January 27, 2021

Editor’s note: This post is the second in a series that began with “Insights on Feeding and Swallowing Differences for Infants With Cleft Lip and/or Palate.

As a speech-language pathologist on a cleft palate team, I help offer guidance—before the infant is discharged—on supplemental bottle-feeding for newborns with a cleft palate and/or lip.

As part of this team, I complete a feeding evaluation to determine the adaptive bottle(s) best suited to the infant and provide caregiver training on proper assembly, priming, and use. In my work with infants with cleft lip and/or palate, I also help parents recognize their infant’s feeding cues, nipple placement along the palatal bones (not within the cleft), proper feeding positioning, and handling techniques.

Supplemental feeding assessment with bottle use starts early, prior to discharge from the hospital. Inhibited capacity to transfer milk at breast due to weak or absent oral suction due to the presence of the cleft, feeding endurance and intake volume needs might warrant use of supplemental bottle feeding.

Here is some of what I share.

Feeding tips for caregivers

Here are general positioning and feeding tips. Each baby with cleft palate/lip might need slightly different positioning or approaches.

  • Swaddle the infant to provide trunk stability, which supports respiration. Older infants don’t need swaddling if they are fully supported close into the feeder’s body for stability. The infant’s trunk should be elongated so they are not hunched over their diaphragm.
  • Position the infant close into the feeder’s body with head/shoulders high near the shoulder with hips slightly forward. Head/shoulders should not be positioned directly over hips until the infant is 4 months old, when the baby’s trunk strength can support respiration.
  • The infant’s nose should be up slightly in a “sniff” position. This is subtle. The head should not be extended, but a fingertip should fit between the chin and chest of a newborn, two fingertips for an older infant.
  • Prime the bottle nipple by placing a gloved index finger and thumb vertically along the nipple, turn the bottle upside down and release the nipple. When you bring the bottle upright, milk will remain in the nipple.
  • Place the bottle nipple along the palate to create maximum contact. Don’t place or allow the bottle nipple to slip into the cleft.
  • Facial taping initiated by the surgeon may assist in improving stability, and therefore, capacity to compress the lateral lips that may otherwise flair outward. Increased contact and pressure on the nipple by the infant with the tape present may improve feeding efficiency for some infants.
  • Allow full range of movement of the jaw. Infants using compression nipples compensate with pronounced use of compression to express and control the liquid bolus. Chin, jaw and/or cheek support can suppress this range of motion and can increase risk of aspiration.

Monitor for stress cues during feeding and signs of aspiration. Burping

Infants with cleft lip and/or palate demonstrate compensatory swallow patterns potentially contributing to ingestion of more air when feeding. For this reason, more frequent burping—with about every ounce consumed—improves their comfort during and after feeding.

Clearing nasal congestion

Managing nasal congestion during feeding supports a more comfortable feeding experience. I don’t recommend the use of suction, however, as it can disrupt feeding.

I’ve experienced success with this strategy: move the infant to their side, hips stacked, and keep head and shoulders slightly higher than hips. Watch for the infant to swallow. Then slowly and gently move them onto their other side and watch again for them to swallow. This maneuver helps move the milk from above the palatal shelves. When the infant is then brought back into feeding position the nasal congestion should have cleared. It is important to keep the head/shoulders slightly higher than the hips when doing this maneuver to prevent reflux from traveling into the nasopharynx.

Allyson Goodwyn-Craine, MS, CCC-SLP, BCS-S, has more than 30 years of clinical experience feeding infants with cleft palate and cleft lip and palate. She is an adjunct professor at Portland State University, and also provides outpatient pediatric feeding services and works as part of the NICU rehabilitation team at Sunnyside Medical Center. Goodwyn-Craine is an affiliate of ASHA Special Interest Groups 5, Craniofacial and Velopharyngeal Disorders; and 13, Swallowing and Swallowing Disorders (Dysphagia). [email protected]    


ASHA Evidence Map on cleft lip and palate

ASHA Practice Portal on cleft lip and palate

Applying Evidence-Based Practice to Bottle Feeding Babies With Cleft Palate

Feeding and Swallowing Issues in Infants With Craniofacial Anomalies

Feeding the Infant Born With Cleft Lip/Palate: A Literature Review

Feeding behaviour of infants with cleft lip and palate

The Nature of Feeding in Infants with Unrepaired Cleft Lip and/or Palate Compared with Healthy Noncleft Infants


Additional Resources


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