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    Initially, feeding may be difficult due to the inability to maintain intra-oral negative pressure due to the open connection between the oral and nasal cavities. Breast feeding may not be possible when the palate is involved. Some mothers are successful but may need to supplement with breast pumping or formula. Feeding the baby may take a period of trial and error. Most mothers are successful with a soft nipple cross cut at the end or side attached to a Mead-Johnson squeeze bottle. Other products include Pigeon Nipple, NUK nipple, Haberman feeder. These feeders allow the baby to gum the nipple and drip or squeeze milk or formula. Infant should be fed in the slightly upright position, also called the "football hold." Air swallowing can be prevented with more frequent and slower feedings. Remember to burp your baby often. Monitor weight and feeding closely. A feeding specialist can be very helpful. All babies have different abilities, likes and dislikes. The urge to feed is strong, and the best technique is quickly determined. Sometimes it requires patience, time and determination but eventually all babies will learn to feed. Babies need time to learn and to strengthen the muscles of the mouth, tongue and throat. Be creative and resourceful.

Breastfeeding
    Breastfeeding an infant with a cleft palate is usually not possible if any part of the palate is affected. If the cleft only involves the lip, then breast feeding may be attempted but will require a more upright positioning so that mother's breast tissue fills the gap in the lip or gum. Nursing at the breast is best limited to 10 minutes, and supplemental bottles are needed if breastfeeding alone does not supply enough food for adequate satisfaction and growth. For most mothers of infants with cleft palate, breast pumping should begin at birth using a high quality electric breast pump and continue each time after the infant eats. A lactation consultant is a breastfeeding mother's best resource for correct positioning and pumping technique. Discuss your feeding plan with this specialist before discharge from the hospital. Weight gain must be followed closely.

Bottle Feeding
    Small, frequent feedings are usual in the first weeks of life for an infant with a cleft palate. Give yourself and your baby time to learn how to eat, and expect longer feeding times. Try to limit feedings to 30 minutes with an additional 10 minutes for burping and changing. Hold your baby upright or slightly tilted back (in your arm with a fat pillow under your elbow) to limit the amount of liquid that enters the nasal passage. Some infants totally ignore drainage into the nose, and you should not be alarmed to see a trickle come out. If there is a great amount of liquid in the nose, tilt the baby forward. Your baby will swallow any extra milk in the back of the throat and the extra milk in the front of the mouth and nose will drain by gravity. You may use a bulb suction to help, but the positioning is most important to prevent any extra liquid from sliding to the back of the throat.

Mead Johnson Cleft Palate Nurser
    Special feeding bottles and nipples work by allowing the milk to come out of the nipple with little or no suction needed. Some cleft palate bottles need compression, or squeezing, along with an enlarged opening cut into the nipple to help the infant get enough flow of milk. Hold your baby up in a semi-upright seated position with the head and shoulders in one hand and the bottle in your other hand. If you are more comfortable with the baby in the crook of your elbow, place a blanket or pillow under that elbow to hold the baby more upright. Tickle the baby's lower lip or corner of the mouth with the nipple and place it over the tongue when the mouth pops open. You may need to pull the lower jaw down gently to get the baby's tongue down and out of the way. When the nipple is placed in the mouth, allow  your baby to suck and breathe a few times before beginning compression of the Mead Johnson Cleft Palate Nurser bottle.

    Begin with gentle compression and slowly increase the pressure while watching your infant's face. If the baby takes more than 40 minutes to eat, or if there is leakage from the nipple ring, it may improve feeding efficiency to increase the crosscut about 1/16th of an inch. Any time the nipple opening is enlarged, take care to squeeze less hard until you know how much the flow of formula has increased. There is little you can do to control the amount of air swallowed during feedings. Your baby will need to burp frequently, but don't interrupt the feeding too much. For very young infants, all you will have to do to is straighten up the baby by pushing gently up at the back of the waist and lifting the front of the chest with the other hand. Any commercial nipple can be used with the compressible bottle if the tip of the nipple is cut in a 1/8 to 1/4 inch "X" (see diagram).

Pigeon Cleft Palate Nipple
    There is a Y cut in the tip of the nipple. Roll the tip with a clean cloth to loosen the opening. Notice the V in the base of the nipple. This is the air vent, and must be positioned on the top of the nipple under the infant's nose for the nipple to work properly. If the nipple collapses or leaks from that hole, remove the nipple from the cap and massage that area to unclog the vent. You may need to poke a toothpick through the vent to clear it. If the bottle system is purchased, follow package directions for assembly. If only the nipple or valve is purchased, the nipple ring from the Enfamil bottle may be used, but not all nipple rings will fit the valve. Put the valve in the base of the nipple, flat side toward the tip. Make sure the nipple lies flat inside the ring and the valve is level with the rim of the nipple. Put the nipple in baby's mouth normally. The infant's tongue will activate the flow. If the nipple collapses, you can unscrew the cap and re-tighten it.

Haberman Feeder (Medela Special Needs Feeder)
    Assemble the bottle and fill with breast milk or formula according to package directions. Line up the shortest line on the compressible reservoir with the baby's nose and tickle the lower lip. Insert the nipple when the mouth opens. Position the nipple on the center of the tongue with the tip turned under the intact part of the palate. The infant will begin to suck. Rotate the nipple until the longest line and greatest flow is under the baby's nose. If your infant cannot tolerate the flow, rotate the bottle back to a slower rate of flow. You may compress the reservoir every second or third suck, or put gently continuous pressure on the section so that more milk will come out of the nipple when the baby compresses the nipple between the palate and tongue.
FEEDING AN INFANT WITH A CLEFT

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