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South Australian Perinatal Practice Guideline 

Cleft Lip and Palate in the 
Neonatal Period  

  Department for Health and Wellbeing, Government of South Australia. All rights reserved. 

 

INFORMAL COPY WHEN PRINTED  Page 1 of 9 

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Note:

This guideline provides advice of a general nature.  This statewide guideline has been prepared to promote and facilitate 
standardisation and consistency of practice, using a multidisciplinary approach.  The guideline is based on a review of 
published evidence and expert opinion.  

Information in this statewide guideline is current at the time of publication.  

SA Health does not accept responsibility for the quality or accuracy of material on websites linked from this site and does not 
sponsor, approve or endorse materials on such links. 

Health practitioners in the South Australian public health sector are expected to review specific details of each patient and 
professionally assess the applicability of the relevant guideline to that clinical situation. 

If for good clinical reasons, a decision is made to depart from the guideline, the responsible clinician must document in the 
patient s medical record, the decision made, by whom, and detailed reasons for the departure from the guideline. 

This statewide guideline does not address all the elements of clinical practice and assumes that the individual clinicians are 
responsible for discussing care with consumers in an environment that is culturally appropriate and which enables respectful 
confidential discussion. This includes: 

  The use of interpreter services where necessary, 
  Advising consumers of their choice and ensuring informed consent is obtained, 
  Providing care within scope of practice, meeting all legislative requirements and maintaining standards of 

professional conduct, and  
  Documenting all care in accordance with mandatory and local requirements 

 

 
Explanation of the aboriginal artwork: 
The aboriginal artwork used symbolises the connection to country and the circle shape shows the strong relationships amongst families and the aboriginal culture. The horse shoe shape 
design shown in front of the generic statement symbolises a woman and those enclosing a smaller horse shoe shape depicts a pregnant women. The smaller horse shoe shape in this 
instance represents the unborn child. The artwork shown before the specific statements within the document symbolises a footprint and demonstrates the need to move forward together in 
unison. 

 

     

 

 

 

 

 

 

Purpose and Scope of Perinatal Practice Guideline (PPG) 

The purpose of this guideline is to provide clinicians with information on the initial 
management of babies with cleft lip and/or palate. It includes details on assessment, transfer, 
feeding, referral and useful websites for parents. 

Australian Aboriginal Culture is the oldest living culture in the world yet 

Aboriginal people continue to experience the poorest health outcomes when 

compared to non-Aboriginal Australians. In South Australia, Aboriginal women are 

2-5 times more likely to die in childbirth and their babies are 2-3 times more likely to 

be of low birth weight.  The accumulative effects of stress, low socio economic 

status, exposure to violence, historical trauma, culturally unsafe and discriminatory 

health services and health systems are all major contributors to the disparities in 

Aboriginal maternal and birthing outcomes. Despite these unacceptable statistics 

the birth of an Aboriginal baby is a celebration of life and an important cultural 

event bringing family together in celebration, obligation and responsibility. The 

diversity between Aboriginal cultures, language and practices differ greatly and so 

it is imperative that perinatal services prepare to respectively manage Aboriginal 

protocol and provide a culturally positive health care experience for Aboriginal 

people to ensure the best maternal, neonatal and child health outcomes. 

 



South Australian Perinatal Practice Guideline 

Cleft Lip and Palate in the Neonatal Period 
 

 

 
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Flowchart: Initial management of babies with cleft lip and/or palate 

 

  



South Australian Perinatal Practice Guideline 

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Table of Contents 
 

Purpose and Scope of Perinatal Practice Guideline (PPG) ...................................................... 1 

Flowchart: Initial management of babies with cleft lip and/or palate ......................................... 2 

Table of Contents....................................................................................................................... 3 

Summary of Practice Recommendations .................................................................................. 3 

Abbreviations ............................................................................................................................. 4 

Definitions .................................................................................................................................. 4 

Background ................................................................................................................................ 4 

Antenatal diagnosis................................................................................................................ 4 

Neonatal Management .............................................................................................................. 4 

Transfer .................................................................................................................................. 5 

Feeding when cleft lip and /or palate is only problem identified ................................................ 5 

Cleft Lip (isolated) .................................................................................................................. 5 

Maternal preference for breast milk feeding ...................................................................... 5 

Maternal preference for formula feeding............................................................................ 5 

Cleft Palate +/- Lip ................................................................................................................. 5 

Maternal preference for breast milk feeding ...................................................................... 5 

Maternal preference for formula feeding............................................................................ 6 

Referral and Follow-Up .............................................................................................................. 6 

Advice for parents .................................................................................................................. 6 

References ................................................................................................................................. 7 

Additional Resources ............................................................................................................. 7 

Acknowledgements .................................................................................................................... 8 

 

Summary of Practice Recommendations  

Where there is an antenatal diagnosis of cleft lip and/or palate, antenatal counselling with a 

plastic surgeon experienced in cleft lip and palate surgery and a specialist in cleft lip/palate 

feeding is recommended. 

