Hospitalization, Breast-Milk Feeding, and Growth in Infants With Cleft Palate

and Cleft Lip and Palate Born in Denmark

Lisa Smedegaard, H.V., Dorthe Marxen, R.N., Jette Moes, H.V., Eva N. Glassou, Cand Scientsan

Objective: To evaluate if the duration of postpartum hospitalization, duration

of breast-milk feeding, and growth during the first year of life in infants with cleft
lip and palate (CLP) and cleft palate (CP) are comparable to infants without facial
clefts.
Design: Prospective data collection using a registration chart developed by
the authors.
Setting: Special health care of infants with CLP/CP born in Denmark.
Participants: All mature infants with CLP/CP born in 2003 and 2004 were
included. Of 165 infants, 115 participated in the study.
Intervention: In Denmark, parents of children with CLP/CP receive counsel-
ing. This counseling is managed by specially trained health visitors/nurses and
is initiated at birth. The counseling seeks to support parents’ confidence in
having an infant with CLP/CP and to initiate a relationship between the infant
and the parents.
Main Outcome Measures: Duration of postpartum hospitalization, duration of
breast-milk feeding, and weight and length at birth, 5 months of age, and 12
months of age.
Results: Hospitalization was 4 days and comparable to that of infants without
CLP/CP. The infants with CLP/CP received breast milk but for a shorter period
compared with infants without CLP/CP. Weights at birth, 5 months of age, and
12 months of age were identical with Danish growth references.
Conclusion: The authors find the results satisfactory and believe that the
counseling provided by the health visitors/nurses plays a part in the results.

KEY WORDS: breast milk, cleft lip and palate, cleft palate, home visits,
hospitalization, length, nutritional status, tube feeding, weight,
well-being

Several international studies have demonstrated that
growth impairments affecting both weight and length are
common in infants with cleft lip and palate (CLP) and cleft
palate (CP; Jensen et al., 1988; Jones, 1988; Cunningham
and Jerome, 1997; Lee et al., 1997; Lazarus et al., 1999;
Gopinath and Muda, 2005). It has been documented that
infants with CLP/CP are smaller than control subjects and
that growth impairment depends on the diagnosis. This
means that infants with CLP/CP are more affected than
infants with isolated cleft lip (Jensen et al., 1988; Lee et al.,
Ms. Smedegaard is Health Visitor, Centre for Communication,
Department of Language and Speech Disorder, Herning, Denmark. Ms.
Marxen is Registered Nurse, Copenhagen Cleft Palate Centre, Copenha-
gen, Denmark. Ms. Moes is Health Visitor, Institute of Speech Therapy,
County of Northern Jutland, Denmark. Ms. Glassou is Research
Associate, Department of Quality in Health Care, Herning, Denmark.
Preliminary data was presented at the 10th International Congress on
Cleft Palate and Related Craniofacial Anomalies, September 4–8, 2005,
Durban, South Africa.
Submitted January 2007; Accepted March 2008.
Address correspondence to: Eva N. Glassou, Department of Quality in
Health Care, Laegaardvej 12N, DK-7500 Holstebro. E-mail feengp@
ringamt.dk.
DOI: 10.1597/07-007.1
1997). It has been suggested that feeding difficulties,
undernourishment, infections of the upper airways, and
surgical interventions are reasons for growth impairment,
and that infants catch up with normal growth values after
surgery (Jensen et al., 1988; Laitinen et al., 1994). Factors
influencing feeding difficulties and intake of breast milk
have been the subject of modest attention in the literature.
A recent Cochrane Review found that no studies have
examined the effect of additional maternal support or
advice during breast-feeding (Glenny et al., 2004).
Growth impairment has also been demonstrated in the
Danish population. Jensen et al. (1988) demonstrated that
postnatal somatic growth was retarded in infants with
facial clefts. Both at the time of Jensen’s work and now,
treatment of all infants with facial clefts in Denmark is
managed by two teams consisting of speech pathologists,
orthodontists, orthorhinolaryngologists, surgeons, geneti-
cists, psychologists, and specially trained health visitors/
nurses.
All newborn infants in Denmark receive two to five
home visits from a local health visitor. The visits concern
the infants’ development and health. In addition to this
general offer, parents of infants with CLP/CP receive

