General Feeding Tips for Parents-Cleft Lip/Palate

General Feeding Tips for Parents

By Claire K. Miller, PH.D.

RELAX
Most parents report feeling anxious about learning how to feed a baby with a cleft, but find the problems to be fewer than expected and easy to overcome when using the right type nipple, bottle, and technique.

FEEDING EQUIPMENT & METHODS
A particular method of feeding is usually recommended shortly after birth by a nurse, speech pathologist, or occupational therapist.  Try to use the adapted nipples, bottles, and feeding methods that are recommended, and be sure not to hesitate to call the nurse or speech pathologist if any questions arise about how to use them.

USING APPROPRIATE POSITIONING
Feeding a baby with a cleft palate in an upright position as opposed to the traditional cradle or reclined position will reduce the amount of liquid that can escape up from the nose during feeding.  Try to use a pillow or small foam wedge to support the baby against you in an upright position.

FEEDING REFUSAL
The baby may seem to be refusing to breast feed or bottle feed.  Try to problem solve what might be happening by considering the length of time between feedings.  If the feedings are too close together, the baby may not be hungry enough to be motivated to feed.

Consider the size of the nipple hole (is the baby working too hard to extract the fluid?).  This is a common problem.  Explore using a nipple that either has a faster flow rate or that is flexible enough for assistive squeezing.

If breast feeding, the baby may be overwhelmed with the initial milk let-down during feeding and demonstrate avoidance.  Experiment with hand expressing some milk before trying to breastfeed.

Experiment with the temperature of the formula if bottle feeding.  Although not proven by research, many infants seem to prefer warm formula as opposed to room temperature.

Try to be consistent with the method being used for feeding.  Train others who may be feeding the baby to use the same feeding equipment, and the same type of strategies you use when feeding your baby.  For example, demonstrate how to use assistive squeezing and how often you give the baby breaks for resting or burping during a feeding.

MANAGING AIR INTAKE DURING FEEDING
Babies with clefts will tend to swallow some extra air while feeding.  After intake of every ounce or so, giving the baby a pause from feeding and chance to burp may help to alleviate discomfort associated with excessive air intake.

PERSISTENT ORAL FEEDING PROBLEMS
Most feeding problems can be easily resolved.  If your baby continues to have trouble feeding and you are concerned, consult your pediatrician for a referral to a speech pathologist or occupational therapist experienced with the special feeding issues associated with cleft lip/palate or other craniofacial anomalies.

Information cited : Kummer, A. 2008, Cleft Palate and Craniofacial anomolies:Effects on speech and resonance,  Delmar: Clifton Park, New York.

Tips for Stimulating Your Baby's Early Speech Sounds

By Adriane L. Baylis, PhD, CCC-SLP and Anna K. Thurmes, MA, CCC-SLP

Before your child's palate repair it will be difficult for them to learn to say sounds that require air (pressure) to build up in their mouth, like "p", "b" and "d".  The main goal before the palate repair is to help your baby learn to speak by using their lips and tongue to create sounds.  We want to encourage the baby to use sounds that they can be most successful at, such as those that do not require their palate to work yet, such as "m", "n", "w", "y" and "h".  Most babies with cleft palate do not say sounds like "p" or "b" before their palate surgery, but we still want them to hear those sounds frequently too, as they are still learning about those sounds and will eventually begin them after their palate surgery.

We do not want to encourage the baby to only learn to use their throat to make sounds (such as grunts or similar sound called "glottal stops").  We hope to avoid having the baby use too many rough sounds like grunts, truck noises, or gruff animal noises.  It's perfectly normal for all babies to use some throat sounds and noises, especially at early ages;however, some children with cleft palate may get into a habit of using these sounds too much as they get older, and this can make it harder for them to learn new sounds.  If you hear your child making a lot of these grunts or throat sounds, we recommend that you just ignore it and instead, say the correct pronunciation or a different sound back at your child.  For example, if your child says "uh" for "truck", you can say "yes truck" "beep beep".  Or, if your child says "aeh-ee" for "daddy", you should just say "yes daddy" back at them, instead of mimicking the incorrect production.  Whenever your child speaks, you should praise them for using their words, or even more specifically, their lips or tongue to continue to encourage normal speech development.

At the bottom of this post. there are a few examples of some words you can emphasize and practice with your baby.  When you say these, feel free to exaggerate how you use your lips or tongue to start the word.  Keep in mind:

• Notice that the target sounds are all at the beginning of the words.  That's because it's common for infants and toddlers to make mistakes ot even leave of the later sounds of words when they are first learning to talk.  In addition, by working on the first sounds of words, research suggests that this might help your child avoid continued use of those throaty sounds (the glottal stops) that they might have used in the past.
• Try to encourage these words during your child's daily routine (For example, you can practice "bubble" during bath time, or "yummy" during meals).
• It's perfectly normal for a bay to not imitate your words and sounds every time, but most babies will repeat sounds back at east occasionally, and more often as they approach 12-15 months of age.
• After the palate repair surgery, you should shift to increased practice of the "p", "b", "d" and "t" words on this list and give your child more specific praises (e.g. for "p" you can say "good job using your lips").