Following birth, babies should have a medical assessment to determine the nature of the cleft 
and any associated abnormalities or co-morbidities.  

Assessment of oxygen saturation using pulse oximetry should be undertaken soon after birth 
and repeated if clinically indicated. 

Consider extended pulse oximetry if there is any concern re upper airway obstruction. 

A feeding assessment by a professional experienced in feeding babies with cleft lip +/- palate 
should occur as soon as possible following birth. They should then initiate a feeding plan. 

Babies with isolated cleft lip can generally be nursed safely with the mother on the postnatal 
ward with routine postnatal care. 

The support of parents by professionals experienced in feeding babies with cleft lip +/- palate 
during the establishment of feeding is essential and has been shown to improve weight gain. 

Referral to and follow-up with the Australian Craniofacial Unit at the Women s and Children s 
Hospital is required. 

  



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Abbreviations   

ABR Auditory brainstem response 

EBM expressed breast milk 

g grams 

mL millilitres 

SaO2 Oxygen saturation 

Definitions 

Cleft lip A congenital opening or split in the upper lip. May be unilateral or bilateral. 

Cleft palate A congenital split or opening in the roof of the mouth. It can involve the hard 
palate and/or the soft palate. The opening allows communication between 
the mouth and nasal passages. 

Cleft lip/ 
palate 
feeding 
specialist 

A professional who has undertaken specific education and has experience 
in assessment of cleft lip and palate feeding issues: For example a speech 
pathologist, lactation consultant or nurse/midwife who has completed 
specific training. 

Background 

Antenatal diagnosis 

Cleft lip and/or palate occurs in approximately 1 per 800 births in South Australia. 

Whilst cleft lip and/or palate may be an isolated finding on ultrasound, it can be associated 
with other congenital anomalies or rare syndromes. Therefore, when a cleft lip and/or palate 
is diagnosed on ultrasound (usually at the 18-20 week morphology scan), referral for second 
opinion ultrasound with a subsequent Maternal Fetal Medicine appointment (+/- Clinical 
Genetics) should be made.  

Where there is an antenatal diagnosis of cleft lip and/or palate, antenatal counselling with a 
plastic surgeon experienced in cleft lip and palate surgery should occur1,2. 

Antenatal counselling with a practitioner experienced in feeding management for babies with 
cleft/palate should also occur. Mode of feeding (including benefits of breast milk versus 
formula) and anticipated feeding issues should be discussed3,4,5,6,7,8. Antenatal breastmilk 
expression can be encouraged if this is the woman s feeding preference. 

Neonatal Management 

Following birth, babies should have a medical assessment to determine the nature of the cleft 
and any associated abnormalities or co-morbidities2. 

Clinical assessment should also pay particular attention to possible airway compromise and 
associated breathing difficulties. Initial assessment of oxygen saturation using pulse oximetry 
should be undertaken, with a low threshold for repeating oximetry in the context of symptoms 
such as increased breathing effort, stridor or episodic dusky appearance.  

Consider an extended period (48 hours) of oximetry monitoring if there is any concern about 
upper airway obstruction or if oxygen saturation is less than 95%. If there is evidence of upper 
airway obstruction referral to paediatric respiratory medicine will be required prior to discharge 
home. 

  



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Transfer 

Issues identified that require admission to a level 5 or 6 neonatal nursery include: 

  Airway concerns (e.g. Pierre-Robin Sequence) 

  Prematurity (? 34 weeks gestation) 

  Birth weight (&lt; 2000g) 

  Other major congenital anomalies 

Note: Babies with cleft lip and/or palate may also require transfer to a facility with higher level 
neonatal services if there is no  in-house  professional support for feeding infants with cleft lip 
and/or palate (e.g. speech pathology, specialist lactation consultant, trained nursing/midwifery 
staff). 

Where a rural practitioner is uncertain whether transfer to a level 5 or 6 neonatal facility is 
required, guidance can be sought via the Perinatal Advice Line on phone 137 827. 

Feeding when cleft lip and /or palate is only problem identified 

Babies born with a cleft may present with a range of feeding difficulties according to the type 
and severity of the cleft6,7,8.  

