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Feeding-Facilitating Techniques for the Nursing Infant

With Robin Sequence

Edamil Nassar, M.S., Ilza Lazarinni Marques, M.D., Ph.D., Alceu Sergio Trindade Jr., D.D.S., Ph.D.,
Heloı́sa Bettiol, M.D., Ph.D.

Objective: To determine the effectiveness of feeding-facilitating techniques

in children with Robin sequence.
Setting: Hospital de Reabilitação de Anomalias Craniofaciais, University of
São Paulo, Bauru, São Paulo, Brazil.
Patients: Twenty-six children less than 2 months of age with Robin se-
quence, whose only cause of respiratory obstruction was glossoptosis. Thir-
teen infants were treated by being placed in the prone position (Group 1), and
13 were treated by nasopharyngeal intubation (Group 2).
Interventions: During hospitalization, the following feeding-facilitating tech-
niques were applied daily to all children: pacifier, massage to relax and anter-
iorize the tongue, long and soft bottle nipple with original or enlarged hole,
global symmetric position, rhythmic movement of the nipple during suction,
and insertion of the nipple on the tongue.
Results: During the first evaluation, Group 1 patients accepted 36.15 6 33.05
mL milk orally within a period of 44.62 6 42.94 minutes, whereas Group 2
ingested 20.00 6 20.51 mL milk within 30.38 6 25.77 minutes. A significant
increase (p , .01) in the volume of ingested milk was observed for the two
groups at hospital discharge after a mean treatment period of 10.7 days (Group
1: 63.46 6 22.58 mL and Group 2: 55.00 6 13.07 mL). The mean duration of
feeding decreased in the two groups, with a value of 21.54 6 7.18 minutes for
Group 1 and of 20.28 6 8.53 minutes for Group 2.
Conclusion: The results showed that feeding-facilitating techniques can fos-
ter oral feeding in infants with Robin sequence.

KEY WORDS: feeding, glossoptosis, methods, Pierre Robin syndrome

Robin sequence is a congenital anomaly characterized by
micrognathia, obstruction of the upper airways and a generally
U-shaped cleft palate (Gorlin et al., 1990; Singer and Sidot,
1992). In addition, glossoptosis is only one of the etiological
mechanisms responsible for breathing difficulties (Gorlin et al.,
1990; Singer and Sidot, 1992). Argamaso (1992) described the
following four types of respiratory obstruction: Type 1, ob-
struction caused by tongue displacement; Type 2, the tongue
Edamil Nassar is a Speech-Language Pathologist at the Hospital de Reabi-
litação de Anomalias Craniofaciais, University of São Paulo, Bauru, Brazil. Dr.
Marques is a Pediatrician at the Hospital de Reabilitação de Anomalias Cran-
iofaciais, University of São Paulo, Bauru, Brazil. Dr. Trindade Jr. is Professor
at the Department of Biological Sciences Faculdade de Odontologia de Bauru,
University of São Paulo, and Researcher at the Department of Physiology Hos-
pital de Reabilitação de Anomalias Craniofaciais, University of São Paulo, Bau-
ru, Brazil. Dr. Bettiol is a Pediatrician and Professor at the Department of
Pediatrics of Hospital das Clı́nicas da Faculdade de Medicina de Ribeirão Preto,
University of São Paulo, Ribeirão Preto, Brazil.
Submitted February 2004; Accepted December 2004.
Address correspondence to: Dr. Alceu Sergio Trindade Junior, Hospital de
Reabilitação de Anomalias Craniofaciais, Rua Silvio Marchione 3-20, Bauru,
São Paulo, Brazil, CEP:17012-900. E-mail atrind@fob.usp.br.
compresses the palate, which, in turn, occludes the airways;
Type 3, obstruction is caused by the contraction of the lateral
walls of the pharynx; and Type 4, sphincter contraction of the
pharynx. Type 1 is the most frequent form of obstruction in
Robin sequence and was found in 75.8% of cases in the study
of Marques et al. (2001). According to these authors, this type
of obstruction is most frequent in cases of isolated Robin se-
quence, with prone position and nasopharyngeal intubation be-
ing the definitive treatment in 75.8% of these patients. The
other three types of obstruction are more frequently found in
patients with Robin sequence associated with genetic syn-
dromes and correspond to cases with highly severe respiratory
and feeding problems, with tracheostomy and gastrostomy be-
ing frequently necessary to maintain open airways and feeding
tracts.
The infant with Robin sequence has not only breathing prob-
lems, but feeding difficulties as well. According to Wolf and
Glass (1992), respiratory obstruction leads to difficulties in the
coordination of suction, swallowing, and respiratory functions,
and glossoptosis impairs anteriorization of the tongue that is
necessary in order to obtain adequate suction. In addition, the

