S O U TH EA S T A S IA N J TR O P M ED P U B LIC H EA LTH

254 Vol 36 N o. 1 January 2005

C orrespondence: D r VK G opinath, School of D ental Sci-
ences, U niversity Sains M alaysia, 16150 Kubang Kerian,
Kelantan, M alaysia.
Tel: 609-764-2026
E-m ail: gopinath@ kb.usm .m y
IN TR O D U C TIO N
C left lip and palate (C LP ) are som e of the
com m onest congenital abnorm alities. C LP is a
gap involving the lip, upper m axilla and/or pal-
ate. The m ajority of C LP appear to be due to a
com bination of genetics and environm ental fac-
tors. Epidem iological studies conducted on the
incidence of C LP in M alaysian preschool children
show ed 1:1,304 for cleft lip and 1:1,594 for cleft
palate (D ental S ervice D ivision, 1995), w hile in-
ternational data show ed craniofacial anom alies
occur in approxim ately 1 in 500 live births (Lee,
1999).
P atients w ith C LP present w ith a num ber
of problem s. Feeding difficulties are com m only
observed and are the m ost traum atic experience
the fam ily has to face. C hildren, especially those
w ith a cleft palate, have an im paired sucking
m echanism . D espite adequate sucking m ove-
m ents, they are unable to generate the negative
pressure required (C hase et al, 1990; D avis,
1990). M ore air than norm al is sw allow ed, feed-
ing takes longer and the child m ay tire before
com pletion of the feed (C hase et al, 1990). These
children are prone to nutritional problem s, since
the healthiest and the safest source of nutrition
for infants is breast m ilk. R ecurrent infections,
repeated operations and adverse psychosocial
influences further aggravate the problem .
These infants are undernourished and have
com prom ised grow th in the early m onths after
birth (Avedian and R uberg, 1980; B ow ers et
al, 1987). The grow th problem s of children w ith
C LP have largely been attributed to inadequate
nutrition (D ay, 1985). S tudies have show n m any
children w ith C LP have im paired grow th w ith
no im pairm ent in w eight gain (Felix-S chotlaart
et al, 1992). A ssessm ent of grow th in children
w ith C LP is crucial, because abnorm alities m ay
be treatable in the early stages.
The purpose of this study w as to 1) as-
sess general health and grow th param eters in
children w ith C LP and in norm al children and
2) to investigate the feeding m ethods of C LP
infants and norm al infants.
M ATER IA LS A N D M ETH O D S
This study w as conducted at the S chool
of D ental S ciences, U niversiti S ains M alaysia.
A S S ES S M EN T O F G R O W TH A N D FEED IN G P R A C TIC ES IN
C H ILD R EN W ITH C LEFT LIP A N D PA LATE
VK G opinath
1
and W an A bdul M anan W an M uda
2
1
S chool of D ental S ciences, U niversity S ains M alaysia,
2
S chool of H ealth S ciences,
U niversity S ains M alaysia, K ubang K erian, K elantan, M alaysia
Abstract. Feeding difficulties in cleft lip and palate (C LP ) infants is com m only observed and is the
m ost traum atic experience the fam ily has to face. These infants are undernourished and have
com prom ised grow th. The purpose of this study w as to 1) assess general health and grow th
param eters in children w ith C LP and in norm al children; and 2) investigate the feeding m ethods
of C LP infants and norm al infants. A total of 221 children from birth to six years of both sexes,
w ith C LP (60 children) and norm al (161 children) w ere selected. The C LP and norm al children
w ere divided into three subgroups by age. The practice of feeding the infants in subgroup I w as
assessed using standard piloted questionnaires. The assessm ent of grow th w as done at baseline
and at six m onths in all the subgroups.The general w ell being of the children w as assessed by
noting the num ber of com m on infections. R esults show ed that a significantly higher percentage
of m others w ith norm al babies (p<0.01) had a positive attitude tow ards breast feeding. W hen
com pared to norm al children, C LP children w ere m ore susceptible to infections (p<0.05) and
m easured significantly low er on the height grow th curve(p<0.05). H ence, height can be used to
m onitor grow th in C LP children.
G R O W TH A N D FEED IN G P R A C TIC ES IN C LP C H ILD R EN
Vol 36 N o. 1 January 2005 255
A total of 221 children from birth to six years of
both sexes, w ith C LP and norm al w ere selected.
The distribution of the sam ple in relation to the
age, sex, and ethnicity are show n in Table 1.
The C LP and norm al children w ere divided into
three subgroups by age. They are, subgroup I:
birth to 24 m onths; subgroup II: 25 to 47 m onths;
and subgroup III: 48 to 72 m onths. D em ographic
inform ation w as obtained through interview s.
