Conference Lectures

POST OPERATIVE FEEDING IN CLEFT LIP AND PALATE SURGERY.
                                                                             Dr.RajendraGosavi.

INTRODUCTION:-
Cleftlip and palate is the most common congenital craniofacial abnormality; occurring in approximately 1:1000live births. Children born with cleft palate may be affected by a combination of facial differences, swallowing and speech disorders, and various disturbances of dentition and growth. Babies with clefts of the lip and palate have problems when feeding. They find it difficult to latch onto the breast or feeding bottle to obtain an oral seal, which results in sucking problems and inadequate intake of food.
The criteria for the post-operative feeding will depend upon pre-operative nutritional status as well as intra operative status and post-operative recovery.

Preoperative assessment in view of nutritional status and optimisation.

  • Socioeconomic status-

Cleft lip and palate iscommon in low socioeconomic group. Babies with cleft lip and palate are usually malnourished.

  • Pre-op nutritional assessment:-

These patients who at risk for malnutrition should have detailed nutritional assessments done. Components of a complete nutritional assessment include a medical history, nutritional history including dietary intake, physical examination, anthropometrics (weight, length or stature, head circumference, midarm circumference, and triceps skinfold thickness), pubertal staging, skeletal maturity staging, and biochemical tests of nutritional status.

  • Milestones/ Immunization:-

Detailed history of milestones achieved as per age, and immunization should be taken.

  • Caloric deficiency:-

This patients are prone for protein energy malnutrition and vitamin deficiencies. That should be evaluated n corrected as per status.

  • Difficulties associated with feeding:-

Babies affected with cleft lip and palate find it difficult to latch on breast or feeding bottle to obtain proper seal. This causes sucking problems and inadequate food intake. An infant with a cleft palate will have greater success feeding in a more upright position. Gravity will help prevent milk from coming through the baby's nose if he/she has cleft
palate. Another common problem with cleft palate is regurgitation of food through nose due to common passage.

  • Different types of feeders:-

Babies with cleft lip and palate can be breast fed directly or with bottle using a palatal obturator. Use of Palatal oburator increases the amount of feed and decreases the chances of regurgitation. Alternatively babies are fed by using cup n spoon or with the help of syringe.
For bottle feeding combination of nipples and bottle inserts like a large hole, crosscut, or slit in the nipple can be used.

Post-operative feeding depends upon Preoperative NBM status and Type of anaesthesia.
Preoperative NBM guidelines:-

Infant under 4 months of age
Breast milk – 3 hours.
Infant formula milk – 4hours prior to anaesthesia

Infants above 4 months of age
Infant formula/ breast milk- 4 hours.
Clear liquids (up to 15 ml / kg ) 2 hours prior to anaesthesia.

Children:
No food or milk – 6hours
Clear liquids ( 10 ml/kg) 3 hours prior to anaesthesia.
Type of anaesthesia:-
Adults- usually done under LA/ block.
Paediatric-keep NBM for at least 2-4 hours.
Preoperative sedation like midazolam/ fentanyl/ ketamine. Routinely ketamine and glycopyrolateis used.

  • Induction and maintenance with inhalation agents and muscle relaxant.
  • Induction with iv drugs and maintenance with inhalation agents.

Analgesia:-
Analgesia in the form of rectal suppository is given and it is supplemented with an infra orbital block.
Post- operative period
Every surgery is a highly catabolic state. Hence Caloric requirement may be high.
Immediate post op:-
Due to effect of anaesthesia patients are kept NBM for at least 2-4 hours.
During this period patient should be given iv fluids to correct electrolytes,sugar.
24 -72 hours postoperatively, based on socioeconomic status parents should be counselled about feeding.

In this patients, two schools of thoughts are considered for post-operative feeding.

  • Early recovery and early oral feeding.
  • Depending upon recovery  IVsupplementation if needed.

Feeding instructions

  • Feed your child carefully using a cup or the side of a spoon to drop fluids and food into the mouth. Do not allow the spoon to touch the roof of the mouth. Do not allow your child to chew on anything. Remember, no bottles or pacifiers!
  • After each feeding, give your child water to drink, to rinse the surgical area and to keep it clean.
  • Do not give any hot food or hot fluids.
  • After each feed baby should be held upright to allow burping.
  • Please note: Your doctor or speech pathologist will meet with you after surgery to talk about feeding plans. Since each child is different, the plan will be specific to your child. However, the following guidelines may be helpful:

First week
Full liquid diet including:

  • Milk
  • Formula
  • Juices
  • Well-melted ice cream

Second week
Soft diet, that consists of foods "that melt in the mouth", such as:

  • Ice cream
  • Sherbets
  • Yogurt
  • Soft cereals
  • Pureed baby foods

Do not give foods that need to be chewed.
Third week

Usual foods that your child would normally eat.

2-3 weeks later parents should report to surgeon for follow up and surgeon must assess nutritional status and weight gain.

Parent’s/Guardian’s Role

The most important role of a parent or guardian is to help your child stay calm and relaxed before the surgery. During the surgery, at least one parent or guardian should remain in the surgical family waiting area at all times, incase the family needs to be reached. Parents should keep their babies calm while giving premedication and post operatively.