Abstract
Objective
Our study goal was to evaluate the rates of breast milk feeding among patients with oral clefts at a large North American Craniofacial Center.
Methods
Parents of patients with oral clefts born from 2000 to 2012 and treated at our center were interviewed regarding cleft diagnosis, counseling received for feeding, and feeding habits.
Results
Data were obtained from parents of 110 patients with oral clefts. Eighty-four percent of parents received counseling for feeding a child with a cleft. Sixty-seven percent of patients received breast milk for some period of time with a mean duration of 5.3 months (range 0.25 to 18 months). When used, breast milk constituted the majority of the diet with a mean percentage of 75%. Breast milk feeding rates increased successively over the 13-year study period. The most common method of providing breast milk was the Haberman feeder at 75% with other specialty cleft bottles composing an additional 11%. Parents who received counseling were more likely to give breast milk to their infant (P = .02). Duration of NasoAlveolar Molding prior to cleft lip repair did not affect breast milk feeding length (P = .72). Relative to patients with cleft lip and palate, patients with isolated cleft lip had a breast milk feeding odds ratio of 1.71.
Conclusion
We present breast milk feeding in the North American cleft population. Although still lower than the noncleft population, breast milk feeding with regards to initiation rate, length of time, and proportion of total diet is significantly higher than previously reported.
The cleft patient population has lower rates of breastfeeding success than the noncleft population (Miller, 2011). Normally during feeding, the soft palate contacts the pharyngeal walls to seal the oral cavity posteriorly (Reilly et al., 2013). Clefts of the palate prevent adequate separation of the nasal and oral cavities during feeding. As such, patients with a cleft palate have less efficient sucking patterns than their noncleft peers (Maserai et al., 2007). The degree of palatal clefting is proportional to difficulty with feeding. In contrast, patients with an isolated cleft lip can often breastfeed successfully (Reilly et al., 2013).
Several population-based studies have been published evaluating breastfeeding rates in the cleft population (Clarren et al., 1987; Oliver and Jones, 1997; Aniansson et al., 2002; Da Silva Dalben et al., 2003; Garcez and Giugliani, 2005; Smedegaard et al., 2008; Britton et al., 2011; Gil-da-Silva-Lopes et al., 2013). However, the only study surveying the North American patient population is over 3 decades old (Clarren et al., 1987).
Awareness of breast milk's benefits has grown in recent years. It is believed to be protective for neonatal sepsis, otitis media, and infectious diseases in the respiratory or gastrointestinal tracts as well as a contributor to cognitive development (Aniansson et al., 2002; Haggkvist et al., 2010; Gil-da-Silva-Lopes et al., 2013). Due to its perceived benefits, the World Health Organization recommends exclusive breastfeeding for 6 months (Britton et al., 2011).
Breastfeeding rates in the United States have increased dramatically in recent decades. Currently, 79% of U.S. infants are breastfed with rates decreasing to 49% and 27% at 6 and 12 months (up from 35% and 16% in 2000, respectively). Because patients with oral clefts often cannot breastfeed, it is important to differentiate between “breastfeeding” and “breast milk feeding” (i.e., delivery of breast milk to the baby via other means; Reilly et al., 2013).
Much of the data regarding breast milk consumption in the oral cleft population are focused on how infants are fed rather than what they are fed. Given that most patients with oral clefts are not breastfed, our study sought to evaluate the rates of breast milk feeding to specifically evaluate breast milk consumption. Patients of all interviewed parents were treated at a large North American craniofacial center. No study to date has examined rates of breast milk feeding in the North American cleft population.
Methods
With Institutional Review Board approval, patients with clefts who underwent NasoAlveolar Molding (NAM) at New York University Medical Center from 2000 to 2012 were contacted from a prospectively maintained registry. Four attempts were made to contact each patient household using available phone numbers. All patients routinely underwent NAM prior to cleft lip repair.
Parents were asked to answer a series of questions regarding their child's cleft diagnosis including timing of diagnosis (prenatal versus at birth), type of counseling received by the parents for feeding their child with an oral cleft, and satisfaction with the counseling. Counseling primarily referred to techniques for successful breastfeeding but could have included education on the benefits of breast milk as well. Results regarding counseling were obtained retrospectively during the telephone call.
Furthermore, parents answered whether the child received any breast milk feeding. If the parents answered “yes” to breast milk feeding, questions were asked clarifying the total number of months of breast milk feeding, method of delivery of breast milk, breast milk feeding timing in relation to NAM and cleft surgery, and the proportion of total feeds that were breast milk.
Total length of NAM in days was calculated from patient records. Two-tailed t-test analysis was used to study the relationship between breast milk feeding habits and counseling for feeding as well as length of NAM. Significance was set at a P value of less than .05. Odds ratio calculations were performed to compare breast milk feeding rates between isolated cleft lips and cleft lips and palates.
Results
In total, parents of 110 patients with oral clefts treated from 2000 to 2012 were included. The 110 patients represent those who were reached from a larger registry of 184 NasoAlveolar Molding patients during the study period. The distribution included 62 patients with unilateral cleft lip and palate, 26 patients with bilateral cleft lip and palate, 16 patients with unilateral cleft lips, and 6 patients with bilateral cleft lips. The majority of patients were male (61.8%). Most cleft diagnoses were made with prenatal ultrasound (74.5%) (Table 1).
