DISORDERS AFFECTING NUTRITIONAL FUNCTIONING

1. Cleft lip and cleft palate
   1. Introduction: Cleft lip and cleft palate are congenital facial malformations resulting from faulty embryonic development; there appear to be multiple factors involved in the exact etiology: mutant genes, chromosomal abnormalities, teratogenic agents, etc. The infant may be born with cleft lip alone, cleft palate alone, or with both cleft lip and cleft palate.
   2. Assessment:
      1. Cleft lip - obvious facial defect, readily detectable at time of birth.
      2. Cleft palate - must feel inside infant’s mouth to check for presence of palatal defect and to note extent of defect: soft palate only or soft palate and hard palate.
      3. Both - major problems with feeding: difficult to feed, noisy sucking, swallows excessive amounts of air, prone to aspiration.
      4. Parent-infant attachment (bonding) may be adversely affected due to “loss of perfect infant,” multiple hospitalizations; note amount and quality of parent-infant interaction.
   3. Analysis/nursing diagnosis:
      1. Altered nutrition, less than body requirements, related to physical defect.
      2. Impaired physical mobility (postoperative) related to postoperative care requirements.
      3. Altered parenting related to birth of child with obvious facial defect.
      4. Knowledge deficit, actual or potential, related to treatment and follow-up.
   4. Nursing care plan/implementation:
      1. Goal: maintain adequate nutrition.
         1. Preoperative: first encourage parents to watch nurse feed infant, then teach parents proper feeding techniques:
            1. Use Breck feeder or Asepto syringe.
            2. Deposit formula on back of tongue to facilitate swallowing and to prevent
            3. Rinse mouth with sterile water after feedings, to prevent infection.
            4. Feed slowly, with child in sitting position, to prevent aspiration.
            5. Burp frequently, because infant will swallow air along with formula due to the defect.
            6. Monitor weight.
         2. Postoperative
            1. Begin with clear liquids when child has fully recovered from anesthesia.
            2. Monitor weight gain carefully, to ensure adequate rate of growth.
            3. No sucking for either cleft lip or palate repair.
      2. Goal: promote parent-infant attachment.
         1. Show no discomfort handling infant;
         2. convey acceptance.
         3. Stay with parents the first time they see/hold infant.
         4. Offer positive comments about infant.
         5. Give positive reinforcement to parents’ initial attempts at parenting.
         6. Encourage parents to assume increasing independence in care of their infant.
         7. Allow rooming-in on subsequent hospitalizations.
      3. Goal: teach parents regarding feeding and need for long-term follow-up care.
         1. Teach parents regarding long-term concerns.
         2. Make necessary referrals before discharge:
            1. Specialists: speech, dentition, hearing.
            2. Home health nurse.
            3. Social service.
            4. Disabled children’s services for financial assistance.
            5. Local facial-malformations support group
         3. Refer parents to genetic counseling services because of mixed genetic/environmental etiology.
         4. Encourage parents to promote self-esteem in infant/child as child grows and develops.
   5. Evaluation/outcome criteria:
      1. Adequate nutrition is provided, and infant grows at “normal” rate for age.
      2. Parent-infant attachment is formed.
      3. Parents verbalize confidence in their ability to care for infant.