Breastfeeding or breast milk feeding is encouraged for all babies.  

Establish maternal feeding preference. 

A feeding assessment by a professional experienced in feeding babies with cleft lip +/- palate 
should occur as soon as possible following birth. They should then initiate a feeding plan. 

Cleft Lip (isolated) 

In the majority of cases, the baby can be cared for safely with the mother on the postnatal 
ward with routine postnatal care.  

 
Maternal preference for breast milk feeding 

Try to facilitate a seal using the breast tissue close to the cleft (this may be easier if the cleft is 
facing down). Feeding and observations follow normal postnatal ward procedure, 

 
Maternal preference for formula feeding 

Bottle feeding may be commenced using a normal bottle and teat at standard volumes. 

Cleft Palate +/- Lip 

Suggested minimum length of stay is 5 days with routine postnatal care. 

With a cleft palate, the major difficulty is an inability to create sufficient negative intraoral 
pressure for effective feeding, thus reducing sucking efficiency. 

Breast milk feeding is encouraged as it is less irritating to the exposed nasal mucosa and 
gives some protection against otitis media with effusion2. 

The support of parents by professionals experienced in feeding babies with cleft lip +/- palate 
during the establishment of feeding is essential and has been shown to improve weight 
gain3,4,5,6,7. 

Babies usually require only small quantities of milk in the first 24 hours. Gentle finger feeding 
of the volume of breast milk able to be expressed, or 5 mL of formula where the intention is to 
formula feed, is safer than a squeeze bottle.  

Squeeze bottles should not be used until after a feeding assessment. 

 

Maternal preference for breast milk feeding 

Transfer of breast milk by suckling at the breast is rarely adequate where there is a cleft 
palate and the emphasis should be on maintaining lactation and providing expressed breast 
milk (EBM).   



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Where there is a strong maternal desire to continue to put the baby to the breast, this can be 
supported by providing top-ups of EBM. 

  Commence breast expression as soon as possible following birth (see Expressed 
Breast Milk: Safe Management and Administration in SA Clinical Directive and the 
Breastfeeding Perinatal Practice Guideline available at 
www.sahealth.sa.gov.au/perinatal for more information). 

  Expressing should be undertaken at least 7-8 times within a 24 hour period, including 
at night, until lactation is well established. 

  Feed with a 4 hour limit. 

  Give top-up feeds of expressed colostrum at the volume available (or 5mL formula) 
by finger feeds following all breastfeeds.  

  Following professional feeding assessment, feeding is either by breast with full EBM 
squeeze bottle top-ups or solely EBM via squeeze bottle (as agreed with mother, 
lactation consultant and/or cleft lip/palate feeding specialist) 

  Offer bottled EBM at the volume that can be expressed 

  Monitor weight gain and adjust feeding plan as indicated 

 
Maternal preference for formula feeding 

  Commence finger feeding with 5mL of formula per feed. 

  Following professional feeding assessment, a squeeze bottle and teat should be 
used. 

  Volume of formula should be determined as per routine recommendations for infants 
being formula fed. 

Referral and Follow-Up 

Includes: 

  Australian Craniofacial Unit at the Women s and Children s Hospital 
o Referral via fax number: 08 8161 7080 
o Surgery generally at around 3 months for cleft lip and 6 months for cleft 

palate (corrected age if born prematurely), depending on weight 

  General Paediatrician 

  Speech Pathology 

  Eye review 

  Consider microarray for isolated cleft palate  

  Other specialties as indicated (e.g. Clinical Genetics, Cardiology) 

 

Please note that direct audiology referral for diagnostic ABR is no longer required. 10 years of 
audiology data in South Australia revealed low rates of hearing loss among babies born with 
cleft palate using AABR methodology. 

 

Advice for parents 

Parents should be advised to seek medical attention if their infant shows signs of respiratory 
distress, such as tachypnoea, chest recession, noisy breathing or poor feeding. 

Note: parental education in resuscitation is suggested. 