628
 Smedegaard et al., HOSPITALIZATION, BREAST-MILK FEEDING, AND GROWTH IN INFANTS 629
counseling from specially trained health visitors/nurses.
The role of the specially trained health visitors/nurses is the
subject of this study.
In Denmark, approximately 120 to 150 infants are born
with CLP/CP each year. Based on geography, these infants
are referred to 1 of 10 specially trained health visitors/
nurses. Counseling is initiated at birth. The maternity ward
notifies the health visitor/nurse, who visits the family within
the first 24 hours after birth. During this visit, brief
information about the cleft is given to the parents. If no
other deformity exists, the infant stays with the mother at
the maternity ward until discharge. Furthermore, by
putting the infant to the breast, the infant’s natural reflexes
are used. Suckling at the breast is considered to encourage
and complete the symbiotic bond between mother and
infant, even though breast-feeding is not possible. It is
recommended that the father stay with the family at the
maternity ward, sharing information and feelings. After
discharge, home counseling is continued as needed. During
home visits, further information about the cleft and
treatment is given, including a photo presentation of an
infant with a similar type of cleft before and after surgery.
The information is important for the parents to gain
confidence in having a child with CLP/CP. When good
contact with the family is established, it is maintained by
either further home visits or phone calls. With respect to
surgery, the health visitor/nurse prepares the parents for the
procedures and postoperative recovery. The health visitor/
nurse is available 24 hours per day.
The primary goal for the health visitor/nurse is to help
the parents bond to an infant with a serious, and in most
cases, unexpected deformity. This is to help the parents
gain confidence in caring for an infant with CLP/CP, so
unnecessarily long hospitalization and experience of illness
are avoided.
Regarding nutrition for infants, the Danish National
Board of Health, like the World Health Organization,
recommends exclusive breast-feeding for 6 months. In
infants with CLP/CP, breast-feeding is, in most cases, not
possible, and the health visitor/nurse guides the parents
regarding breast-milk feeding or formula milk. In early
infancy, comfort and closeness during feeding are more
important than the type of nutrition. It is important to
provide optimum conditions for the mother whether she
wants to express breast-milk or not. To ease the procedure
of breast-milk feeding, breast pumps are at families’
disposal without charge. The health visitor/nurse evalu-
ates the child’s ability to suck, providing a basis for the
right choice of teat and soft-feeding bottle. Specific
guidance is given to each family regarding position during
feeding, frequency of meals, and quantity. When the
infant is 4 to 6 months of age, the health visitor/nurse
guides the family in the infant’s introduction to solid
food. Furthermore, the health visitor/nurse coordinates
information between the families and social and medical
services.
It is undocumented whether specially trained health
visitors/nurses influence the CLP/CP infants’ well-being.
However, the understanding is that infant with CLP/CP
who is assisted by the health visitor/nurse thrives in the
following areas: (1) infants with CLP/CP have a postbirth
course comparable to that of infants without CLP/CP, (2)
infants with CLP/CP receive breast-milk as infants without
CLP/CP, and (3) infants with CLP/CP follow the growth
curves for infants without CLP/CP. Therefore, the purpose
of this study was to evaluate if duration of postpartum
hospitalization and tube feeding, duration of breast-milk
feeding, and growth during the first year of life in infants
with CLP/CP are comparable to infants without facial
clefts.
MATERIALS AND METHODS
Infants with CLP/CP born in Denmark in 2003 and 2004
were included in the study. Preterm infants (#36 weeks)
and infants who died before the age of 12 months were
excluded. The health visitors/nurses collected data using a
registration chart developed by the authors. The chart
enabled the health visitors/nurses to gain information
about duration of postpartum hospitalization and tube
feeding in relation to birth, duration of breast-milk feeding,
weight and length, and number of home visits.
Duration of hospitalization was plotted against number
of births and compared with mean duration of hospital-
ization in infants without CLP/CP. This information was
available through the National Board of Health and
consisted of all infants without CLP/CP born in 2004
(Danish National Board of Health, 2006). No official
information about need for tube feeding was available, and
data regarding tube feeding in this study were therefore
discussed qualitatively. Two Danish studies of breast-
feeding conducted in 1994 and 2002 are used for a
qualitative comparison of duration of breast-milk feeding
(Michaelsen, Larsen, et al., 1994; Fogh et al., 2002). Weight
and length at birth were obtained from health visitors/nurse
case notes. Information regarding weight and length at 5
and 12 months of age was obtained from the parents.
Growth data were in relation to sex compared with growth
references for Danish children (Michaelsen, Petersen, et al.,
1994).
Statistical comparisons regarding duration of hospital-
ization and weight and length were made using two-sample
t tests. Weight data were log transformed. The level of
significance was set at 5%. This study was conducted in
accordance with principles outlined in the Declaration of
Helsinki.
RESULTS
In 2003 and 2004, 156 infants with CLP/CP were born in
Denmark. One hundred fifteen infants (66 boys and 49
girls) were included in the study. For various reasons, 41
630 Cleft Palate–Craniofacial Journal, November 2008, Vol. 45 No. 6

