การเตรียมความพร้อมทางโภชนาการ ก่อนผ่าตัดปากแหว่งและเพดานโหว่ (Non syndromic และ syndromic ) วิทยา

Yes

Prenatal dx

Prenatal education concerning feeding techniques Gailey DG. Oral Maxillofacial Surg Clin N Am 2016;28:153-9.

Miller CK. Semin Speech Lang 2011;32:115-26.

No

Feeding methods training is

Syndromic

immediate priority

No

Nutrition Rx Cleft Lip/Palate

Anatomicstructural deformity affecting only the oral phase of the suck-swallowbreathing mechanism

Nuthapong Ukarapol 2019

Risk of aspiration and airway obstruction

CL/P Isolated CP Isolated CL

Clinical evaluation • Identify airway problems • Complete PE to identify associated anomalies/ syndromes • Manual palpation of the palate, if a bifid uvula is noted, to identify submucous cleft palate • Growth monitoring • Hearing screening b/f d/c • Establish feeding w/n 48 h • Multidisciplinary approach

Yes

47%

21%

Lt Rt Bilat

32%

1 : 300-800 Berkowitz S. The cleft palate story. Chicago (IL): Quintessence Books; 1994.

60% 10% 30%

Cleft lip

Calzolari E, et al. Am J Med Genet A 2007;143A:528-37.

N = 5,449

Cleft lip, only

Cleft lip/palate

100

73% Chromosome defect

N = 3,453

20.8%

34%

+ anomalies

+ anomalies

N = 415

N = 1,174 N = 1,589

+ anomalies

Calzolari E, et al. Am J Med Genet A 2007;143A:528-37.

Recognized syndromes & sequences

61%

75

%

N = 1,996

27%

29%

50

25

39%

Recognized condition

N = 970

0

Musculo-
 CNS skeletal

CVS

CL CL/P CP CP 25 + anomalies Syndrome Isolated

50

75

100

Calzolari E, et al. Am J Med Genet A 2007;143A:528-37.

Calzolari E, et al. Cleft Palate Craniofac J 2004;41:244-9.

%

4%

10%

Harper PS. Practical genetic counseling. 6th Edition. London: Edward Arnold Ltd.; 2004.

Mechanistic difference • Shorter sucking burst • Faster sucking rate • Higher suck-swallow ratio • Inability to generate adequate intra-oral pressure • Increase in feeding effort leading to requiring more caloric intake to maintain adequate growth • Excessive air intake Gailey DG. Oral Maxillofacial Surg Clin N Am 2016;28:153-9.

Masarei AG, et al. Cleft Palate Craniofac J 2007;44:321-8.

Parameter Length of sucking burst (sec) Rate of sucking (sucks/min) Suck-swallow ratio

Normal N=30

CL/CP N=49

13.28 75.07

8.97 109.26

1.20 : 1

2.97 : 1

Masarei AG, et al. Cleft Palate Craniofac J 2007;44:321-8.

Masarei AG, et al. Cleft Palate Craniofac J 2007;44:321-8.

Suboptimal v Optimal BF and infection-related mortality 1.7X

Predominant v Exclusive BF 0-5 mo (I2 = NA)

4.56X

Partial v Exclusive BF 0-5 mo (I2 = NA)

8.66X

No v Exclusive BF 0-5 mo (I2 = NA)

Feeding intervention

2.09X

No v Any BF 6-23 mo (I2 = 13.2%) Oral feeding

Specialized feeding

facilitation techniques

equipment

0.01

0.1

1

10

100

Favors optimal (exclusive) BF Sankar MJ, et al. Acta Paediatrica 2015;104:3-13.

Asthma up to 5 years of age

↓10%

Eczema up to 2 years of age

↓ 24%

Obesity1

↓ 30%

T1DM1,2

↓ 40%

T2DM1,3

• Infant formula

• Bottle feeding either HM or IF

↓26%

AR

up to 5 years of age

BF and Risk of NCD

↓21% 0.1

Food Allergy

1

10

Favor BF any or >3 mo

Acta Paediatr 2015:104:38-53.

0%

1Evid

Rep Technol Assess (Full Rep) 2007 ;153:1-186.

2Diabetes Metab Res Rev 2008 ;24:211-22.

3Am J Clin Nutr 2007 ;85:1436-7.

