Hi everyone, welcome to the LactFact podcast, which highlights recent, clinically relevant research, policy statements, and protocols that you, as a practicing lactation professional, should know about. I am your host, Dr Anne Eglash. I am a board-certified family physician and breastfeeding and lactation medicine specialist at the University of Wisconsin School of Medicine and Public Health.

This podcast is written and produced by the nonprofit organization IABLE, which is the Institute for the Advancement of Breastfeeding and Lactation Education. There are no commercial funders for this podcast series.

Today’s Lactfact comes from the following article:

The Impact of Human Milk on Tympanostomy Tube, Hearing, and Speech Sequelae in Children With Cleft Palate

The first 2 authors are Hannah Piston and Noel Jabbour, Published in the Cleft Palate Craniofacial Journal in 2025.

As background the authors state that children with cleft palate with or without cleft lip have a unique set of challenges that put them at risk for speech and language disorders. For example they are very prone to otitis media with effusion which can be accompanied by hearing loss, which then negatively impacts their speech and language development. This is because the middle ear does not aerate very well among children with cleft palate. Typically these children have myringotomy tubes, which are tubes placed in the ear drums to alleviate and prevent fluid build up in the middle ears. Those of us in clinical practice have experience seeing toddlers with a history of chronic middle ear fluid who really take off with their speech skills after they have tubes placed.

There is strong evidence that breastfeeding or receiving human milk decreases the risk of ear infections. The duration of breastfeeding matters- infants who breastfeed for 4-6 months have twice the risk of recurrent ear infections as compared to those who exclusively breastfeed for at least six months.

The decreased risk of OM during breastfeeding is probably mediated by secretory IGA, which is the main antibody in breast milk, and by human milk oligosaccharides which prevent adhesion of at least 2 key bacteria that cause ear infections, hemophilus influenza and strep pneumonia.

Children with cleft palate are at high risk for acute ear infections, but also chronic fluid in the middle ears, known as otitis media with effusion (OME). The authors cite 1 study that identified a lower risk of OME among infants receiving human milk, and a lower risk of having myringotomy tubes placed before 24 months of age, compared to those who received no human milk.

In this study we're going to be talking about human milk feeding rather than breastfeeding among the study infants because most babies with cleft palate cannot generate enough vacuum to remove milk from the breast directly and need to have milk expressed and fed to them in a specialty bottle.

The authors in this study hypothesized that human milk feeding would result in 1)decreased prevalence of abnormal hearing exams before and after myringotomy tube placement, 2)decreased number of tubes placed over time, and 3) better speech and language outcomes at two and five years of age.

This is a retrospective cohort study, which means they reviewed medical records of 319 patients who were born between April 2005 and April 2015 who were cared for at the cleft craniofacial clinic at Pittsburgh School of Medicine, and who met their criteria. They had several exclusions, such as infants who had their cleft repaired at an outside hospital or who had other reasons for hearing loss such as aural atresia. They also excluded babies who had no record of feeding history.

Demographically 95.5% of these children were white, 13.5% had a genetic disorder and 21% had Robin sequence. 49% had isolated cleft palate, approximately 34% had unilateral cleft lip and palate, and 16% had bilateral cleft lip and palate.

Among these 319 patients, 45% received some human milk, and among these infants, 45% received HM for at least three months and 23% received HM for at least six months. The infants who received any HM were more likely to have private insurance as compared to those who did not receive HM.

Just about all infants received myringotomy tubes. Most were placed before palate surgery, and the minority placed during or after palate surgery. Fluid in the middle ears was measured by doing tympanograms. Abnormal tympanograms were found in at least one ear in 99% of children who received no HM and in

85.2% of infants who received any amount of HM

81% among those who received HM for at least 3 months

and 69% of children who received HM for at least 6 months.

The children who did not receive human milk were more likely to have received 2 or more sets of myringotomy tubes by age 5 compared to those who received HM for at least 3 months. The age of last tube placement was younger among those who were fed human milk versus those who were not.

In terms of hearing screens:

30% of newborns with cleft palate did not pass their newborn hearing screen. These infants underwent repeated hearing screens before undergoing palate surgery. The infants who received HM for at least three months were less likely to have abnormal follow-up hearing tests before having tubes placed. 77.8% of children who received human milk for at least 6 months had bilateral ME effusions at first tube placement compared with 93.3% of children who received no human milk.

In terms of speech and language development,

At 2 years of age, 52% of those who received any HM had a speech language delay compared to 64% of those who received no human milk.

At five years of age speech and language delay was present among 5% of those who received any amount of human milk versus 16% of those who did not receive human milk.

So the bottom line is that infants with cleft palate greatly benefit from human milk feeding because they have less fluid in their middle ears, they are at less risk of acute otitis media which means not having to be on antibiotics as much, and experiencing less inflammation in their middle ears. They also are less likely to have recurrent tubes placed which can cause chronic scarring and other complications of the eardrums. This all translates into less chronic hearing loss and improved speech and language development over time.

Hopefully craniofacial healthcare teams discuss infant feeding with their families and share that their babies will have better hearing, speech and language outcomes if they provide human milk. These mothers and other lactating parents need a lot of support because they will need to pump and bottle feed until at least palatal surgery is complete, and possibly beyond.

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