Practical Information for Parents and Speech Pathologists

Feeding

Parents of babies with Velo-Cardial-Facial Syndrome (VCFS) and particularly with cleft palate are frequently unprepared for the special needs that their babies will have. The most pressing issue before cleft palate repair is for the baby to get enough nutrition. The cleft palate results in a difference of the oral structures that effect the ability to get liquid from either a breast or bottle (“Cleft Feeding,”n.d.).

http://www.nationwidechildrens.org/cleft-palate-and-feeding-your-baby

Babies with cleft palate need special equipment in order to get the nutrition that they need (Crowley et al., 2010). The opening between the oral cavity and the nasal cavity eliminates the pressure that a baby needs to suck (“Tips for Feeding,”n.d.). The Mead-Johnson cleft palate nurser  (Miller, 2011) and the Haberman feeder are modified bottles that can be used with babies with unrepaired cleft palate (“Cleft Feeding”; Crowley et al., 2010; Fullman & Boyer, 2012).   Some clinicians also use bottles with bags that have been modified to allow the person feeding the baby to control the flow (Glass & Wolf, 1999).  Nipples can be selected based on shape, size, pliability and hole size (“Feeding the Baby”, 2009). Modified nipples can also be used (“Feeding the Baby”, 2009). These include the Haberman feeder nipple and the pigeon nipple (“Cleft Feeding,” n.d.). Both of them have a one-way valve in the nipple or at the entrance to the nipple (“Cleft Feeding,” n.d.). The pigeon nipple releases fluid by compressing the nipple (“Cleft Feeding,” n.d.). The nipple should be positioned against a bone (“Feeding the Baby”, 2009; Fullman & Boyer, 2012).  It should also be in the middle of the mouth to allow for typical tongue movement (Glass & Wolf, 1999).

http://www.rch.org.au/kidsinfo/fact_sheets/Cleft_lip_and_palate_infant_feeding/

Since there is an opening between the oral cavity and the nasal cavity in babies with unrepaired cleft palate, there is the potential for food that enters the mouth to come out the nose (“Tips for Feeding,” n.d.). Using modified equipment will not eliminate the possibility of food coming out the nose. Special positioning is used to minimize the occurrence of food entering the nasal cavity (“Tips for Feeding,” n.d.; Fullman & Boyer, 2012). Babies should be in an upright or slightly reclined position (“Feeding the Baby”, 2009; “Tips for Feeding,” n.d.). The baby's head, neck and shoulders should be aligned (“Tips for Feeding,” n.d.). Hands and fingers can be used to keep the baby's mouth around the nipple during feeding (“Feeding the Baby, 2009).  The lips, cheeks, and jaw can be supported by the person feeding the baby (Miller, 2011).  The jaw can be stabilized by putting the middle finger under the chin and the index finger between the chin and the lower lip (Miller, 2011).  The hands can also be used to assist in oral control (Miller, 2011). Miller (2011) suggests that the viscosity of the liquid be increased through additive thickener in order to better protect the airway.  There is little evidence to support this.  

Speech

Children with VCFS and a repaired cleft palate may experience some speech issues due to velopharyngeal insufficiency (Kummer; G., 2012; Fullman & Boyer, 2012). This causes speech to become nasalized (Kummer; Fullman & Boyer, 2012). This should be treated by first developing an awareness of the difference between normal speech and hypernasal speech (Kummer; n.d., G., 2012; “Speech Development”, 2010). Other areas that could be effected by cleft palate are hearing and speech sound development (“Speech Development”, 2010).

Auditory feedback can be achieved through using a listening tube or the Oral and Nasal Listener (Kummer, n.d.). The Oral and Nasal Listener allows both the clinician and the child to listen to the production (Kummer, n.d.). A nasometer can be used to provide visual feedback (Kummer, n.d.). Auditory discrimination can also be achieved through listening to both normal speakers and speakers with hypernasal speech (G., 2012). If hypernasality is moderate to severe, surgery such as pharyngeal flap or sphincter pharyngoplasty should be considered (“Speech Development”, 2010).

