Feeding a baby with a cleft: what to expect early on

Feeding is often the first worry for new parents. It's also one of the first things your cleft team can help with. ACPA's standards say the team should contact families shortly after referral to help with feeding, and that a specialized assessment is needed so the right feeding system is chosen for your baby.^[8] This guide explains the basics so those first conversations make more sense. It is general information, not a feeding plan. Your baby's own team will tell you what is right for them.

Why it can be harder

To feed, a baby needs to seal their mouth around a nipple and create suction. A gap in the roof of the mouth makes that hard. The American Academy of Pediatrics says babies with a cleft palate "suck weakly and need a special bottle to feed."^[1] The NHS notes that many babies with a cleft palate have trouble breastfeeding and may struggle to gain weight in their first few months.^[6]

A cleft lip on its own is usually a different story. The AAP says "most babies with cleft lip can feed from the breast or a normal bottle."^[1] Nemours KidsHealth adds that the only change needed might be positioning the nipple so the baby can latch, or, when breastfeeding, changing position so the breast fills the cleft.^[2]

Bottles and nipples: the main types

Special cleft bottles work in one of two ways: either a caregiver gently squeezes milk into the baby's mouth in time with their sucking, or a one-way valve lets the baby get milk by working the nipple with their tongue and gums instead of sucking.^[4][2] Common examples include:

• Valve systems, such as the Dr. Brown's Specialty Feeding System. Its one-way valve means the baby can compress the nipple rather than suck, and KidsHealth says it "often is the easiest for parents and caregivers."^[2]
• Squeezable bottles, such as the Mead Johnson (Enfamil) Cleft Lip/Palate Nurser or MAM soft bottles. The caregiver squeezes to match the baby's sucking.^[2][4] ACPA's booklet explains that pressure is applied while the baby sucks and released when the baby stops.^[5]
• Valve plus squeeze, such as the Medela SpecialNeeds Feeder (Haberman), which has a valve but usually needs a caregiver to squeeze in time with the baby.^[2]
• The Pigeon feeder, which has a one-way valve and a Y-cut nipple that comes in two sizes.^[2]

Not every baby with a cleft will need special equipment.^[3] And squeezable bottles need training first: CLAPA warns that squeezing at the wrong moment can make a baby choke or cough, and advises speaking to your cleft nurse before buying or using any feeding equipment.^[3][4] If you switch systems, ACPA says to allow up to 48 hours for your baby to adjust.^[5]

Look after the nipples too. ACPA advises checking them regularly and replacing any that look misshapen, feel soft or gummy, or have cracks.^[5] CLAPA says MAM teats need replacing every 4 to 6 weeks.^[4]

Positioning

• Hold your baby fairly upright. ACPA describes a semi-upright position, with the bottle tilted so the nipple stays full of milk.^[5]
• Keep your baby upright during the feed and for 20 to 30 minutes afterward to cut down on milk coming out of the nose.^[2]
• If milk comes out of the nose, ACPA suggests holding your baby more upright and considering a slower flow.^[5] It can look alarming, but it is common with a cleft palate.
• Some babies do better in a different position, such as on their side. Your cleft nurse will show you if that's needed.^[3]

Pacing, burping and how long a feed should take

Babies with a cleft often swallow extra air, so they need burping more often.^[3][5] KidsHealth suggests burping about every 5 minutes during the feed.^[2]

Long feeds tire babies out and use up calories they need for growing. ACPA says a feeding should take about 30 minutes or less,^[5] and KidsHealth suggests trying a faster-flow nipple if feeds take longer, with your team's guidance.^[2] ACPA also says that in the first weeks a baby should not sleep more than 3 to 4 hours between feedings.^[5]

Breastfeeding and pumping: the real picture

This is often the hardest part emotionally, so it's worth being honest. CLAPA says a cleft "can make breastfeeding extremely difficult."^[3] With a cleft lip only, babies may be able to breastfeed.^[3] With a cleft palate, CLAPA says breastfeeding may be possible when the cleft is very small or narrow,^[3] but most babies with a cleft palate cannot get all the milk they need from the breast. ACPA's booklet quotes La Leche League International: "except in rare cases, a baby with a cleft palate cannot get all the milk he needs by breastfeeding alone."^[5]

That doesn't mean breast milk is off the table. Many parents pump and give their milk in a cleft bottle.^[6][5] CLAPA points out that "any amount of breastmilk is still beneficial."^[3] A few things parents and teams say help:

• Pump often in the early weeks. One children's hospital advises pumping 8 to 10 times a day during the first three weeks after birth to build your supply.^[7]
• An electric pump can make this easier; CLAPA's parent tips note that manual pumps can be "time-consuming and tiring," and your team or a local organization may be able to lend one.^[3] In the US, check your insurance for breast pump coverage.^[7]
• Once bottle feeding is going well, ACPA says you can still put your baby to the breast for comfort sucking, which can be satisfying for both of you.^[5]
• Ask for help early. The AAP suggests support from a feeding therapist, a certified lactation consultant and/or a nurse experienced with cleft feeding.^[1]

Formula feeding is also a good, loving choice. Feeding your baby well matters far more than how the milk gets there.

Weight checks: how you'll know it's working

Regular weight checks by your baby's doctor or the cleft team are the main way to make sure your baby is gaining enough.^[2] CLAPA says babies usually regain the small weight they lose after birth within two to three weeks.^[3] ACPA's booklet suggests weighing once a week on the same scale for the first one to two months, and gives about half a pound a week as an average gain.^[5] Day to day, CLAPA says a baby with five to six wet diapers a day, regular bowel movements, and who seems healthy and alert is probably getting enough milk.^[3] Some babies need higher-calorie milk in the early weeks,^[3] and very occasionally a baby may need tube feeding for a while before surgery.^[6]

When to call your team

• Feeds regularly take longer than about 30 minutes, or your baby tires before finishing.^[5]
• Your baby isn't back to birth weight within two to three weeks, or you're worried about weight gain.^[3]
• Fewer wet diapers than usual, or your baby seems unusually sleepy.^[3]
• Your baby coughs, chokes or struggles during feeds.
• You are exhausted or worried. That alone is reason enough.

Asking early is always the right call. Feeding gets easier for most families as they learn their baby's rhythm, and your team is there to help you get there.