Problem-Solving: Aerophagia in infant with cleft lip

QUESTION:

One of my friends just had a baby with a partial cleft lip. She is 6 weeks old and started having trouble with feeding last week. Her pediatrician feels like she is sucking too much air in when feeding. The mother has tried different bottles and nipples. She is on thin formula. She is also having diarrhea and her bottom is raw. Her pediatrician feels like it is caused from the air coming in from her cleft during bottle feeds. She has a cleft lip repair surgery date set in September. What recommendations should if give her? Applying chin support and pressure to cheeks to get a good lip seal? Thickening the formula to slow the flow rate?

Thank you for any advice!

ANSWER:

It is uncommon for a partial/incomplete cleft in isolation to lead to the feeding problems you describe. In my experience, an isolated cleft of the lip does not contribute to feeding problems in infants. It can, however, co-occur with other alterations in oral-motor/structural integrity. These would include: a cleft of the soft palate (even just the uvula) that is not readily apparent to the physician – it would alter the effectiveness of intra-oral suction and lead to ineffective compensatory sucking behaviors that may lead to air swallowing. Other possibilities are a tongue tie (posterior and/or anterior, as these often co-occur with clefts d/t timing of intrauterine aerodigestive structure formation; the tongue tie(s), if present, can lead to ineffective tongue-palate seal and again, air swallowing with each bolus, as well as fatigue and decreased transfer of milk. Another option is that there is co-occurring mandibular hypoplasia (a retruded and/or small jaw, as we used to call it – ENTs typically call it mandibular hypoplasia); this can lead again to poor tongue-palate seal, ineffective tongue patterns for sucking d/t altered intrauterine motor-learning by the tongue, and again compensatory sucking patterns that become maladaptive and not functional. Another possibility is a submucous cleft, which again may not be clear, and lead to ineffective suction, leading to the same maladaptations and adverse functional sequelae.

She may also have altered sucking or coordination patterns unrelated to any structural differences, just “co-occurring”, that has the same undesired results. For example, she may also have a prolonged sucking pattern that can lead to air swallowing. In that case, co-regulated pacing would support a more stable burst-pause pattern and avoid air swallowing,  or the flow are may be too fast, which can lead to swallowing air with each bolus, so a more controllable flow rate would help (i.e., slow flow). I would not thicken liquids or continue changing nipples, as her learning starts over each time, and some of that may be maladaptive. We really need is to understand the “whys” before we can determine what interventions would be indicated.

The loose stools also are concerning for poor formula tolerance or other GI issues that may further adversely affect feeding pleasure and growth. A consult with a pediatric SLP, ENT and GI would be beneficial to complete a thorough differential to find out what is contributing to her poor feeding.

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