55
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56 Cleft Palate–Craniofacial Journal, January 2006, Vol. 43 No. 1
FIGURE 1 Infant with Robin sequence performing nonnutritional suc-
tion with a pacifier.
authors pointed out that a cleft palate favors a deficit in the
negative intraoral pressure necessary for efficient suction, as
well as nasal reflux of food.
The feeding difficulties of infants with Robin sequence often
prevent oral feeding. This fact frequently leads to the use of a
feeding tube, which increases the risk for the development of
pathological gastroesophageal reflux, as confirmed by Baptista
(1996), Monteiro (1997), Badriul and Vandemplas (1999), and
Marques et al. (2001).
Cruz et al. (1999) observed feeding difficulties in infants
with Robin sequence and reported that 37% of the patients
studied used a feeding tube for a period of at least 12 weeks.
According to these authors, the literature regarding strategies
favoring feeding of these children through the oral route is
scarce and heterogeneous, with wide variation in the proce-
dures and with no reports of a universal conduct being avail-
able.
Children with Robin sequence show a predisposition to gas-
troesophageal reflux due to a decline in intrathoracic pressure
triggered by the respiratory effort and aggravated by the pro-
longed use of a feeding tube (Dudkiewicz et al. 2000; Marques
et al., 2001). Therefore, the objective of the present study was
to determine the effectiveness of feeding-facilitating tech-
niques (FFTs) in nursing infants with Robin sequence by pro-
moting the discontinuation of the feeding tube, thus minimiz-
ing one of the etiological factors for the development of gas-
troesophageal reflux in Robin sequence.
MATERIALS AND METHODS
Patients
The study was conducted on 26 infants with Robin sequence
with Type 1 respiratory obstruction (glossoptosis only) 3
months of age or less, who did not present neurological in-
volvement, genetic syndromes (except for Stickler’s syn-
drome), or other malformations that could aggravate their gen-
eral clinical status. In 13 children, airways could remain open
only by placing them in the prone position (Group 1); the other
pg 56 # 2
FIGURE 2 Massage to stimulate anteriorization and relaxation of the
tongue of the infant with Robin sequence.
13 children underwent nasopharyngeal intubation (Group 2).
Group 1 was considered to be the low severity group, because
patients showed only mild breathing difficulties, whereas
Group 2 consisted of patients with highly severe breathing
difficulties who, in contrast to Group 1, presented crises of
cyanosis that improved immediately after nasopharyngeal in-
tubation. Patients with extremely severe respiratory obstruc-
tion, in whom airway maintenance was only possible by sur-
gical treatment (glossopexy or tracheostomy), and children
with other types of respiratory obstruction (Types 2, 3, and 4)
were excluded from the study due to their high complexity and
severity in terms of oral feeding, with many of them requiring
a feeding gastrostomy.
The infants were stimulated by FFTs eight times a day from
the first assessment to the time of discharge from the hospital.
In Group 2, FFTs were only started after nasopharyngeal in-
tubation (performed by a pediatrician) with improvement of
respiratory discomfort.
The FFT was performed prior and during feedings. The cri-
teria that indicated FFTs were established previously and are
described below.
FFTs and Their Criteria of Indication
Suction of a Pacifier
A pacifier was indicated by the need for strictly nonnutri-
tional suction in order to anteriorize the tongue, with no con-
cern about systematizing the type of pacifier, but rather to
adapt the infant to this type of suction (Wood and Kevill, 1970;
Wolf and Glass, 1992; Fig. 1).
Massage to Anteriorize and Relax the Tongue
For this massage, according to Wolf and Glass (1992), the
speech pathologist, using sterile and disposable gloves, carried
out postero-anterior movements on the tongue of the infant
with the small finger of his hand in order to anteriorize and
relax the tongue (Fig. 2).
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Nassar et al., FEEDING-FACILITATING TECHNIQUES FOR ROBIN SEQUENCE 57

FIGURE 5 Original hole.

