Preparing Your Child for Cleft Palate Surgery

At Gillette Children’s, we perform cleft palate surgery when children are between 9 and 12 months of age. 

We discourage bottle feeding the first 1-2 weeks after repair of the palate. We do this to protect the incision inside the mouth. Maintaining good nutrition both before and after your child’s surgery is important. Before cleft palate repair, you’ll need to develop feeding methods other than the bottle feeding of breast milk and/or formula. 

By 9 months of age, most infants have been introduced to a variety of solid foods. Solids provide additional calories, vitamins and minerals that infants need as they move from strictly breast milk or formula feeding to a combination of foods. 

Introducing solids can be challenging for parents whose children have cleft palate. Occasionally, infants with cleft palate have difficulty managing solids. They may become very anxious if they are unable to get the solid food to the back of the mouth in order to swallow. They may cough and cry, then refuse to take any more. 

In addition, infants with cleft palate may have gastric reflux, meaning food comes back up through the nose. This is often related to increased air in the stomach during feeding, or it may be due to a weak sphincter muscle at the opening to the stomach. Reflux usually is not harmful to your infant. Just stop the feeding, calm your infant and wipe the nose, then continue the feeding. 

Understandably, infants who have difficulty with solids may refuse to eat them. If that’s the case, don’t force your child. The goal is to assure that feeding remains a positive experience for your baby. Adjusting how the food is delivered may make solids more tolerable to your infant. 

The Craniofacial Team specialists at Gillette are trained to help children with feeding issues. If your child has special needs beyond cleft palate, or you have concerns about your child’s feeding patterns, please contact a team member, and we can arrange a feeding evaluation. 

In addition, the following answers to frequently asked questions will help as you prepare your child for cleft palate surgery.  

Could we just wait to start solids until after the surgery? 

Some parents delay introducing solids until after palate repair. We discourage this for three reasons: 

1. Your child may miss out on the opportunity to develop oral skills that are needed for speech development. 
2. To ensure adequate nutrition for growing infants, the American Academy of Pediatrics (AAP) recommends introducing solid foods between 4-6 months of age. 
3. When preparing for palate surgery, your child will benefit from solid foods that are a good source of calories and fluids. 

To promote normal growth and development in infants with cleft palate it’s best to follow the same feeding guidelines recommended for infants without clefts. 

Remember if you introduce solid foods before surgery, your child will get used to eating them. Following surgery, you can offer favorite solid foods to help ensure adequate nutrition during recovery. Post-op, some infants even prefer solids, especially if they don’t like taking fluids from a cup. In addition, because solid foods provide additional calories that are metabolized (used up) more slowly, your child may be able to eat less frequently. 

How will I know my child is ready for solid foods? 

At or before the 4-month, well-baby visit, your primary care provider will talk with you about foods to offer your baby. Infant cereal, which is usually the first solid food introduced, provides growing infants with a good iron source that supplements the iron in breast milk and formula. Vegetables and fruits are slowly introduced at 5-6 months of age, and meats at approximately 8-9 months of age. 

• Infants signal that they are ready for solid foods in a number of ways. They may: 
• Be able to sit up with some support and hold their heads stable (without “bobbing”). 
• Follow a spoon with their eyes. 
• Express interest in watching others eat. 
• Open (or close) mouth when they see food coming. 
• Take 40 oz or more of breast milk and/ or formula per day, yet still seem hungry. 

If I can’t use a bottle after surgery, how will my baby drink fluids? 

We recommend cup feeding, which your child can “practice” as early as 6 months of age. Initially, infants may not be good at cup drinking. But with practice, they will learn to form their lips around the cup. Ideally, your child should not have anything inside the mouth during the recovery period, including bottle nipples or pacifiers. Sucking on a bottle or pacifier right after repair of the palate can cause injury to the new repair and potentially disrupt the new incision. After the 1-2 week follow-up visit, you can reintroduce bottle nipples. 

At Gillette, we provide samples of adapted feeders that can be used after palate repair. The nurse practitioner from the Craniofacial Team can show you how to use them. You can decide which works best for you and your infant. Ideally you will want to select a feeding system at the pre-op visit when you child is about seven months old. If you practice at home with these feeders before surgery, your child will feed more efficiently when you go home. 

I’m worried about dehydration after surgery. What if I can’t get my baby to drink from any of the cups or alternative feeding devices? 

The Craniofacial Team can help you establish a method of feeding your baby before you leave the hospital. 