The attitude and practice of feeding the infants
in subgroup I w as assessed using standard
piloted questionnaires. A ssessm ent of grow th
w as done at baseline and at six m onths in all
the subgroups. The general w ell being of the
children w as assessed by noting the num ber
of com m on infections.
The total num ber of children in the study
w as 221. In-group I, the C LP group, there w ere
60 children. These w ere divided into subgroups
as follow s: in subgroup I, age from birth to 24
m onths, there w ere 20 children; in subgroup
II, age 25 to 47 m onths, there w ere 20 chil-
dren; and in subgroup III, age 48 to 72 m onths,
there w ere 20 children. In-group II, the norm al
group, there w ere 161 children. These w ere
divided into subgroups as follow s: in subgroup
I, from birth to 24 m onths, there w ere 62 chil-
dren; and in subgroup II, age 25 to 47 m onths,
there w ere 48 children; and in subgroup III, age
48-72 m onths, there w ere 51 children.
Criteria for selection
The inclusion criteria for the study w ere
as follow s: C LP patients and norm al children
w ithout other system ic or congenital abnorm ali-
ties; new C LP patients w ho present to the H os-
pital U niversiti Sains M alaysia; children w ho w ere
operated on for C LP at the H ospital U niversiti
S ains M alaysia; and healthy children age from
birth to 6 years.
Exclusion criteria
The exclusion criteria for the experim en-
tal group w ere: C LP patients and norm al chil-
dren w ith system ic or congenital abnorm alities;
children m ore than 6 years of age; and incom -
plete repair of C LP. The norm al healthy chil-
dren w ere selected from nurseries, kindergar-
tens and prim ary schools by a random sam -
pling m ethod.
Table 1
D escriptive statistics of the study sam ple.
Variable N orm al C left lip and palate
n=161 n=60
Age
B irth-24 m onths 62 (38.5% ) 20 (33.3% )
M ean age (SD ) 8.55 (8.2) 15.25 (7.1)
25-47 m onths 48 (29.8% ) 20 (33.3% )
M ean age (SD ) 39.85 (7.1) 37.05 (5.9)
48-72 m onths 51 (31.7% ) 20 (33.3% )
M ean age (SD ) 64.16 (7.9) 56.75 (9.9)
Sex
M ale 85 (52.8% ) 30 (50% )
Fem ale 76 (47.2% ) 30 (50% )
Ethnicity
M alay 161 (100% ) 57 (95% )
O thers 0 3 (5% )
Fathers age
M ean age (SD ) 36.2 (5.8) 38.9 (8.2)
(n=151) (n=59)
Mothers age
M ean age (SD ) 33.5 ( 5.2) 34.3 (6.6)
(n=152) (n=60)
R ES U LTS
The com position of the sam ple by age, sex,
and ethnicity is given in Table 1. The results
show that in term s of incom e, 71.7% of the
parents of the C LP children had a fam ily in-
com e of less than R M 1,000.00. P arents of C LP
children had low er education levels than par-
ents of norm al children (p<0.001). A m ong the
C LP children, 31.7% of them cam e from a fam ily
size of 9-12 people (Table 2).
The practice of feeding from birth to 24
m onths in norm al and in C LP infants w as in-
vestigated. R egarding m othersattitudes to-
w ards breast-feeding, 100% of those w ith nor-
m al babies had a positive attitude, w hile only
76.5% of m others w ith C LP babies had a positive
attitude (p<0.001). A lthough 88.2% of m oth-
ers w ith C LP babies tried to breast feed, only
40% of them w ere successful (Table 3). A m ong
the C LP infants, 76.5% w ere bottle-fed and
69.2% w ere spoon-fed com pared w ith norm al
infants, w here 49.2% w ere bottle-fed and 1.7%
w as spoon-fed (p<0.05). M ore of the parents
used form ula m ilk instead of bovine or hum an
S O U TH EA S T A S IA N J TR O P M ED P U B LIC H EA LTH
256 Vol 36 N o. 1 January 2005
Table 2
S ociodem ographic indicators.