TABLE 1 Duration in Days of Postpartum Hospitalization for TABLE 2 Duration in Weeks of Exclusive Breast-Milk Feeding in
Infants of First Parturients and Second or Third Parturients Infants of First Parturients and Second or Third Parturients

Infants of First Parturients Infants of Second or Third Infants of First Infants of Second or
(n 5 42) Parturients (n 5 65) Parturients Third Parturients

Median (range) 5 (1–52) 3 (0–31) Median (range) 9 (2–30) 6 (1–31)

25% 4 2 25% 6 2
75% 6 4 75% 17 14,5

infants did not participate. The main reasons for not
participating were nonacceptance by the parents or no
return of registration charts. In addition, the reports of all
infants with CLP/CP (10 infants) followed by one health
visitor/nurse were missing. The remaining infants who did
not participate were allocated evenly among the rest of the
health visitors/nurses. CLP was the most common diagno-
sis and was present in 64 (56%) infants (46 boys and 18
girls). CP was present in 51 (44%) infants (20 boys and 31
girls). Ten (12%) infants were diagnosed with the Pierre
Robin sequence (four boys and six girls). The median
number of home visits was six (range, 2 to 31). None of the
participating infants was diagnosed before birth.
Duration of Postpartum Hospitalization and Postpartum
Tube Feeding
The median duration of postpartum hospitalization in
the maternity ward was 4 (range, 0 to 52) days. The
quartiles were 3 and 5 days. Hospitalization was longer for
first parturients compared with second or third parturients
longer. Of the 107 infants who received breast milk, breast-
milk feeding was stopped before 4 months of age in 70
(65%) infants. Fourteen (13%) infants were breast-milk fed
for at least 6 months. The durations of exclusive breast-
milk feeding in first parturients and second or third
parturients infants are presented in Table 2.
Growth
Weight and length at birth and at 5 and 12 months of age
are presented in Table 3 together with normal values.
There were no statistically significant differences in
weight at either birth or at 5 or 12 months of age between
the CLP/CP infants and the references for Danish children
(Michaelsen, Petersen, et al., 1994). However, there were
significant differences in length for both sexes. Infants with
TABLE 3 Median and Quartiles for Weight and Length in Infants
With CLP/CP and Infants Without CLP/CP*
Boys Girls