Oral Feeding facilitation technique • Positioning : upright or at least 60° head elevation • Stabilization of the jaw • Assistive squeezing • Pacing or adjusting the rate of intake to maintain a stable and organized swallowing pattern • Burp more often • Cup feeding may be necessary https://www.youtube.com/watch?v=hD8rE8Xz6Cc

Specialized feeding equipment

To facilitate latching to the breast To assist in forming a seal to increase suction

Specialized feeding equipment • Pliability > to ↑ rate of fluid flow • but must be firm enough to provide appropriate degree of proprioceptive input to stimulate sucking • Shape > to support oral-motor pattern of sucking • Size > to maintain adequate contact w/ the tongue during sucking • Hole > Crosscut hole allow much more fluid flow from the nipple and only allow flow during compression

Medela special

needs feeder เ"นขวดนม พลาส,ก.ม แ0สามารถใ4 5อ7วย 9บ นมออกมาไ<ในขณะ?@ก Aดนม โดยแ0CองEกFงเกตและ7วย ควบIมJงหวะการ9บใLFมMนNOบ การกPนของ@ก Qกนมจะเ"นแบบ crosscut

gอเhยiอไ0SฝาครอบQกนม XใLไ0สะดวกในการเkน ทาง และการAแลเmองความสะอาด

Specialized feeding equipment

Soft

Firm

Mead Johnson bottle for Cleft lip

Qกนม (nipple-slit hole) จะSความ.ม TาเUกVบ (compress) WจะXใLYนมไหลไ< โดยไ0Cอง suck แ0สามารถ7วย9บนมออกมาไ<ในJงหวะ?FมMนNOบ การAด กPนของ@ก โดยZตราไหลและป\มาณนม?ออก ในแ]ละค^งสามารถป_บไ< โดยS`ด 3 `ดแสดงไaบน Qกนม นอกจากb cงS one-way valve ?dองOนไ0ใL นมeอนกfบเgาไปในขวด

Pigeon nipple and bottle

Qกนม (nipple) <านหnงจะ firm กoา pงจะqไปไa? roof of mouth rวนsก<านหnงจะ soft กoา วางไaบนtน@ก เuอ7วยในการAด โดยTาใ4vOบขวดนม pigeon เองW จะสามารถ9บ?ขวดนมไ< เuอ assist feeding ไ<

• Expensive • Difficult to use/apply • Irritate oral tissue • Ongoing adjustment and replacement to accommodate growth

70 Number of cases having poor feeding

Goal to be achieved • Breast or bottle feeding established w/n 48 h • Feeding time <20 min • Consistent weight gain ≥200 g/week in neonatal period • WHZ above -1 in infant • No complications e.g. nasal regurgitation, aspiration, apnea, etc.

60

PRS/Syndrome

50

Isolated CL/P

15X risk of poor feeding

40 30

32%

20

19%

10 1d

2 wk

3 mo

16%

14 mo

Reild J, et al. Cleft Palate Craniofac J 2006;43:702-9.

Reild J, et al. Cleft Palate Craniofac J 2006;43:702-9.

25

With complex chronic condition Total No complex chronic conditions

Rigid v.s. Squeezable bottle: wt

% Gastrotomy

20

15 Study

10

Rigid

Squeezable

Total

Mean

Total

Weight

Brine 1994

10.6

13

10.14

18

30.5%

0.46 (-0.22, 1.14)

Shaw 1999

9.22

50

9.64

49

69.5%

-0.42 (-0.87, 0.03)

67

100%

-0.15 (-0.53, 0.22)

Total

63

Heterogeneity: Chi2 = 4.48, df=1 (P=0.03); I2 = 78% Test for overall effect Z = 0.79 (P=0.43)

5

Odds Ratio

Mean

IV, Fixed, 95% CI

-4

-2

0

2

4

Favor Rigid

0

Bessell A, et al. Cochrane Database Syst Rev 2011;Feb 16;(2):CD003315.

2000 2003 2006 2009 2012

Cleft lip

2000 2003 2006 2009 2012

Cleft lip and palate

2000 2003 2006 2009 2012

Cleft palate

Boonipat T, et al. Cleft Palate Craniofac J 2019;56:21-30.

Maxillary plate v.s. no plate: wt Study

Rigid

Squeezable

Total

Mean

Total

Weight

IV, Fixed, 95% CI

Masarei 2007

10.06

20

10.11

12

36.8%

-0.05 (-1.09, 0.99)

Prahl 2005

9.77

6

9.59

12

63.2%

0.18 (-0.61, 0.97)

24

100%

0.10 (-0.53, 0.77)

26

Treatment strategy

Prenatal

• • • • •

Genetic counseling Speech-Language Pathology (SLP) consultation for feeding SLP for feeding & growth Monitor hearing Nasoalveolar molding (if indicated)

• • • • • •

Cleft lip repair Ear tubes (if COM) Palatoplasty Ear tubes (if COM) Introduction to Pediatric Dentist Assess language development

0-5 mo

Odds Ratio

Mean

Total

Age

Heterogeneity: Chi2 = 0.12, df=1 (P=0.73); I2 = 0% Test for overall effect Z = 0.30 (P=0.77)

-4

-2

0

2

4

9-12 mo

Favor no plate

Bessell A, et al. Cochrane Database Syst Rev 2011;Feb 16;(2):CD003315.

1-4 y

Worley ML, et al. Perinatol Clin 2018;45:66-78.

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Kasten EP, et al. Curr Probl Pediatr Adolesc Health care 2008;38:138-58.