Workshop Nutrição HRAC-USP - Módulo 1

Main Ideas & Lessons Conveyed

• Context and purpose of the workshop (HRAC/USP + Smile Train) The video introduces a training workshop for healthcare professionals focused on nutrition and feeding in children with cleft lip and palate, starting with a module on breastfeeding guidance for these children.

Breastfeeding benefits (clinical, developmental, protective effects)

Breast milk is presented as beneficial across multiple body systems:

• Brain/cognitive development: studies cited as showing higher IQ and improved verbal/non-verbal reasoning.
• Metabolic health: described as protective (dose-dependent) against childhood and adult obesity, lowering risk of overweight, obesity, and type 2 diabetes.
• Gastrointestinal health: less fermentation and gas, helping prevent colic; contains prebiotics that support bifidobacteria colonization.
• Immune protection: described as protecting against common allergies (e.g., rhinitis) and reducing risk of infections (respiratory and gastrointestinal).
• Mother-child bond: breastfeeding is emphasized as reducing crying/anxiety and strengthening attachment, supporting emotional security.

Breastfeeding when direct breastfeeding isn’t possible

If direct breastfeeding fails for anatomical or practical reasons, the workshop emphasizes:

• Best-possible alternatives (formula or expressed milk),
• Ongoing support so caregivers don’t feel discouraged.

For vegetarian/vegan mothers:

• Breastfeeding can still provide benefits, but attention must be paid to maternal nutrient quality, especially vitamin B-complex and protein.

Nutrition content of breast milk (what’s inside and why it matters)

Rough nutrition profile per 100 ml:

• ~70 kcal
• ~51% lipids, 43% carbohydrates, 6% protein

Key components:

• Lipids: energy mostly from triglycerides; discussion of fatty acids (e.g., omega-3/omega-6) and downstream roles in inflammation and development.
• Carbohydrates: mostly lactose; mentions lactose intolerance scenarios and substituting carbohydrates (e.g., maltodextrin).
• Protein: described as highly bioavailable, so a smaller amount is needed.
• Vitamins/minerals: described as supporting immunity, bone/teeth formation, energy metabolism, and healing; specific vitamins highlighted include A, D, and B-complex.

---

Methodologies / Instruction Lists Presented

A) Breastfeeding hormonal physiology (how “success” is biologically driven)

• Prolactin

  • Released from the anterior pituitary.
  • Drives milk production.
  • “The more the baby nurses,” the more milk is extracted → next feeding has adequate supply.

• Oxytocin

  • Released from the posterior pituitary.
  • Promotes milk let-down/ejection.
  • Requires effective sucking and neuro-hormonal feedback pathways.

B) Breastfeeding stages and practical implications

• Colostrum: early primary milk (richer in proteins and immunoglobulins).
• Transitional milk: roughly between day 6–15 (more lipids, nutrients, minerals).
• Mature milk: begins around day 15 (nutrients/components maximized).

Exclusive breastfeeding recommendation

• Up to 6 months (no need for water or other liquids if truly exclusive).

C) Breastfeeding effectiveness criteria in infants with cleft lip/palate

Key concept: direct breastfeeding becomes harder when the cleft affects:

• Latch (nipple/areola grasping)
• Sucking effectiveness and negative intraoral pressure

Major success indicators:

• Adequate weight gain for age (most important)
• Infant well-being during/after feeds:
  • peaceful sleep and no intense crying
  • note: sleep alone isn’t sufficient (baby may be tired rather than successfully fed)
• Mother satisfaction and interaction
• Ongoing breast emptying (stress and engorgement can reduce effectiveness)

D) Positioning techniques to facilitate breastfeeding in cleft cases

General preparation

• Be in a quiet, pleasant environment
• Wash hands before feeding
• Express a small amount if nipples are very full to aid latch
• Observe breathing and swallowing to ensure comfort and safety

1) “Horseback/straddle” position

• Use pillows/supports.
• Support baby’s head while baby straddles on mother’s chest.
• Guide baby to open mouth → insert nipple and latch.
• Control breast with hand/finger; ensure mother comfort and baby breathing.
• Switch sides and offer the other breast in the same posture.

2) Reclining position

• Baby supported on bed/sofa with back supported.
• Baby placed prone/stomach between mother’s breasts.
• Offer one breast; support head; observe breathing and swallowing.
• Alternate breasts between feedings (right then left).

3) Forearm support / commonly used technique

• Mother uses pillows and supports baby on forearm.
• Keep hand to control so baby’s nose isn’t blocked.
• Place baby at breast as soon as mouth opens.
• Use positioning to help the fissure face downward (aimed at improving sealing/occlusion).
• Offer milk on the side of the fissure (with fissure facing down) and/or use cheek/occlusion strategies to improve suction and latch.

E) Expression of breast milk when direct breastfeeding is not possible

Manual expression

• Massage the breast along its length, especially where lumps are present.
• Loosen areas with fingertip pressure.
• Always express by the areola, never by the nipple to avoid cracks/fissures/trauma.

Mechanical expression (breast pumps)

• Electric pump: place, turn on, milk drains automatically.
• Manual pump: applies pressure/extracts milk; position may be adjusted to drain different areas.

How to use expressed milk (alternatives)

• Expressing is not only for storage—milk may be offered using bottle or cup/spoon, especially if breastfeeding is ineffective.

F) Bottle feeding guidance for cleft lip/palate (speech therapy approach)

Demystification

• Special nipples are not strictly necessary; recommended bottle features matter more.