 

 

  




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References 

1. Hartzell LD, Kilpatrick LA.  Diagnosis and management of patients with clefts: a 

comprehensive and interdisciplinary approach. Otolaryngol Clin North Am. 2014 Oct; 

47(5); 821-52  
2. Hsieh ST, Woo AS. Pierre Robin Sequence. Clin Plast Surg 2019 Apr; 46(2): 249-

259 

3. Scand J, Bergland AL. Mother s experience of feeding babies born with cleft lip and 

palate. Scan J Caring Sci. 2014 Mar;28(1); 66-73 

4.  Gallagher E, McKinney C, Glass R. Promoting Breast Milk Nutrition in Infants with 
Cleft Lip and Palate. Adv neonatal Care. 2017 Apri;17(2): 79-80 

5. Jones WB. Weight gain and feeding in the neonate with a cleft: a three centre study. 

Cleft Palate Journal 1998; 25:379- 

6. Maserei AG, Sell D, Habel A, Mars M, Sommerlad BC &amp; Wade A. The nature of 
feeding in infants with unrepaired cleft lip and/or palate compared with healthy non 
cleft infants. Cleft Palate Craniofacial Journal. 2007. 44(3): 321-328  

7. Shaw WC, Bannister RP, Roberts CT. Assisted feeding is more reliable for infants 

with clefts - a randomised trial. Cleft Palate Craniofacial Journal 1999; 36(3): 262- 

8. McGuire E. Breastfeed Rev 2017 Mar; 25(1): 17-23 

Additional Resources 

Information for Health Professionals: 

Australian Craniofacial Unit (based at the Women s and Children s Hospital) 

http://www.wch.sa.gov.au/services/az/divisions/psurg/craniofacial/index.html  

Australasian Cleft Lip and Palate Association Inc. 

http://www.cleft.org.au/  

 

Information for parents on cleft lip and cleft palate repair from: 

Australian Craniofacial Unit (based at the Women s and Children s Hospital) 

http://www.wch.sa.gov.au/services/az/divisions/psurg/craniofacial/acfu_patient_info.html 

Australian Government Department of Health 

https://www.healthdirect.gov.au/cleft-lip-and-cleft-palate 

Raising Children Network 

https://raisingchildren.net.au/guides/a-z-health-reference/cleft-lip-palate 

 

Information for parents on feeding infants with cleft lip and/or palate 

https://www.rch.org.au/kidsinfo/fact_sheets/Cleft_lip_and_palate_infant_feeding/  

https://www.rch.org.au/uploadedFiles/Main/Content/kidsinfo/cleft-lip-and-palate-infant-

feeding-booklet.pdf 

https://www.breastfeeding.asn.au/bf-info/cleft 

https://www.clapa.com/treatment/feeding/ 

 

Cleft Connect 

Cleft Connect Australia unites cleft affected families and individuals with one another, and 
with the professionals who can best assist them at all stages of their journey 

http://cleftconnect.org.au/  

  














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Acknowledgements 

The South Australian Perinatal Practice Guidelines gratefully acknowledge the contribution of 

clinicians and other stakeholders who participated throughout the guideline development 

process particularly:  

Write Group Lead 

Dr Vanessa Ellison 
 

Write Group Members 

Dr Jojy Varghese 
Dr Chad Andersen 
Dr Nigel Stewart 
 

Original PPG contributors 

Christine Frith 
Dr Marcus Nikitins 
Dr Scott Morris 
Professor David David 
 

SAPPG Management Group Members 

Sonia Angus 
Lyn Bastian 
Dr Elizabeth Beare 
Elizabeth Bennett 
Corey Borg 
Dr Feisal Chenia 
John Coomblas 
Prof Jodie Dodd 
Dr Vanessa Ellison 
A/Prof Rosalie Grivell 
Jackie Kitschke 
Dr Kritesh Kumar 
Dr Anupam Parange 
Rebecca Smith 

  



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Document Ownership &amp; History 

Developed by: SA Maternal, Neonatal &amp; Gynaecology Community of Practice 

Contact: HealthCYWHSPerinatalProtocol@sa.gov.au 

Endorsed by: SA Health Safety and Quality Strategic Governance Committee 

Next review due:  17/10/2024  

ISBN number:  978-1-76083-490-6 

CGSQ reference:  PPG014 

Policy history: Is this a new policy (V1)?  N 

 Does this policy amend or update and existing policy?   Y 

 If so, which version? V2 

 Does this policy replace another policy with a different title?  N 

 If so, which policy (title)? 

 
 

Approval 
Date 

Version 
Who approved New/Revised 
Version 

Reason for Change 

09/03/2022 V2.1 

Clinical Governance, Safety and 

Quality Policy Domain Custodian 
Change in Newborn Hearing 
Screening Program 
recommendations 

17/10/2019  V2 
SA Health Safety and Quality Strategic 
Governance Committee 

Reviewed 

18/10/2011  V1 
SA Maternal &amp; Neonatal Clinical 
Network  

Original SA Maternal &amp; Neonatal 
Clinical Network approved version. 

 



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