Feeding with a syringe can be used for infants who refuse a cup. Soft-tipped sippy cups are also available, and as a last resort the bottle can be used. These are less desirable options as they might disrupt the repair. Ideally, you can successfully introduce the cup before surgery, when infants are less stressed and more open to learning a new skill. 

What can I feed my baby after surgery? 

After repair of the palate, your baby will need to be on a full-liquid diet until the surgeon instructs you to advance to soft foods. Most infants are able to work up to their pre-surgery intake within a few days. Thoughtful meal planning after discharge can help your child get the nutrition needed for wound healing. Here are some tips for doing just that. 

• Protein is particularly important for tissue repair. In most instances, parents can meet their child’s protein requirements with adequate breast milk and/ or formula, plus the solid foods the child was eating prior to surgery. 
• Your baby can drink breast milk or formula from a regular cup or approved alternative feeding device after surgery. Bottles and nipples are not recommended, as they can disrupt the repair. It’s possible to boost the number of calories in breast milk and or formula by increasing the amount of powdered formula that is added to water (or to breast milk). Formula and breast milk typically contains 20 calories per ounce. This can be increased to 24 calories per ounce, as needed to provide extra calories. Talk with the Craniofacial Team’s nurse practitioner to determine if your child needs this. 
• Solid foods are recommended as part of the full-liquid diet, but they must be smooth foods without “chunks”. Number one and number two, jarred baby foods are okay. With the exception of some fruits without chunks, such as applesauce, number three foods are not approved. Solid foods can be thinned by pureeing them with breast milk or formula, and butter, margarine, or gravy. Doing so adds fluids as well as calories. 
• If you make your own baby food or if your infant eats table food, be sure to puree it. Food chunks can lodge in the incision and may lead to infection or disrupt the repair. Be sure to strain chunks and lumps out of the foods you prepare. 
• Reading labels will help you find high-calorie, nutrient-dense foods that are great sources of nutrition. Some of the strained baby food dinners, such as Heinz Chicken and Gravy or Beef and Gravy dinners, are good choices. At 70 calories per 2 oz, adequate calories are packed into small serving sizes. 

Parents, who are concerned about cholesterol and heart health, may be uncertain about adding fats to their infant’s diets. The full-liquid diet is a temporary method of feeding that boosts calories and provides adequate nutrition children need during recovery. 

• Introducing new foods at this time is not advised, as sensitivities may arise. Wait until you child is fully recovered to try any new foods. 

What about feeding toddlers and older children? 

If children are older than one year of age and drinking cow’s or soymilk, you can use over-the-counter products to supplement their nutrition. Pediasure” and Kindercal ’P’ are two brand name, milk-based but lactose-free nutritional supplements. Both are good sources of
protein, vitamins and minerals. An economical alternative to these products is Carnation Instant Breakfast®. which can be stirred into milk. 

In addition, table foods can be pureed (as described above). If children are older than one year, you can puree and thin foods with whole milk. You also can thin food with broth, Pediasure/Kindercal, cream, or half- &-half. Smoothies, too, are a great way to deliver extra calories and protein, as are creamed soups, yogurts, puddings, and custards (assuming your child has been introduced to eggs). 

How long will my baby be in the hospital? 

Repair of the palate takes about 1-11/2 hours. Your child will be admitted to the preoperative area on the day of surgery. After the procedure and recovery in the post-anesthesia recovery unit (PACU), your child will be transferred to the general medical-surgical floor for a one-night stay. Infants are generally discharged to home once they are taking fluids well. Usually, that is late morning or early afternoon of the following day. 

Will my child be in pain? 

Older children who have had palate repair report discomfort in the area of the incision. However, this generally lasts only a few days and improves each day post-op. Of course, it’s difficult to determine what’s causing fussiness in a child who is unable to communicate verbally. It might be pain, a disruption in schedule, hunger or something else. Your child may want to be held more frequently after surgery. Doing so helps ease your child’s discomfort, and may decrease the need for pain medication. 

Medicines for pain are provided during the hospital stay, and you will be sent home with a prescription and instructions for pain control. Many children do fine with plain Tylenol®. 

Is there any special care for the incision? 

The incision inside the mouth is closed with absorbable sutures, which dissolve in 10-14 days. Do not rinse or rub the incision to clean it. It will heal best without any manipulation or handling. We may send your child home with soft arm restraints called “no-no” sleeves. The sleeves keep your child from putting hands, toys, or other objects in the mouth. You may remove them when you are holding and supervising your baby. Just make sure your child doesn’t put anything in the mouth. Your child will wear the sleeves until follow-up with the craniofacial surgeon, in about 7-10 days.