Polly Ubben, a speech pathologist with Saint Elizabeth Regional Medical Center in Lincoln, NE, was our featured speaker during the month of July.  She shared information regarding swallowing, speech and language information, and information relating to cleft lip and palate.  Following is a synopsis of the information presented at our July 20, 2000 meeting.

       Swallowing is made up of three phases: the oral phase, the pharyngeal phase and the esophageal phase.  The oral phase involves the chewing and preparing of the food and liquid for the swallow.  The pharyngeal phase involves the transfer of the food/liquid from the mouth down through the pharynx (throat) to the entrance of the esophagus.  The esophageal phase is the transfer of the food/liquid down the esophagus into the opening of the stomach.  The oral phase takes approximately one second, as does the pharyngeal stage.  The esophageal stage takes approximately 12-15 seconds to empty into the stomach.

       When considering the difficulties related to cleft palate, the affected stage is the oral stage.  The most immediate difficulty is creating suction to be able to effectively suck a nipple or breastfeed.  Negative air pressure is required to pull the nipple into the mouth and effectively "milk" the nipple/breast.  The primary reason that a baby with cleft palate has such difficulty creating negative air pressure is due to the fact that the soft palate does not close off the nasal cavity.  The soft palate moves up and back to close off the entrance into the nose from the pharynx.  If this structure is not able to close off this cavity, it is extremely difficult to create suction.

       Polly demonstrated this difficulty by viewing a modified barium swallow test done on an infant with a cleft palate using a regular Nuk nipple.  In viewing this test, it was easily seen how little the baby was able to swallow using this "traditional style" nipple, and how hard the infant was working to get anything to eat.  Even enlarging the hole in the nipple was unsatisfactory for providing adequate nutrition.  Polly also demonstrated a normal swallowing pattern during sucking.

        Polly discussed some of the options of feeding when a cleft palate was available, including the Pigeon Nipple, Haberman and Mead Johnson systems.  She also discussed one of the pitfalls in the hospital for being able to provide consistent care.  One of the problems in the hospitals is that she provides education and training to families regarding a specific feeding method, then the baby goes to the nursery.  The nurses use a different method for feeding and instruct the parents to use something different.  This is a problem in most hospital settings and has to do with the limited amount of knowledge that nurses and other medical staff have about cleft lip and palate and feeding.  It is also due to the fact that nurses don't read the charts to see what type of feeding is being done with the infant.

       Polly then discussed information regarding speech and language.  She talked about how speech sounds are classified.  These three ways to classify sounds are 1)place, 2)manner and 3)voicing. 

       Place has to do with the location that the sound is being made.  For example, /p/ is made at the location of the lips, /t/ is made on the hard palate behind the front teeth. 

       Manner is the how the sound is made.  For example, /p,b/ is made by closing the lips to build up air, then releasing it.  This is known as a plosive.  Because it is made with the lips, it is known as a bilabial plosive.  Other sounds that require a buildup and release of air (plosives) are the /t,d,k and g/.  The /s,z,sh,dz, zh/ sounds are made by restricting the air into a turbulent sound, which is known as a sibilant.  The /f,v, th/ sounds are also made by restricting the air, but more forward in the mouth, and are known as fricatives.  The /k,g/ sounds are made at the back of the mouth by having the tongue come up and contact the soft palate, which also closes off the nasal port.  This is known as a velar sound.  The /m,n,ng/ are known as nasals, because they allow the air to go through the nose for a nasal sound.  These sounds are the easiest for children with cleft palate to make.  The other category is known as glides, which requires the tongue make the air go around it by slightly changing the shape of the oral cavity.  These sounds include the /ra, er, w, y, and l/.

       The other category for describing a speech sound is voicing.  It simply means either the voice is turned on or off to make a sound.  For example, the /v/ is a voiced fricative, whereas the /f/ is the voiceless cognate fricative.  So, the way a speech therapist describes sounds is by using these terms.  A speech therapist would describe the sound /d/ as a lingualveolar (place), voiced (voice) plosive (manner).

       Polly also discussed articulation (speech sound) errors common in children with cleft palate.  Any sound that requires a buildup of air to produce is often difficult before the palate is repaired.  These sounds include /p,b,t,d,k,g,s,z, sh,dz,zh,ch, voiced and voiceless th,f, and v/.  These 16 sounds require some degree of air pressure to produce.  Children should be able to produce all other sounds /l, er, ra, m, n, ng and all vowel sounds/.