Cleft lip and palate

Cleft palate is a malformation in which the palate has a fissure and is missing in a more or less large part, which allows communication between the mouth and the nasal cavity.
Cleft lip is a break or slit of the upper lip from the nose to the mouth, with which the oral cavity is communicated with the outside.
Depending on the country, one to three out of every thousand newborns is born with one of these malformations and in half of the cases both coexist at the same time. In 30% of cases, it is part of a polymalformative syndrome that can worsen the prognosis (Boyce 2019).

The problem in relation to breastfeeding is that a vacuum and sealing of the breast is required in the infant's mouth and as there are these openings, air enters, and a vacuum cannot be produced, the breast slips away from the infant, and the infant cannot suckle; breastmilk can leak through the infant’s nose.
These difficulties mean that there are lower rates of breastfeeding and less duration in cases of cleft palate and/or cleft lip (Boyce 2019, Gottschlich 2018).

Information should be provided to the mother and family as soon as possible, prenatally if the diagnosis is known. The advice of a breastfeeding expert should be sought (Boyce 2019, Burca 2016) and each case individually evaluated, especially if there are associated malformations. Parents can receive help from local associations working on the issue (Boyce 2019).

The mother should know that breastfeeding is also the best for her baby with a cleft palate and/or cleft lip and that, with greater or lesser difficulty and applying certain techniques, it may be possible.
Babies with this disorder suffer more frequently from otitis media and orofacial musculature disorders that can be prevented and corrected by breastfeeding (Aniansson 2002).
The emotional impact of a baby with this malformation on the mother and family makes breastfeeding even more advisable.

Although there has been much discussion about the lack of evidence of the benefits and risks of prenatal expression of colostrum to administer to the newborn thus avoiding the use of milk formula (East 2014), the benefits are clear when neonatal problems (diabetes maternal, scheduled cesarean section, twins, premature infants, cleft lip/palate, etc.), which is why it is a practise that is recommended by health institutions and several authors (NHS 2018, Wszolek 2015), and is well tolerated by mothers and improves their self-confidence (Brisbane 2015).

In cases of cleft lip without cleft palate, the breast itself can seal the fissure and prevent the entry of air allowing breastfeeding. In contrast, when there is a cleft palate, direct breastfeeding is very inefficient and often cannot be done without certain aids. It is also more complicated if the cleft lip is double, bilateral.
Changes in posture are helpful in these cases. In cases of cleft lip, a posture that "sticks" the upper lip to the breast (changes from classic sitting to "inverted" sitting, or the mother herself covering the cleft lip with a finger) can allow effective breastfeeding. In cases of double cleft lip, a position that can be tried to seal both fissures is the posture of the rocking horse. Holding the baby's chin with your hand to place it on the breast is also a good approach (Boyce 2019).

Keeping the baby in a semi-vertical position is advisable in order to reduce the regurgitation of milk through the nose. This may also reduce the risk of middle ear infections via tranfer of milk into the ear from the nose (Boyce 2019).

Manually milking the breast directly into the baby's mouth can compensate for the lack of a proper latch.

If postural changes and milking are insufficient, it is necessary to resort in all or some feeds to the expressing and administration of breastmilk with a glass, spoons or special nipples or tube. The mother’s own breastmilk is always preferable to an artificial formula.

Prostheses that provisionally occlude the palate defect prior to surgical correction do not always improve breastfeeding technique (Boyce 2019, Rodríguez 2010).

Within hours of reconstructive surgery, which is usually performed between 3 and 6 months of age for cleft lip and 6 to 12 months for cleft palate, the baby can be returned to the breast (Boyce 2019, Matsunaka 2019 and 2015). Infants cry less when fed directly at the breast or with a bottle than with a spoon or syringe, and this protects the surgical wound (Matsunaka 2015, Augsornwan 2013). It may happen that it takes the infant some time after the operation to learn to suckle correctly.

It can be very instructive to read the experiences of mothers and guides for mothers of babies with cleft lip/palate (Rachel Morgan-LLL 2015, Intermountain Healthcare 2013, multilingual video “Mauro, yes he can”).