FIGURE 3 Manual support to control position of the mandible of infant
with Robin sequence.
Original Hole
This procedure was applied in cases of absent or inconsis-
This is the hole introduced into the nipple by the manufac-
tent tongue displacement during suction, which impairs the
turer (which does not favor spontaneous dripping), with milk
maintenance of the bottle nipple on the tongue during nutri-
only being ejected as a result of the intraoral pressure exerted
tional suction, causing an accumulation of milk on the floor
by the baby (Fig. 5). This nipple was used in cases when a
of the oral cavity and, consequently, external draining of food.
smaller flow of milk was required, mainly during the gradual
All these factors impair the swallowing process.
transition period from tube to oral feeding, because uncoor-
dinated suction/swallowing/respiration is frequently observed
Support for Sustaining the Mandible
in nursing infants at the beginning of adaptation to this type
of feeding.
This maneuver was applied in cases of exaggerated lowering
of the mandible during nutritional suction (Fig. 3). The objec-
Criterion-Dependent Enlargement of the Hole
tive of this technique was to improve the effectiveness of seal-
ing and of the labial sphincter by manually pressing the man-
The hole of the nipple was enlarged in cases in which the
dible (Wolf and Glass, 1992).
infant already showed coordination between suction/swallow-
ing/respiration, but became tired or took more than 30 minutes
Type of Nipple
to ingest the volume of milk prescribed by the pediatrician
(Fig. 6). The hole was enlarged with a heated, needle-shaped
Food was administered using a soft, long latex nipple (Ger-
sharp instrument until measuring 1 mm in diameter.
ber Lillo Miniform, Gerber Products Co., Fremont, MI; Fig.
4).
Postural Change
It is important to note that hospitalized infants adapted to
other nipples only received the Gerber Lillo Miniform nipple
Placement of the baby in a global symmetric position was
when subsequent assessment revealed inadequate suction and
favored, with the upper limbs positioned along the midline,
swallowing due to the type of nipple used.

FIGURE 4 Gerber Lillo Miniform bottle (Gerber Products Co., Fremont, FIGURE 6 Criterion-dependent enlargement of the hole to 1 mm in di-
MI). ameter.
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58 Cleft Palate–Craniofacial Journal, January 2006, Vol. 43 No. 1

FIGURE 7 Maintaining infant with Robin sequence in a global symmet- FIGURE 8 Rhythmic movement of the nipple in the oral cavity during
ric position at the time of feeding. the nutritive suction of an infant with Robin sequence.

and the lower limbs and head semiflexed to facilitate alignment
of the baby as a whole (Wolf and Glass, 1992; Fig. 7). This
procedure was applied to nursing infants with Robin sequence
who showed a posture different from that cited above, espe-
cially in cases of hyperextension of the head that interfered
with the adequate process of swallowing and favored tongue
displacement.
Rhythmic Movement of the Nipple in the Oral Cavity
During Nutritional Suction
This technique consisted of sequential movements of the
bottle nipple on the tongue in the antero-posterior and postero-
anterior direction in order to favor the establishment of a rhyth-
mic pattern of suction/swallowing/respiration during nutrition-
al suction, minimizing excessive pauses and favoring longer
and more organized sequences of nutritional suction (Fig. 8).
Positioning of the Bottle Nipple Exactly on the Tongue
This strategy was used so that the tongue could remain un-
der the nipple even in the presence of glossoptosis (Fig. 9).
to and the discharge from the hospital and during the time of
hospitalization of the two studied groups.
Statistical Analysis
Differences in the volume of milk ingested and in the du-
ration of feeding between the first assessment at each infant’s
admission and the last assessment on the day of discharge were
used to determine the effectiveness of FFTs and were analyzed
by the paired t test. A Student’s t test was used to compare
differences in the volume of milk ingested and the duration of
feeding between Groups l and 2.
RESULTS
Mean age of the infants at the time of the first assessment
was 31.6 6 19.4 days, with 18 (69.2%) infants being fed by
the oral route, but not in a functional manner, and 8 (30.8%)
receiving food exclusively through a nasogastric tube. In 13
(50%) of the 26 individuals of the sample, the airways were
kept open by placing the child in the prone position (Group