Bottle/nipple characteristics

• Use a soft nipple (rubber/silicone type mentioned)
  • Avoid latex wear/tear; silicone lasts longer.
• Nipple shape can be universal or orthodontic.
• Choose the base (bulb) size based on:
  • baby’s mouth opening width
  • width of the cleft
• Select appropriate flow hole size:
  • too small → tiring
  • too large → choking risk
  • generally ~0.5 to 1 mm diameter (as stated)
  • aim for commercially available appropriate flow sizes if possible
• Nomenclature examples mentioned:
  • “M” (medium), “GD” (large), sizes for thickened liquids
  • “Number 3/4” for fast/extra-fast flow

Avoid air column

• Ensure the bottle bulb stays full of milk.
• Correct positioning so baby doesn’t swallow excessive air (prevents aerophagia and false satiety impression).

G) Speech therapy feeding physiology (reflexes and feeding safety concepts)

• Infants retain feeding-related reflexes:
  • rooting, swallowing, and protective reflexes (gag, cough).
• Feeding difficulty is mainly explained as:
  • cleft palate causing communication between nasal and oral cavities
  • inability to generate effective suction pressure

Common feeding events and responses:

• Nasal reflux during swallowing
  • reassure it’s usually not choking
  • manage by positioning baby elevated/semi-seated, not lying down
• Aerophagia (swallowing air)
  • watch discomfort signals
  • encourage burping
  • prolonged feeding times may occur; pauses to burp aren’t counted as wasted feeding time

H) Industrialized formulas: selection framework (nutritionist instructions)

When breastfeeding and expression fail:

• Use industrialized formulas appropriate for age and needs.

General starter (“0–6 months”)

• Conform to Codex Alimentarius (as stated).
• Described as:
  • similar calorie density to breast milk (~0.6–0.7 kcal per 100 ml)
  • carbohydrate base: lactose + added maltodextrin
  • slightly higher protein than breast milk due to different digestibility
  • vegetable fat to improve digestibility
  • added components mentioned: DHA/arachidonic-type constituents to support development and immunity
• Dilution example: 13% dilution (e.g., 1 scoop per 30 ml water)

Follow-on formulas (“6 months to 1 year”)

• “Number 2” formulas
• Slightly higher iron; similar nutrient aims
• Dilution stated as 15% (example: typical instruction given for scoop ratios)

Special formulas

• Lactose-free: lactose removed, replaced with maltodextrin
  • dilution 15%
• Anti-reflux: starch thickening strategy (pre-gelatinized rice/corn starch)
  • dilution 15%
• “Transition” at 1 year: shift toward cow’s milk alternatives or transition formulas (“number 3” described)
  • cow’s milk discussed as having low iron/linoleic acid/vitamin E and higher sodium/potential digestive load

Cow’s milk protein allergy

Stepwise approach described:

1. Extensively hydrolyzed formulas first (peptides; dilution ~15%)
2. If not tolerated: amino-acid formulas (free amino acids; dilution ~15%)

(Brand names were provided as examples, not endorsements.)

High-calorie concentrated approach for feeding-limited infants

• Mentioned for cleft-related small-volume tolerance (e.g., babies taking ~60 ml instead of 150 ml).
• Option: ready-made hypercaloric formulas (example given).
• If not affordable: build a high-calorie diet by adding:
  • glucose polymers
  • MCTs with essential fatty acids (AGE)
  • concentrating the underlying formula as needed

Titration schedule (multi-day ramp)

• Day 1: 3% glucose polymers + 1% MCTs
• Day 3: 5% polymers + 2% MCTs/AGE
• Day 5: 8% polymers + 3% MCTs/AGE
• Maximum targets:
  • polymers up to 10%
  • MCTs/AGE up to 3%

Safety warning

• Avoid prolonged overfeeding.
• Overfeeding risks listed:
  • hyperglycemia, hyperuricemia, hypertriglyceridemia
  • respiratory/liver issues
  • negative immune effects

I) Supportive care principles (caregiver counseling emphasized)

Healthcare professionals should:

• Provide lactation/breastfeeding support regardless of caregiver decisions
• Offer alternatives (expression, different feeding methods, or formulas)
• Post-operative feeding strategy:
  • use non-suction utensils (cups/spoons) to reduce stress and support appropriate feeding mechanics later

---

Speakers / Sources Featured (as named in the subtitles)

• Cristiano Flanela (surgeon; introduced the workshop)
• Suely Prieto de Barros (Nutritionist at USP HRAC; coordinator/host for nutrition module)
• Dr. Maria Júlia Costa de Souza Vilela (physician/immunology clinical aspects of breast milk benefits)
• Armando (nurse at Centrinho Hospital in Bauru; breastfeeding mechanics/hormones/positions and cleft-specific considerations)
• Aline Coracini Miguel (speech therapist; bottle/nipple adaptations and suction mechanics)
• Rosana Prado (speech therapist; feeding dysphagia/reflexes, reflux/aerophagia, cleft-palate physiology)
• Telma (lactation consultant; nipple hole-piercing tools/methods for feeding)
• Bruna (nurse; demonstration of manual vs mechanical milk expression)
• Nurse Maila (nurse referenced as presenting main breastfeeding positions)

Also referenced:

• Aline (appears later in the speech therapy segment; may refer to Aline Coracini Miguel)

Institutional sources mentioned

• Smile Train
• Hospital for Rehabilitation of Craniofacial Anomalies (HRAC/USP), Bauru
• World Health Organization (WHO)
• Ministry of Health (Brazil) (exclusive breastfeeding until 6 months)
• Codex Alimentarius
• Brazilian Society of Pediatrics