Palliative care through single visit flexible feeding aid for an infant with Pierre Robin sequence: A clinical report

Pierre Robin sequence (PRS) is named after the French stomatologist who described the problems associated with newborn micrognathia. The phenomenon comprises the triad of mandibular micrognathia, U-shaped cleft palate, and glossoptosis. The developmental anomaly was originally classified as a syndrome but was reclassified as a sequence in 1982.[^1,2] PRS is a congenital condition involving a combination of micrognathia and glossoptosis with or without a cleft palate. PRS is considered as a nonspecific anomalad occurring either as an isolated defect or as a broader group of malformations.[³] Feeding problems are most commonly encountered with cleft anomaly which leaves the neonate with inadequate nutrition. This case report discusses an 18-day-old neonate with PRS rehabilitated in whom flexible feeding aid was provided.

CASE REPORT

An 18-day-old male neonate was referred with complaint of difficulty feeding on milk. The medical history revealed PRS. On extraoral examination, the neonate showed characteristic receded chin with bird face appearance [Figure 1]. Intraoral examination revealed a large U-shaped palatal cleft with healthy appearing gum pads [Figure 2]. Based on these clinical findings, treatment plan was made with the purpose of improving the functional ability (suckling) as an initial prosthetic rehabilitation with an immediate approach. The parents were consented before treatment execution.

Figure 1. Lateral view of neonate with Pierre Robin sequence

Figure 2. Intraoral occlusal view showing U-shaped cleft palate

A custom-made tray was fabricated using modeling plastic impression compound (DPI Pinnacle, Mumbai, India) [Figure 3]. The flanges of the compound tray were adjusted accordingly, and retentive holes were made across the custom-made tray. Vinyl Polysiloxane putty super soft (Affinis, Coltene Whaledent Pvt. Ltd. Mumbai, India) was used for impression; constant crying and intermittent suckling during the impression procedure created the desired tissue molding. The impression was evaluated for satisfactory coverage of the vestibule and defect [Figure 4]. Once the master cast was obtained, a wire framework was adapted over the vestibular area of the master cast leaving a U-shaped frame (holder and safety mechanism) extra to the cast in the anterior region, using a 21-gauge orthodontic wire. A Bio-plastic sheet (2.00 mm × 125 mm) was adapted to master cast using vacuum former machine (Biostar VI, USA) and extra border was trimmed leaving 3–4 mm of margins. Using the roll-on technique, 3–4 mm sheet borders were well-adapted over the wire framework [Figure 5]. The completed flexible feeding aid was tried, and satisfactory outcome was noted while feeding the infant [Figure 6]. Instructions were given to the parents regarding insertion, removal, and cleaning of the feeding aid. A regular follow-up of the patient was done after 24 h, 1 week, and monthly follow-ups were scheduled.

Figure 3. Custom made tray constructed using impression compound

Figure 4. Impression made with addition silicone for accurate reproduction of features

Figure 5. Feeding aid fabricated using biocryl sheet

Figure 6. Occlusal view of the feeding aid in situ

DISCUSSION

PRS is a congenital abnormality characterized by the presence of a combination of mandibular hypoplasia, glossoptosis, and clefting of the palatal bone.[^1,3] Reconstructive management of cleft lip and palate requires coordinated multidisciplinary care. Early surgical repair of the cleft lip and palate is the treatment of choice, but time of surgery depends on various vital factors including age and general health of the patient. Although various presurgical approaches to resolve feeding problems such as specially designed soft bottle with enlarged nipple were instituted, they appear not sufficient for large clefts. The palatal cleft interferes with feeding and causes regurgitation through nose. Infection of the nasopharynx is frequent. Otitis media may also be a consequence leading to hearing impairment or permanent deafness.[^4,5] Hence, the construction of the palatal obturator or a feeding plate is very important until the surgical correction of the defect is carried out.

Feeding obturator is a prosthetic aid that is designed to obturate the cleft and restore separation between the oral and nasal cavities. It creates a platform against which the infant can extract milk. It also facilitates feeding, reduces nasal regurgitation, reduces choking, and shortens feeding time.[^6,7] Prosthodontics care at primary level involves addressing feeding difficulties, and prevention of middle ear infections. However, multiple visits, increase laboratory time, and lengthy adjustment procedures were some of the drawbacks.[^6,8.⁹] This article presented an alternative, easy, and convenient procedure of flexible feeding obturator fabrication which overcame the drawback of traditional materials. There were added advantages of the new materials’ flexibility for ease of placement intraorally and delivering prosthetic feeding aid at single appointment. Feeding aid constructed maintains the rigidity and adaptability of flange of obturator around gum pad area. Finally, addressing such problem at initial stage helps to boost the rehabilitation process significantly.

CONCLUSION

The advantages of enhancing nourishment with proper feeding, allows a positive psychological impact on the parents. These

steps allow performing a definitive treatment in a more conducive way. The design of the feeding tube presented is easily cleanable permitting convenience of maintenance to the parents. The technique of fabrication involves use of routine dental materials.

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