(Table 1). The mean duration of hospitalization for infants CLP/CP No CLP/ CLP/CP No CLP/
(n 5 66) CP (n 5 49) CP
without CLP/CP was 6.5 days for first parturients. For
multiple parturients, the mean duration of hospitalization At birth
was 3.9 days (Danish National Board of Health, 2006). Weight, g
Median (range) 3495 (2280– 3600 3500 (2290– 3460
There were no statistically significant differences in 4950) 4500)
duration of hospitalization for either first (P 5 .4) or 25% 3280 3280 3200 3030
second/third parturients (P 5 .6) between infants with 75% 3870 4020 3780 3890
Height, cm
CLP/CP and infants without CLP/CP. Median (range) 52 (47–58) 51,0 52 (43–57) 50,4
Nineteen infants (17%) were tube fed during postpartum 25% 51 49,4 50 48,7
hospitalization. The median was 2 (range, 1 to 95) days. 75% 53 52,6 53 52,0
The quartiles were 1 and 8 days. For most infants, the At 5 months
reasons for tube feeding were other abnormalities or Weight, g
Median (range) 7600 (5000– 7570 6750 (4000– 6920
dysfunctions such as heart disease, respiratory problems, 10,600) 8850)
postmaturity, and hypoglycemia. There was also one case 25% 7000 7060 6400 6450
of late diagnosed CP. All but one of the infants with Pierre 75% 8000 8150 7450 7440
Height, cm
Robin sequence was tube fed. Median (range) 68 (59–86) 66,8 67 (60–73) 64,9
25% 66 65,3 65 63,6
Breast-Milk Feeding 75% 70 68,1 69 66,4
At twelve months
Of the 115 infants, 107 (92%) received breast milk. The Weight, g
Median (range) 10,281 (7700– 10,220 9484 (6500– 9240
median duration of breast-milk feeding was 15 (range, 0.5 13,300) 11,400)
to 52) weeks. The quartiles were 6 and 22 weeks. Of the 107 25% 9475 9540 8900 8700
who received breast milk, 82 infants (77%) were fed 75% 11,000 11,080 10,200 9900
Height, cm
exclusively with breast milk. The median duration of Median (range) 78 (68–85) 76,5 77 (71–96) 73,8
exclusive breast-milk feeding was 8 (range, 0.5 to 31) 25% 76 74,5 74 72,3
weeks. The quartiles were 4 and 16 weeks. Eighteen infants 75% 80 77,7 79 75,2
(22%) were fed exclusively with breast milk for 4 months or * CLP 5 cleft lip and palate; CP 5 cleft palate.
 Smedegaard et al., HOSPITALIZATION, BREAST-MILK FEEDING, AND GROWTH IN INFANTS 631
CLP/CP were taller at all times (boys: birth p 5 .003, 5
months p 5 .003, 12 months p 5 0.01; girls: birth p 5 .005,
5 months p 5 .000, 12 months p , .00).
DISCUSSION
Of all infants with CLP/CP born in 2003 and 2004 in
Denmark, 70% were included in this study. As the
nonresponding infants were equally allocated among health
visitors/nurses, and by that geographically, there is no
reason to believe that these infants were different from the
included infants in relation to diagnosis, duration of
hospitalization, need for tube feeding, or growth. The risk
of selection bias is therefore judged as minimal. Even
though CP is not the presenting problem relative to feeding
in infants with Pierre Robin sequence, these infants were
included in the study. Infants with Pierre Robin sequence
met the criteria for inclusion, and the counseling of these
infants is the responsibility of the health visitors/nurses.
Because of the criteria for Pierre Robin sequence (in
Denmark: CP, micrognatia, and obstruction of the tongue),
the diagnosis is often recommended or excluded by the
health visitor/nurses.
Counseling provided by the health visitors/nurses is
initiated in the maternity ward. The health visitors/nurses
underline the importance of an early visit as the counseling
seeks to support the mother-infant relationship and the
parents’ self-confidence in caring for an infant with CLP/
CP. This study gives us no information about the effect of
this counseling in relation to hospitalization and tube
feeding nor in relation to breast-milk feeding. However, the
findings give us reason to believe that counseling provided
by specially trained health visitors/nurses has a positive
influence on the outcome of these measures.
Duration of Postpartum Hospitalization and Postpartum
Tube Feeding
Duration of hospitalization was consistent with the
general pattern in Denmark. Not surprisingly, first-born
infants were hospitalized a little longer than infants of
second or third parturients. The relatively short-term
hospitalizations at birth are taken as an indication that
parents quickly gain confidence in caring for the infant.
Even though infants with CLP/CP are at higher risk for
other congenital dysfunctions that may indicate a need for
tube feeding than are infants without CLP/CP, the health
visitors/nurses did not expect that almost one-fifth of the
children were tube fed. The expectation was a far smaller
number of infants with CLP/CP in need of tube feeding
during postpartum hospitalization. It is the impression of
nurses at maternity wards that the use of tube feeding is
increasing in infants in general. If this observation is true, it
may explain some of the incidences in this study. In
addition, the Pierre Robin sequence, for which tube feeding
can be expected, accounts for 7 of the 19 tube-fed infants.
Breast-Milk Feeding
Several factors influence breast-feeding. Higher age,
education level, and socioeconomic background have an
influence on the duration of breast-feeding in a positive
way, while supplements of fluid or formula have been