Demographics of Surveyed Cleft Population From 2000 to 2012 at New York University Langone Medical Center (NAM = NasoAlveolar Molding)
All of the patients received NAM prior to cleft lip repair. Mean age for initiating NAM was 26.6 days (range 8 to 104 days) with a mean total treatment time of 105.4 days (range 47 to 257 days). Distribution of patients across time periods was fairly uniform with 28.2% of patients treated from 2000 to 2003, 33.6% from 2004 to 2007, and 38.2% from 2008 to 2012 (Table 1).
Approximately two-thirds (67.3%) of patients received breast milk for some period of time. The mean duration for breast milk feeding was 5.3 months (range 0.25 to 18 months). Relative to NAM, 100%, 75%, and 44% of mothers gave breast milk before, during, and after NAM, respectively (Table 2). Notably, when used, breast milk was the majority diet composing a mean percentage of 75% or more of total diet (Table 2).
Breast Milk Feeding Distribution Among Cleft Patients Undergoing NasoAlveolar Molding (NAM) from 2000 to 2012
The most common method for providing breast milk was the Haberman feeder at 75% (Fig. 1). Another 11% of patients utilized a different specialty cleft bottle (Table 3). Eighty-four percent of parents reported receiving counseling on feeding methods for their child with a cleft. Parents who received counseling were significantly more likely to give breast milk to their infant compared to parents who did not receive any (72% versus 44%, P = .02) (Table 4).
Distribution of preferred breast milk feeding methods for patients with oral clefts.
Method of Delivery of Breast Milk for Infants Receiving NasoAlveolar Molding
Relationship Between Breast Milk Feeding, Counseling, Type of Cleft and Length of NasoAlveolar Molding (NAM)
Significance is set at p < .05.
Finally, patients with unilateral and bilateral cleft lip only had an odds ratio of 1.71 for breast milk feeding as compared to unilateral and bilateral cleft lip and palate patients, and a 95% confidence interval of 0.57 to 5.11. Notably, length of NAM therapy did not have a significant effect on length of breast milk feeding using two-tailed t test analysis (P = .72) (Table 4). Rates of breast milk feeding increased over each successive time period (Fig. 2).
Percentage of mothers who provided breast milk feeding to their infant with an oral cleft stratified by year of birth.
Discussion
The majority of data evaluating breastfeeding in the cleft population emphasize how infants are fed rather than what they are fed. Increasing evidence of the advantages of breast milk over formula has raised interest in whether patients with oral clefts receive breast milk.
With two-thirds of patients receiving breast milk for any period of time, rates in our cleft population still remain lower than the rest of the noncleft population in the United States. Comparison data are limited as most studies evaluated breastfeeding versus bottle or spoon feeding without specifying the type of diet administered through these alternative methods (Oliver and Jones, 1997; Garcez and Giugliani, 2005; Gopinath and Muda, 2005; Britton et al., 2011; Gil-da-Silva-Lopes et al., 2013).
Two older studies that discussed bottle feeding with milk did not specify milk source: cow versus maternal (Da Silva Dalben et al., 2003, Gopinath and Muda, 2005). The only comparable study is the Scandinavian experience in which the median duration of breast milk feeding was 8 weeks (Aniansson et al., 2002; Smedegaard et al., 2008). Only 13% of infants were breast milk fed at 6 months in the 2008 study by Smedegaard et al. In contrast, the mean duration of breast milk feeding in this study was 5.3 months. When utilized, breast milk was the major component of an infant's diet, averaging 75% or more of total intake. Our data population is nearly a decade younger than the Danish experience; breastfeeding emphasis has increased in recent years, and rates have risen concurrently across all populations.
Furthermore, our cohort is North American and at a center where patients underwent NasoAlveolar Molding (NAM). This presurgical appliance is used to rotate the cleft alveolar segments into orthotopic position and mold the nose prior to cleft lip repair (Grayson et al., 1993). The presence of NAM precludes traditional breastfeeding in nearly all cases.
Because the technique requires frequent and diligent follow-up on the part of parents, it selects for families who are able to comply with the increased demands. Providing breast milk to infants similarly requires increased effort compared to formula feeding. Eighty percent of mothers breastfeed because they believe it is in their infants’ best interest (Oliver and Jones, 1997). By selecting for parents who are willing to undergo NAM for perceived benefit to their child, it may partially explain the higher rates and prolonged periods of breast milk feeding. Supporting this possible selection bias is the finding that increased length of NAM therapy did not adversely impact length of breast milk feeding.
Consistent with previous research, parents who were counseled about feeding were more likely to use breast milk (Reid, 2004). The challenge of generating sufficient negative pressure during breastfeeding with a cleft palate is well-documented (Miller, 2011). Infants with clefts of the palate as well as lip had lower rates of breast milk feeding compared to infants with cleft lip alone, although the confidence interval was not significant, possibly due to insufficient power. The increasing rates of breast milk feeding from 2000 through 2012 mirror national trends.
As patients with clefts mostly were unable to breastfeed, the most common alternative utilized was the Haberman feeder. This reflects institutional and national biases (Ize-Iyamu and Saheeb, 2011). The Haberman feeder allows an infant to obtain milk from the nipple without suction (Shaw et al., 1999; Goyal et al., 2004; Reid, 2004; Reid et al., 2007; Miller, 2011). Limitations of this study include its retrospective nature.
All cohort data regarding breast milk feeding habits are self-reported, which introduces recall bias. In the future, it would be beneficial to record breast milk feeding prospectively in patients actively undergoing NAM to obtain realtime and, presumably, more accurate data.
While lower than the noncleft population, breast milk feeding initiation rates, length of time, and proportion of total diet are significantly higher than in older reports. Routine use of NAM did not adversely impact breast milk feeding and may introduce a favorable selection bias.