Variable
Frequency (% )
N orm al C LP
n=161 n=60
Fathers education
Prim ary school 4 (2.5) 10 (16.7)
Low er secondary 8 (5.0) 15 (25.0)
U pper secondory 70 (43.4) 34 (56.6)
H igher education 79 (49.1) 1 (1.7)
Mothers education
Prim ary school 2 (1.2) 4 (6.7)
Low er secondary 10 (6.3) 14 (23.3)
U pper secondory 72 (44.7) 39 (65.0)
H igher education 77 (47.8) 3 (5.0)
Family income
<R M 1,000 18 (11.2) 43 (71.7)
R M 1,000-2,000 28 (17.4) 10 (16.7)
> R M 2,000 115 (71.4) 7 (11.6)
Household size
<4 people 57 (35.4) 11 (18.3)
5-8 people 92 (57.2) 30 (50.0)
9-12 people 11 (6.8) 19 (31.7)
>12 people 1 (0.6) 0 (0)
dren w as significantly low er (p<0.05) than the
norm al children (Table 5).
D IS C U S S IO N
The norm al and C LP children w ere divided
by age. The m ean age of the norm al children
from birth to 24 m onths w as 8.55 m onths and
the C LP child w as 15.25 m onths. The differ-
ence in the m ean ages can be attributed to a
larger percentage of norm al infants below 6
m onths. This sam ple had alm ost equal num -
bers of m ale and fem ale subjects. The m ajority
of the sam ple cam e from the M alay race. This
m ay be due to the predom inance of this race
in the state of K elantan in M alaysia w here the
study w as conducted.
The m ean age of the fathers w as 36.17
years and the m others w as 33.54 years for the
parents of the norm al children, com pared to
m ean age of parents w ith C LP infants, w here
the m ean age of the fathers w as 38.88 years
and m others w as 34.28 years (Table 1). The
m aternal ages at risk for children w ith C LP are
ages less than 15 years or greater than 35 years
(S ipek et al, 2002).
W e noted that the parents of the norm al
children had higher education levels than the
parents of the C LP children. In term s of fam ily
incom e, 71.7% of the fam ilys w ith C LP infants
had a total incom e less than R M 1,000 and
31.7% of the C LP infants lived in houses w ith
9-12 people (Table 2). Therefore, a larger pro-
Table 3
Feeding practices from birth to 24 m onths in norm al and C LP children.
Variable
N
N orm al C LP p-value
N orm al C LP Freq (% ) Freq (% )
A ttitude tow ards breast feeding 60 17 60 (100) 13 (76.5) 0.002
b
Tried breast feeding 60 17 60 (100) 15 (88.2) 0.046
b
S uccessful feeding 60 15 54 (90) 6 (40.0) 0.000
b
B ottle feeding 59 17 29 (49.2) 13 (76.5) 0.046
M ilk used in bottle 29 13 0.141
b
H um an and bovine m ilk 6 (20.7) 6 (46.1)
Form ula m ilk 23 (79.3) 7 (53.9)
S poon for feeding 58 13 1 (1.7) 9 (69.2) 0.000
b
M ilk used in spoon 1 9 1.000
b
H um an and bovine m ilk 0 (0) 4 (44.4)
Form ula m ilk 1 (100) 5 (55.6)
Fisher extract test = b; Freq = Frequency
m ilk (Table 3).
C LP children from birth to 24 m onths w ere
m ore susceptible to infection as evidenced by
fever (p<0.05) and diarrhea (p<0.05), com pared
to norm al children (Table 4). A t the 6-m onth
grow th m easurem ent, the height of the C LP chil-
G R O W TH A N D FEED IN G P R A C TIC ES IN C LP C H ILD R EN
Vol 36 N o. 1 January 2005 257
Table 5
C om parison at baseline and at 6 m onths of different grow th param eters in norm al and C LP children.
Variable
N
N orm al C LP p-value
N orm al C LP
W eight (m edian, IQ R ) 102 49 1 (0.50-1.97) 1 (0.50-1.50)
a
0.709
b
H eight (m edian, IQ R ) 102 49 4.6 (3.1-6.7) 1 (1.0-2.0 )
a
0.035
b
Arm circum ference M ean (SD ) 101 49 0.64 (1.03) 0.63 (0.79) 0.96
c
H ead circum ference (m edian, IQ R ) 102 49 0.7 (0.4-1.4) 1 (1.0-2.0 )
a
0.096
b
C hest circum ference M ean (SD ) 102 49 2.14 (3.62) 1.46 (1.50) 0.103
c
IQ R =Interquartile range; b=M anW hitney test; c=ttest equal variances
portion of C LP infants com e from low er levels
of society.