Practice Words:
M: More, Mama,/Mom, Me, Mine, Moo, Meow
N: No-No, Nana, Num-Num, Nose, Night-Night, Neigh
H: Hi, Hop, Hot, Happy, Hug, Here, Het, Hat, Head
W: Whoa, Wow, Whee, Want, Wawa/water, Whoops, Wash
Y: Yeah, Yea, Yes, Yipee, Yummy/YumYum, You
B: Bye, Ball, Boo, Bowl, Boo-Boo, Bottle, Bib, Bite, Beep, Bubble, Book, Baa-Baa, Bath
P: Pop, Pooh, Papa, Peek-a-Boo, Puppy
D: dadda, Done, Down, Diaper, Duck
T: Two, Toy, Teeth

Here are some ideas for how to work these words into your child's daily routine.

• Bubbles: When playing with bubbles you can emphasize the "p" and "b" in the words "bubble" and "pop".  Have your child request more by saying "mmmm" or "more"
• Reading books: When reading books, pick ones with just a few pictures on the page and point out the pictures with "p", "b", "m" and "n" and model the sounds and words for your baby.
• Snack time: Give one piece or part of the snack at a time to create opportunities for your child to request "more".  during snack time, try to make situations your child has to gesture or point, sign or attempt to say the word "more" or "please".  Then you say "yummy" when they take a bite too:  Remember to model the words for your child and reward even the simplest attempts that make towards the goal.
• Blocks: This is a great activity to practice "p" and "b".  remember to not give out all the blocks at one time, and instead have your child request them one at a time by attempting to gesture/point, sign or say "more" or "please".  You can model words such as "blocks, blue, build, pile, please, put down, up and boom" and so forth during playtime.  hold the block by your mouth when you model the words so your child looks at your face when you make the sounds.
• Farm animals: modeling animal sounds like "baa, moo, meow, neigh, and woof" while playing with the animals is a great way to keep your child interested in the activity and to encourage imitation.
• Bath and bed time:  This is a good time to emphasize words like "bed, bath, brush, nap, sleep, pillow, blanket, papa, mama, bubble".

The effects of Cleft Lip/Palate on Communication

A history of Cleft lip or palate can affect the child's ability to develop verbal communication skills.  The following aspects of vernal communication may be defective.

Articulation(Speech)-the physical production of sounds to form spoken words

Language-the message conveyed back and forth in talking.  This includes the ability to understand the speech of others (receptive language) and the ability to express thoughts through words and sentences (expressive language).

Voice-the sound that results from the vibration of the vocal cords (phonation).

Resonance-the vibration of voiced sound in the oral cavity (mouth, and nasal cavity (nose).

Dental Abnormalities

If the cleft extended into the gum ridge, dental development may be affected, causing the following:
-Missing teeth in the area of the cleft
-Extra teeth
-Malocclusion(poor closure of the top and bottom jaws)

Dental abnormalities may cause speech errors as follows:
-A lisp type of distortion on sibilant sounds (/s/, /z/, /sh/, /ch/, /j/)
-Difficulty producing teeth to lip sounds (/p/, /b/, /m/)
-Difficulty producing teeth to lip sounds (/f/, /v/)
-Difficulty producing tongue-tip sounds (/t/, /d/, /n/, /l/)

These distortions can usually be corrected with a combination of dental and orthodontic treatment, and speech therapy.


Hearing Loss

The Eustachian tube connects the middle ear and the back of the throat.  It opens with swallowing.  This allows fluids to drain out of the middle ear and equalizes air pressure in the ear with the environment.  Children with a history of cleft palate often have chronic ear infections (Otitis media) because that muscle in the soft palate that is responsible for opening the Eustachian tube does not function well.  As a result, negative pressure and fluid build up in the middle ear, causing ear infections ans a conduction hearing loss.  A conductive hearing loss can affect the child's ability to develop language and even speech skills.
To avoid middle ear problems, pressure equalizing (PE) tubes are often inserted in the eardrum at an early age.  This helps to prevent fluids from building up in the ear that cause infection and hearing loss.


Velopharyngeal Dysfunction (VPD)

Also known as Velopharyngeal Insufficiency or Incompetence-VPI)
In order to close off the nose from the mouth during speech, several structures come together to achieve "velopharyngeal closure" These includes the following:
-Velum-soft palate
-Lateral pharyngeal walla-side walls of the throat
-Posterior pharyngeal walls-the back wall of the throat.

When the velopharyngeal valve closes, the speaker is able to build up air pressure and sound in the mouth to produce carious consonant sounds and vowel sounds.  Velopharyngeal closure also occurs during other activities, such as swallowing, gagging, vomiting, sucking, blowing, and whistling.
After a cleft palate repair, the velum (soft palate) may still be too short or may not move well enough to reach the posterior pharyngeal wall (back of throat).  This results in velopharyngeal dysfunction (VPD) which causes problems with speech.

Effects of Velopharyngeal Dysfunction on Speech

Velopharyngeak dysfunction can cause the following speech characteristics"
-Hypernasality (too much sound in the nose during speech)
-Nasal air emission during consonant production
-Weak or omitted consonants due to inadequate air pressure in the mouth
-Compensatory articulation productions (speech sounds produced in a different way)

Treatment of Velopharyngeal Dysfunction (VPD)

Treatment of VPD usually includes surgical intervention and speech therapy.  Prosthetic devices can also be used on a temporary or permanent basis in some cases.

Information cited : Kummer, A. 2008, Cleft Palate and Craniofacial anomolies:Effects on speech and resonance,  Delmar: Clifton Park, New York.