Children with velopharyngeal insufficiency have issues with speech articulation in several different areas. They have difficulty with nasalizing plosives and fricatives, and palatal-dorsal productions (Kummer n.d.; G., 2012). They also have issues with nasalizing vowels and affricates (Kummer, n.d.). Glottal stops are sometimes produced with oral sounds (Kummer, n.d.' Fullman & Boyer, 2012). In order to produce plosives, the clinician can ask the child to yawn and produce the sound at the same time (G., 2012; Kummer, n.d.). The yawn makes the back of the tongue go down (Kummer, n.d.; G., 2012). Auditory feedback can also be used at this time (Kummer, n.d.). Nasalized affricates can be treated by having the client produce /t/ and then close the teeth to produce the /s/ sound (Kummer, n.d.; G., 2012). After the child produces a /t/ with a long /s/ have the child eliminate moving the tongue for /t/ and then round the lips to produce the affricate 'ch' (Kummer, n.d.). In order to produce the 'sh' sound the same procedure is used except for eliminating the tongue movement (Kummer, n.d.). Palatal-dorsal productions can be treated by bite on a tongue depressor that is situated on the middle of the tongue and between canine or molar teeth (Kummer, n.d.). Have the child produce the lingual alveolar sounds or the velar sounds while biting on the tongue depressor (Kummer, n.d.; G., 2012). Parents should be involved in the treatment of speech sounds (Kummer, n.d.; “Speech Development”, 2010).

References

Cleft feeding instructions. (n.d.) Seattle Children's. Retrieved from:

http://www.seattlechildrens.org/medical-conditions/chromosomal-genetic-conditions/cleft-lip-palate-feeding/

Crowley, L., Gist, L., Gregson, M. K., Hufnagle, K., Falzone, S. P., Smythe, N. C., & Trivelpiece, R.
            (2010). Cleft palate foundation: Your baby's first year. Retrieved from:
            http://www.cleftline.org/docs/Booklets/FYL-01.pdf

Feeding the baby with cleft lip and palate. (2009). Cincinnati Children's. Retrieved from:

http://www.cincinnatichildrens.org/assets/0/78/759/781/9c3837a6-d930-4587-b113-c55390488457.pdf

Fullman, L., & Boyer, V. (2012). Velocardiofacial syndrome and early intervention.   

            Contemporary Issues in Communication Science and Disorders, 39, 21–29. 

            doi: 1092-5171/12/3901-0021.

Glass, R.P., & Wolf, L.S. (1999). Feeding management of infants with cleft lip and palate and  

           micrognathia. Infants & Young Children, 12(1), 70–81. doi:10.1097/00001163-199907000-      

           00010.

G. J., (2012). Top 4 cleft palate speech therapy techniques. Retrieved from:

https://www.speechbuddy.com/blog/speech-therapy-techniques/top-4-cleft-palate-speech-therapy-techniques/

Kummer, A. W. (n.d.) Speech therapy for cleft palate and velopharyngeal dysfunction (VPD). Retrieved

from: http://www.cincinnatichildrens.org/assets/0/78/759/781/65e90133-9243-4926-a065-8a97951944fb.pdf

Miller, C.K. (2011). Feeding issues and interventions in infants and children with clefts and 

     craniofacial syndromes. Seminars in Speech and Language, 32(2), 115–26. doi:10.1055/s-

     0031-1277714.

Speech development related to cleft palate. (2010). Parent/Family Education. Retrieved from:
            http://www.childrensmn.org/Manuals/PFS/ChildDev/193473.pdf

Tips for feeding an infant with cleft lip. (n.d.) St. Louis Children's Hospital. Retrieved from:

http://www.stlouischildrens.org/our-services/cleft-palate-and-craniofacial-institute/tips-feeding-infant-cleft-lip