Criteria of Feeding Functionality

In the present study, functional feeding was considered to

be present when the infant less than 3 months of age achieved
the following four established parameters: accepting a mini-
mum of 50 mL or 70% of the milk formula volume recom-
mended for a normal child of the same age (with the addition
of 5% to 7% glucose polymers and 3% to 5% medium-chain
triglycerides), exclusively by the oral route every 3 hours;
maintaining a duration of bottle feeding of 30 minutes or less;
adequately coordinating the functions of suction, swallowing
and respiration; and, finally, being free of complications such
as coughing, frequent choking, or cyanosis during feeding.
Data were recorded regarding volume of orally ingested FIGURE 9 Insert nipple of the bottle exactly on the tongue of the infant
milk and duration of oral feeding, measured at the admission with Robin sequence.
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Nassar et al., FEEDING-FACILITATING TECHNIQUES FOR ROBIN SEQUENCE 59

TABLE 1 Individual Values of the Volume of Orally Ingested TABLE 2 Individual Values of the Volume of Orally Ingested
Milk (V1) and the Duration of Oral Feeding (T1) of Group 1 Milk (V2) and the Duration of Oral Feeding (T2) of Group 1
(Prone Position) and Group 2 (Nasopharyngeal Intubation) (Prone Position) and Group 2 (Nasopharyngeal Intubation)
Patients at Hospital Admission Patients at Discharge

Group 1 Group 2 Group 1 Group 2

V1 (mL) T1 (min) V1 (mL) T1 (min) V2 (mL) T2 (min) V2 (mL) T2 (min)

90 50 10 15 100 30 60 10
40 30 50 60 40 15 70 30
60 90 20 60 70 10 60 20
0* 0* 30 30 60 25 55 20
30 120 0* 0* 50 25 60 20
30 60 60 60 60 30 15 10
50 30 0* 0* 100 25 50 15
100 120 0* 0* 95 25 50 40
0* 0* 0* 0* 55 20 60 15
0* 0* 40 45 40 30 60 20
30 40 15 45 70 10 55 20
40 40 30 60 50 15 60 30
0* 0* 5 20 35 20 60 15
26.15 6 33.05** 44.62 6 42.94 20.00 6 20.51 30.31 6 25.77 63.46 6 22.58* 21.54 6 7.18 55.00 6 13.07 20.38 6 8.53
* Unable to feed orally. * Mean 6 SD.
** Mean 6 SD.