In analyzing feeding practices in infants from
birth to 24 m onths of age, it w as observed that
100% of the m others w ith norm al children w ere
w illing to breast feed their infants, w hen given
a preference, w hereas only 76.5% of the m others
w ith C LP infants w anted to breast feed. P revi-
ous studies have reported that prior to birth,
the m ajority of m others w ith C LP infants intended
to breast feed their child, how ever, after birth,
the m ajority of infants w ere bottle fed. The m a-
jority of the m others felt that they had been a
part of the decision to change the m ethod (O liver
and Jones, 1997). In this study, although 88.2%
of the m others w ith C LP infants tried to breast-
feed, only 40% w ere successful (Table 3). It has
been reported (Trenouth and C am pbell, 1996)
that 12 of the 25 m others w ith C LP infants tried
to breastfeed, but none of them w as success-
ful. The reasons the m others could not breast
feed their infants w ere attributed to the ana-
tom ical defect in the lip and palate and the in-
ability of the m others to position the nipple prop-
erly in the infants m outh. In our study, the use
of bottles and spoons for feeding the C LP in-
fants w as m ore com m on w hen com pared to
norm al infants. This practice can be attributed
to the inability of the m others to successfully
breast feed their infants. M ost of the m others
w ho used bottles or spoons to feed their in-
fants preferred form ula m ilk to hum an or bo-
vine m ilk, w hich can be attributed to the easy
availability of the form ula m ilk.
It w as observed that C LP infants from birth
to 24 m onths w ere at risk for com m on m ani-
festations of infection, such as fever and diar-
rhea, w hen com pared to norm al infants (Table
4). This m ay be attributed to the use of bottles
or spoons for feeding the C LP children, w hich
could be contam inated, resulting in recurrent
infections in these C LP children. N orm al breast
feed infants w ere less susceptible to com m on
infections. A previous study (D anner, 1992) has
reported that breast-feeding provides protec-
tion against upper respiratory infections, par-
ticularly otitis m edia.
A t 6 m onths, the C LP infants m easured
low er on the height grow th curve than norm al
infants, but there w as no difference in the other
grow th param eters. The rate of grow th in height
is faster than the other param eters so w e w ere
able to note a difference betw een the tw o groups
by 6 m onths. Few previous studies had sim ilar
findings. Lee et al (1997) reported that C LP chil-
dren age 0-4 m onths grew relatively poorly in
early infancy, but subsequently recovered, at-
taining both expected w eight and height by
follow up at age 25.5 m onths. Lipm an et al (1999)
reported that children 3 to 12 years old w ith
nonsyndrom ic orofacial clefts had significantly
m ore grow th failure than the general popula-
tion. S tudies of w hite children birth to 10 years
w ith isolated C L,C P, or C LP, dem onstrated a
Table 4
R isk for com m on infections in children below
tw o years of age.
Variable
N
N orm al C LP p-value
N orm al C LP N (% ) N (% )
Fever 56 17 22 (39.28) 12 (70.5)0.023
D iarrhea 56 17 3 (5.4) 5 (29.4)0.015
b
Ear infection 55 17 6 (10.9) 0 (0) 0.325
b
Fisher extract test = b
S O U TH EA S T A S IA N J TR O P M ED P U B LIC H EA LTH
258 Vol 36 N o. 1 January 2005
m ean heig ht b elo w the p o p ulatio n m ean
(C unningham et al,1997). W hile another study
reported that C LP children are neither consis-
tently shorter nor taller than norm al (R analli and
M azaheri, 1975). A n early lag period occurred,
but by three years C LP children caught up to
the norm al grow th, confirm ing the concept of
catch-up grow th. A study by S eth and M c W il-
liam s (1988) assessed the w eight from birth to
2 years in 77 babies w ith C LP and in norm al
infants, and reported that the m ean birth w eight
w as not significantly different betw een the tw o
groups.
H eight can be used as one tool to assess
grow th in C LP infants. G row th assessm ent m ust
be included in prim ary and specialty care of chil-
dren w ith C LP. If grow th failure is dem onstrated,
these children should be referred for evalua-
tion of the etiology of their short stature.
In conclusion, the rate of grow th in height
in C LP children. In our study, w as slow er than
in norm al children. O nly 40% of the m others
w ith C LP infants w ere successful in breast feed-
ing their infants, but 90% of the m others w ith
norm al infants w ere successful. W hen com pared
to norm al children, C LP children w ere m ore sus-
ceptible to infection. H eight can be used to m oni-
tor grow th in C LP children.
A C K N O W LED G EM EN TS
The authors w ould like to express thank
for the U S M short-term grant, and thanks to
the S chool of D ental S ciences for providing the
facilities for the research. W e w ould like to ex-
tend our gratitude to the people involved in the
data collection, entry and analysis: S harifah
Zahhura A bdullah, B asaruddin A hm ad, G opal
N air, Soo K ah Leng, R ohana Jalil, R uhaya H asan,
and M arina A bd M anaf.
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