- Pediatrics
- Clinicals
Cleft Lip and Cleft Palate Features and Management
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- Revised on: 2020-07-25
Cleft lip and palate (orofacial clefts) refer to a part of facial defects that occur when a baby's lip or mouth does not form properly during the gestational period.
These disorders occur as:
- cleft lip [CL]
- cleft lip and palate [CLP]
- cleft palate [CP] alone
- median, lateral [transversal], oblique facial clefts
Prevalence
These defects are among the most common congenital anomalies. Approximately 1 case of orofacial cleft occurs in every 500-550 births.
From a genetic standpoint, cleft lip with or without cleft palate is distinct from isolated cleft palate.
Cleft lip more common in males, the cleft palate in females.
Although both can occur in a single-family, particularly in association with certain syndromes, this pattern is unusual.
Race
There is racial variation in the incidence of facial clefting. Among Asians, whites, and blacks, the incidence is 1.61, 0.9, and 0.31, respectively, per 1000 live births.
Clinical Findings
A cleft lip may be:
- unilateral or bilateral and
- complete or incomplete.
It may occur with a cleft of the entire palate or just the primary (anterior and gingival ridge) or secondary (posterior) palate.
An isolated cleft palate can involve only the soft palate or both the soft and hard palates.
It can be a V-shaped or wide horseshoe cleft.
A cleft associated with micrognathia and glossoptosis (a tongue that falls back and causes respiratory or feeding problems) is called Pierre Robin syndrome.
Among individuals with facial clefts-more commonly those with isolated cleft palate-there is an increased incidence of other congenital abnormalities.
The incidence of congenital heart disease, for example, is between 1% and 2% in liveborn infants, but among those with Pierre Robin syndrome, it can be as high as 15%.
Associated abnormalities should be identified in the period immediately after birth and before surgery
Problems associated with facial clefts include
1.Early feeding difficulties, which may be severe;
2.Recurrent serous otitis media associated with fluctuating hearing and language delays
3.Speech problems, including hypernasality and articulation errors
4.Dental and orthodontic complications.
Long-term management should ideally be through a multidisciplinary cleft palate clinic.
Gaining weight and preventing aspiration and ear infections are the most important parts of caring for neonates with a cleft during their first days and weeks of life.
Management of cleft lip and palate
Below is the most common treatment protocol presently used in most cleft treatment centers:
For a Newborn –
- Diagnostic examination
- General counseling of parents
- Feeding instructions
- Palatal obturator (if necessary)
- Genetic evaluation and specification of diagnosis
- Empiric risk of recurrence of cleft calculated;
Age 3 months
- -Repair of cleft lip and placement of ventilation tubes
Age 6 months
- Presurgical orthodontics, if necessary; first speech evaluation
Age 9 months
- -Speech therapy begins
Age 9-12 months
- -Repair of CP (placement of ventilation tubes if not done at the time of cleft lip repair)
Age 1-7 years
- -Orthodontic treatment
Age 7-8 years
- -Alveolar bone graft
Older than 8 years
- Orthodontic treatment continues Other surgical procedures can be performed in patients with severe clefts as necessary
Surgical therapy:
Closure of the CL is the first major procedure that tremendously changes children's future development and ability to thrive.
Variations occur in the timing of the first lip surgery; however, the most usual time occurs at approximately age 3 months.
Pediatricians used to strictly follow a rule of "three 10s" as a necessary requirement for identifying the child's status as suitable for surgery (ie, 10 lb, 10 mg/L of hemoglobin, and age 10 wk).
Although pediatricians are presently much more flexible, and some surgeons may well justify a neonatal lip closure, considering the rule of three 10s is still very useful.
Team for the multidisciplinary treatment of a child with an orofacial cleft includes the following specialists:
- Pediatrician
- Nurse practitioner
- Plastic surgeon
- Pediatric dentist
- Otolaryngologist
Other recommendations are:
Breastfeeding an infant with a cleft
In a case of an isolated cleft lip, the infant typically does not experience feeding problems beyond learning how to "latch on" to the nipple at the beginning of the feeding. Infants with cleft palate must squeeze the milk out of the nipple by compressing the nipple between the tongue and whatever portion of the palate that remains.
Massaging the breast and applying hot packs on the breast 20 minutes before nursing usually helps.
The mother should apply pressure to the areola with her fingers to help the engorged nipple protrude. She should hold the infant in a semi-upright, straddle, or football position. She should support the breast by holding it between her thumb and middle finger, making sure that the infant's lower lip is turned out and the tongue is under the nipple.
If the infant cannot hold onto the nipple any more, the mother can collect the remaining milk using an electrical or manual breast pump or by squeezing the breast with both hands and can finish the feeding with collected milk in a bottle.
The mother should increase her fluid intake (drink lots of water).
Feeding breast milk with a bottle particularly for infants with bilateral CLP, breastfeeding is not possible.
The mother can use a breast pump (an electric pump ensures the highest level of success).
Then, she can feed the baby with a bottle.
More upright or seated positions prevent the milk from leaking to the nose and causing the infant to choke.
Advise the mother to stop feeding and allow the infant to cough or sneeze for a few seconds when nasal regurgitation occurs. A palatal obturator may be used.