1), and nasopharyngeal intubation was used in the other 13
(50%) patients (Group 2).
Suction and swallowing reflexes were observed in the whole
sample following the first assessment, but 23 (88.4%) infants
showed nonfunctional feeding at this evaluation, because they
did not achieve one or more of the four previously cited func-
tionality parameters. At admission, nine (33%) infants were
fed exclusively through a nasogastric tube.
At discharge, 24 (92.3%) infants were fed by the oral route
and 2 (7.6%) received part of the food through the oral route
and part through a nasogastric tube.
Table 1 shows the individual values of total volume of milk
ingested (V1) and duration of feeding (T1) reached at the time
of the first assessment. For Group 1, V1 5 36.15 6 33.05 mL
and T1 5 44.62 6 42.94 minutes. For Group 2, V1 5 20.00
6 20.52 mL and T1 5 30.38 6 25.77 minutes. There were
no significant statistical differences between groups.
Table 2 shows the individual values of total volume of milk
ingested (V2) and duration of feeding (T2) at the time of dis-
charge from the hospital, after a mean stimulation period of
10.7 6 6.7 days. For Group 1, V2 5 63.46 6 22.58 mL and
T2 5 21.54 6 7.18 minutes. For Group 2, V2 5 55.00 6
13.07 mL and T2 5 20.38 6 8.53 minutes. There were no
significant statistical differences between groups.
Comparison of the volume of ingested milk between the first
(V1) and the last assessment (V2) revealed a significant in-
crease from V1 to V2 (p , .01) for the two groups. On the
other hand, the duration of feeding did not differ significantly
between the two phases (T1 and T2), although a decline in
duration was observed for the last assessment. In this respect,
it is interesting to note the decrease in the standard deviation
for T2.
With respect to complications during feeding (cyanosis,
choking, aggravation of glossoptosis), a significant reduction
was observed between the first and last evaluation. At the be-
ginning, only 34.6% of the infants were free of complications
during feeding, whereas 65.3% had difficulties. At discharge,
84.6% of the infants fed without difficulties and only 15.3%
showed complications.
The percentages for frequency of use of each FFT for the
entire sample showed the following decreasing order: suction
of pacifier (applied to 100% of the sample), criterion-depen-
dent enlargement of the hole of the nipple (100%), positioning
of the bottle nipple exactly on the tongue (100%), use of the
Gerber Lillo Miniform bottle with a criterion-dependent in-
creased nipple hole during feeding (88.4%), postural change
(76.9%), rhythmic movement of the nipple in the oral cavity
during nutritional suction (73.0%), massage to relax and an-
teriorize the tongue (57.6%), support for sustaining the man-
dible (15.3%), and original hole (11.5%).
DISCUSSION
Despite the differences in the respiratory patterns of Groups
1 and 2, both groups showed a similar behavior in terms of
oral feeding acceptance at admission and discharge.
Interesting results of the present study are the increase in
the volume of milk ingested by the infant and the reduction in
the duration of feeding after a mean stimulation period of 10.7
6 6.7 days using FFTs. Comparison of the results between the
initial and final assessments by the paired t test showed a sig-
nificant increase in the volume of milk ingested by the infants.
The mean target was a minimum of 50.0 mL, with mean values
of 63.46 mL and 55.0 mL being reached by Groups l and 2,
respectively. In addition, a reduction in the duration of feeding
to a time considered to be functional was observed. Although
this reduction was not statistically significant, it was significant
from a clinical point of view, because the means reached were
21.54 minutes and 20.38 minutes for Groups l and 2, respec-
tively, with one of the objectives for the acquisition of func-
tional feeding being that the infants should complete feeding
within a period of 30 minutes or less. This is in agreement
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60 Cleft Palate–Craniofacial Journal, January 2006, Vol. 43 No. 1
with Clarren et al. (1987), Wolf and Glass (1992), and Arved-
son (1993), who reported that the duration of complete feeding
should not exceed 30 minutes to prevent excessive energy ex-
penditure and fatigue that, among other factors, might interfere
with weight gain by the baby.
The results obtained are close to the definition of functional
feeding established in the present study (i.e., oral ingestion of
at least 50 mL milk within a period of 30 minutes or less, with
the presence of coordination between suction/swallowing/res-
piration and without complications). These data indicate the
efficacy of the FFTs used in the present study, especially when
considering that the mean time of total stimulation until dis-
charge was only 10.7 days. This time is too short to attribute
the response to treatment solely to the neurological maturation
of the infant.
It is interesting to note that the sample was initially highly
heterogeneous in terms of the volume of milk ingested and the
duration of feeding. However, at the end of the study period,
the entire sample was much more homogeneous, as shown by
the decrease in the standard deviation values of the two pa-
rameters observed for the two groups. In addition, not only
the volume and duration, but also the type of infant feeding,
became more homogeneous because all patients of the present
study reached the condition of being fed by the oral route,
with none of them being discharged with exclusive tube feed-
ing. Final evaluation showed that 92.3% of the infants were
fed exclusively by the oral route and 7.6% only partially, with
feeding being complemented with a nasogastric tube.
The presence of complications during feeding was in agree-
ment with the findings of Bachega et al. (1985), Sher et al.
(1986), and Shprintzen (1992). The significant reductions of
complications suggested that FFTs resulted in greater safety
during the process of oral feeding.
In the present study, FFTs were found to be an important
contribution to the treatment of infants with Robin sequence
whose airways could remain open with the prone position or
by nasopharyngeal intubation for the acquisition of the ability
to feed orally.
CONCLUSION
The results of the present study demonstrated that infants
with Robin sequence and Type 1 respiratory obstruction,
whose airways could remain open with the prone position or
nasopharyngeal intubation, presented a significant increase in
pg 60 # 6
the volume of ingested milk at discharge after daily stimulation
with FFTs for a mean period of 10.7 days. The duration of
feeding at the end of the study was reduced from the initial
evaluation and, although this difference was not significant, a
more homogeneous feeding behavior with an increase in the
ingested volume and a reduction of feeding complications was
accomplished within an extremely short period of time, per-
mitting the discharge of these children with oral feeding.
Therefore, these data suggest that, within a context of in-
terdisciplinary action in Robin sequence, therapy based on
FFTs is an efficient method to improve the acceptance of oral
feeding and to prevent the prolonged use of a feeding tube.
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