shown to affect the duration of breast-feeding negatively
(Michaelsen, Larsen, et al., 1994). Furthermore, the
duration of breast-feeding is influenced by the mother’s
experience with breast-feeding. Multiple parturients in a
general population breast-feed for a longer period com-
pared with women with only one child (Holk et al., 2006).
Michaelsen, Larsen, et al. (1994) documented that 52% of
201 randomly chosen infants in Copenhagen were breast-
fed at 6 months of age. A national study conducted in 2002
showed that 50% of the general population was exclusively
breast-fed for 4 months or longer and that breast-feeding
was stopped before the age of 4 months in 24% of the
population (Fogh et al., 2002).
The present study showed that infants with CLP/CP did
not receive breast milk to the same extent as infants without
CLP/CP, as reported in previous studies (Michaelsen,
Larsen, et al., 1994; Fogh et al., 2002). On the other hand,
the study showed that most infants with CLP/CP received
breast milk, and that these infants were exclusively fed with
breast milk. It is difficult to say whether the outcomes of the
present study can be improved with additional interventions.
In addition to the above-mentioned factors influencing
breast-feeding, for which only earlier experience with breast-
feeding is evaluated in this study, mothers of infants with
CLP/CP have to deal with other factors that affect breast-
milk feeding. Infants with CLP/CP are rarely able to suckle,
which results in prolonged and fatiguing feeding times. The
specially trained health visitor/nurse supports the mother in
expressing breast milk by offering her a breast pump. But the
main role of the health visitor/nurse is to initiate a close
relationship between the infant and the parents, and
regarding nutrition, to support the family in what is best
for them. If the mother-child relationship is jeopardized
because of prolonged and troublesome feeding sequences,
formula milk is to be recommended. The share of infants
who did not receive breast milk may be larger among the
missing infants. This means that the results regarding breast-
milk feeding in this study may be overestimated.
Growth
Even though many international studies report tempo-
rary growth impairment, direct comparisons are difficult.
Two of the most recent studies, which also report severe
growth impairments, are from developing countries (Laz-
arus et al., 1999; Gopinath and Muda, 2005). At the same
time, some studies from comparable countries such as
Scandinavia, the Netherlands, and the United Kingdom are
relatively old (Jensen et al., 1988; Jones, 1988). Two more
recent studies (Laitinen et al., 1994; Lee et al., 1997)
632 Cleft Palate–Craniofacial Journal, November 2008, Vol. 45 No. 6
demonstrate growth impairments in infants with CLP/CP.
The present study showed no significant growth impair-
ment in infants with CLP/CP at 5 months of age. However,
weight and length values between birth and 5 months of age
would provide a more subtle picture of early growth
impairments. Such data were not available.
In the present study, weight at birth, 5 months, and 12
months of age did not differ significantly from normal
values; whereas, the infants were significantly longer than
infants without CLP/CP at all three time points. The
descriptive comparison in Table 3 underlines these results,
and the findings are consistent with the expectations of the
health visitors/nurses. They expected that infants with CLP/
CP will follow the growth curves for infants without CLP/
CP—or even be a little longer than normal. Health visitors/
nurses anticipate that infants with CLP/CP in general are
longer and more slender. Such a tendency was also seen by
Felix-Schollaart et al. (1992), who reported that the length
of female infants with CLP is above average.
All infants in Denmark are offered a routine examination
by their local family physician at 5 and 12 months of age. In
addition to weight and length, these examinations include
vaccinations. Compliance can therefore be expected to be
high. As time for examination, and therefore the age of the
infants varies, weight and length at 5 and 12 months of age
can be imprecise. If infants were much older than 5 or 12
months at the time of examination, weight and length
reported in this study may be overestimated.
CONCLUSION
For infants with CLP/CP born in Denmark, duration of
postpartum hospitalization is comparable to that of infants
without CLP/CP. Infants with CLP/CP are hospitalized in
maternity wards for 4 days. Tube feeding is used in
approximately one-fifth of infants with CLP/CP. Infants
with CLP/CP receive breast milk but for a shorter period
compared with infants without CLP/CP. Weight and length
at birth and 5 and 12 months of age are identical to Danish
growth reference values.
The authors believe that counseling provided by specially
trained health visitors/nurses plays a part in these findings,
but to see if this is really true, further investigations are
needed. As it is not possible in Denmark to randomize
infants with CLP/CP to either counseling or no counseling,
multicenter studies are required. Furthermore, real-time
reference data regarding growth and duration of breast-
milk feeding are necessary.
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