until 9 months in female patients, both genders remained at the 50th percentile (p50) and improved after the 4th month of age for boys and the 9th month of age for girls. Conclusion. Children with cleft palate weigh less than regular children during their first months of life. At the end of the first year, weight gain is similar comparing normal and affected children. However, factors that optimized weight gain included choosing the best treatment for each case, proper guidance, and multiprofessional integrated care.

A modified feeding plate for a newborn with cleft palate

Objectives : Cleft palate is a common congenital maxillofacial defect. We wish to present the fabrication of a modified feeding plate that will adapt to the changing palatal and velopharyngeal morphology during function. Case Report : A neonate with unilateral cleft lip and palate was referred to our clinic for the fabrication of a feeding plate. Intraoral examination revealed a cleft involving the uvula and the soft palate, with an alveolar defect on the left side. An impression was taken and a dental cast was obtained. A 1-mm Bioplast clear soft plate was pressed on the model. After trimming the edges of the plate, several retentive holes were made for its attachment to the hard plate. With the Bioplast soft plate replaced on the cast, plaster was used to cover parts of the soft plate that were not to come in contact with the hard plate. Biocryl resin was put on the retentive holes and 2-mm Biocryl C Rosa-transparent plate was pressed. The edges of the plate were cut, trimmed, and polished. Conclusion : This modified feeding plate effectively obstructed the soft palate defect. The adaptation of the flexible bulb of the appliance with the soft palate was excellent. Evaluation with nasoendoscopy revealed the synchronized movement of the bulb of the appliance with the soft palate during swallowing. Soft extension of the feeding plate eliminated the risk of irritation, and the baby accepted the appliance easily.