To the Editor:

Burca and colleagues1 are to be congratulated for their efforts to promote breast milk for infants with cleft lip and/or cleft palate (CL/P). They nicely outline the important benefits of breast milk for this vulnerable population, and we commend the authors for their position that human milk "should be central to the care of these infants." However, we are concerned with several recommendations related to how human milk is delivered.

First and most concerning is the statement by the authors that "breastfeeding usually/sometimes works well" for an infant with a cleft palate and recommendations in this regard (see Table 1 in Burca et al1). We caution the authors to avoid giving the impression that children with isolated cleft palate are likely to feed effectively or fully at the breast. The vast majority of children with a cleft palate do not feed well at the breast and require an adaptive feeding method. Efforts should focus on ways to improve availability of breast milk for these patients, beginning with support and education of parents during the prenatal visit, and continuing through the perinatal period and infancy.

The advice that an infant with a cleft palate can breastfeed shows a misunderstanding of the sucking mechanics of an infant with a cleft palate, which is distinct from an infant with a cleft lip. As the authors point out, an infant with a cleft lip and intact palate will most likely be able to feed at the breast effectively. A lactation consultant can assist the mother with positioning to assist with lip seal, which often, but not always, allows breastfeeding. With a cleft palate, the infant is unable to generate sufficient intraoral suction to breastfeed effectively. Regardless of size or location of the cleft palate (as stated in the article), the presence of the cleft palate prohibits the infant from isolating the oral cavity from the nasal sinuses, thereby preventing the infant from developing the negative pressure vacuum needed to draw milk from the breast.2 There are only extremely rare cases where the mother and infant can work together so the infant may feed directly and fully from the breast.

Second, the authors state that "infants with CL/P consume less milk, gain less weight, and measure lower on growth curves" than infants without CL/P. Nutrition in children with oral clefts has not been well studied. There are many potential confounders that impact the published studies suggesting suboptimal growth in children with clefts, and some studies have shown that children with clefts do have adequate growth whether or not the palate is involved.3 Given the mostly small or anecdotal studies in this field, the reason for poor growth may stem from infants who are not given appropriate feeding methods to compensate for the cleft or have other malformations or medical problems leading to inadequate nutritional status. Most infants with clefts who are managed with the proper feeding tools grow at the same rate as an infant without a cleft. Numerous adaptive bottles are available for infants with clefts, which assist with milk flow so the infant can feed well without needing to create a vacuum. Assistive devices may also be used at the breast but require careful instruction to ensure adequate milk intake. If there is a delay in diagnosing the cleft palate or implementing the correct feeding adaptation, there will be a risk of infant weight loss and diminishing maternal milk supply if milk expression is not started quickly after birth.

Lastly, the authors state that "feeding human milk by bottle is the preferred approach if direct breastfeeding is not possible." This is true for infants in high-resource settings. In low-resources settings, however, the World Health Organization and United Nations Children's Fund4,5 recommend cup feeding for infants unable to breastfeed as the safest tool. Because 94% of children born with an oral cleft are born in a developing country,6 this advice should be included in guidance on adaptive equipment to support feeding.

We do applaud the authors for their efforts but believe it is imperative that the clinical community clearly understand the differences in the potential for infants with various types of clefts to feed at the breast. What does not differ is the ability of these infants to benefit from breast milk feeding. Future efforts should focus on interventions to support mothers in providing this valuable source of nutrition to their infants.

Emily Gallagher, MD, MPH

[email protected]

Christy McKinney, PhD, MPH

Robin Glass, MS, OTR, IBCLC

Seattle Children's Hospital Craniofacial Center,

Seattle, Washington

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