Swallowing evaluation with infant with a cleft palate

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Answer

There is no single protocol available to my knowledge for evaluation of all infants in any category of feeding and swallowing problems. There are numerous factors that should be considered in evaluation of infants with cleft palate. First, determine if the cleft palate is essentially the only anomaly in an otherwise healthy and typically developing infant. If that is the case, the evaluation and modifications are likely to be relatively minor. These infants can suck, swallow, and breathe in appropriate functional ways. However, the sucking is altered by the lack of a palate, particularly a soft palate, to close off the nasopharynx. These infants cannot build up the necessary intra-oral pressure to ''strip'' a nipple adequately to take liquid efficiently enough to gain weight well. They can compress a nipple and when they get liquid, they should be able to swallow without risks for aspiration or other pharyngeal phase deficits. There are special nursing units (e.g., Haberman feeder, Mead-Johnson cleft palate nurser) that may help some infants offset the inability to extract liquid from a regular nipple. Some would suggest that a larger hole in a nipple is all that is needed (caution: if liquid flow is too fast, that is a bigger problem for an infant than one that may require some work). The bottom line is that nipple feeding much be non-stressful and efficient, so that the infant takes in adequate volume and calories to gain weight appropriately.

However, I am suspicious about an 8-week-old infant needing a referral for a feeding evaluation. Has the infant been gaining weight and growing adequately? Is she having new problems? Or have there been problems since birth that are just now being recognized? Is she now in a state of Failure to Thrive (undernutrition) that is bringing her for feeding evaluation? Has the infant shown signs of airway instability? Does this infant have a posterior cleft that is consistent with Pierre Robin sequence (usually U-shaped cleft of posterior palate, glossoptosis, and micrognathia)? That infant may have other factors that impact negatively on the ability to feed orally. A thorough history and physical examination are important as for all infants, to include, but not limited to: tone, levels of alertness, vocal quality, gross and fine motor skills, cognitive and pre-linguistic levels, and nonnutritive sucking strength and rhythm. Findings in these areas will yield important information as to whether it is appropriate to proceed with a feeding evaluation.

I have recently updated a chapter on Feeding with Craniofacial Anomalies in the second edition of Arvedson and Brodsky (2002) with as many evidence based references that I could find related to evaluation and intervention for infants with feeding difficulties. The references may be helpful to the person asking the question as well as for other SLPs who are called upon to examine infants at risk for prolonged and stressful feedings that could result in undernutrition and could exacerbate other medical/surgical issues. In infants with complex etiologies that include cleft palate as one of the findings, it is often the case that the cleft palate is a minor factor in the feeding difficulties. The various contributing factors must be delineated clearly in order to make recommendations for intervention. Every infant deserves a thorough physical examination and feeding evaluation that incorporates findings related to upper airway and pulmonary status, neurologic and neurodevelopmental status, and gastrointestinal tract functioning.

Arvedson, J.C. & Brodsky, L.B. (2002). ''Feeding with craniofacial anomalies,'' in Pediatric swallowing and feeding: Assessment and management. (2nd Ed.) (pp. 527-561). Albany, NY: Singular Publishing Group, a division of Thomson Learning, Inc.


Joan C. Arvedson, PhD, is Program Coordinator of Feeding and Swallowing Services at the Children's Hospital of Wisconsin - Milwaukee, Wisconsin. She is also Clinical Professor in the Department of Pediatrics, Medical College of Wisconsin. Dr. Arvedson received her BS, MS, and PhD degrees from the University of Wisconsin-Madison. She has two books in publication: Pediatric Swallowing and Feeding: Assessment and Management, second edition, 2002 (with L. Brodsky, MD) and Pediatric Videofluoroscopic Swallow Studies: A Professional Manual with Caregiver Guidelines, 1998 (with M. Lefton-Greif, PhD). She has given numerous workshops and seminars on the topic of swallowing and feeding disorders in infants and children throughout the United States, Canada, Europe, and Asia. Her teaching and research endeavors are focused in these areas. Patient care focuses include swallowing and motor speech disorders in varied pediatric populations.