Cleft Lip and Palate
Cleft lip is a kind of facial deformity, often congenital in nature, which occurs as a small /wide split or gap in the upper lip since birth. On the other hand, cleft palate is the occurrence of a split in the roof of the mouth. Both, cleft lip and cleft palate, occur due to an improper joining of facial tissues during the development of the fetus in the mother’s womb.
In India, there are almost 1 million untreated cleft afflicted patients and every year almost 35000 infants are born with cleft lip and palate.
What are the Signs and Symptoms of Cleft Lip and Palate?
Usually, cleft i.e. a split in the lip or in the palate can be recognized easily at the time of birth. According to its physical manifestations, the types of cleft deformities of the lip are categorized as
- Forme fruste unilateral cleft – A gap or subtle split present on one side of the lip. It is not a complete cleft but it appears as an indentation in the upper contour of the lip of the affected individual.
- Incomplete unilateral cleft lip – When cleft is on one side of the upper lip but it doesn’t extend up to the nose.
- Complete unilateral cleft lip – When the cleft is on one side of the lip and the split extends into the nose/ nasal cavity.
- Incomplete bilateral cleft lip – When clefts occur on both sides of the upper lip but don’t extend up to the nose.
- Complete bilateral cleft lip – The clefts occurring on both sides of the upper lip and extends into the nose/ nasal cavity.
The different types of cleft palate deformities are –
- Incomplete cleft palate –cleft or split occurring in the soft palate/ back of the mouth
- Complete cleft palate –cleft or split occurring in both the hard and soft palate exposing the mouth and nose cavities to each other
- Submucous cleft palate –This involves cases where cleft involves soft and/ or hard palate and is covered by the mucous membrane and may be at times difficult to visualize, if not carefully examined.
In addition to the above signs (physical identification), other signs of cleft occurrence are –
- Stuttering, speech disorder and/ or impaired voice
The usual symptoms of cleft deformities are –
- Difficulty in breathing and speaking
- Feeding difficulties in new-borns and above
- Nasal congestion and inability to breathe through the nose
- Loss of hearing (in some cases).
Cleft Lip and Cleft Palate Causes
A particular reason for cleft deformities is still unknown. Although widely considered a congenital birth defect, cleft occurrences have also been observed in babies among couples with no history of similar deformity in both maternal and paternal sides. Among others causes cleft lip and cleft palate are linked to:
- Lack of optimum folic acid intake during pregnancy.
- Intake of steroids or anti-seizure medication in the early stages of pregnancy.
- Smoking or drinking alcohol during pregnancy.
As per latest studies among reasons for cleft palate and cleft lip, a defect in chromosome 22 – also referred to as the velocardiofacial/ DiGeorge syndrome – is a popular theory in this regard.
Diagnosing cleft lip and palate
In most of the cases, cleft lip and palate are identified right at the time of birth and hence doesn’t need any particular type of diagnostic test. In fact, a cleft lip can be noticed on ultrasound even before the birth of the child. Cleft palate, on the other hand, is difficult to detect through ultrasound.
Ultrasound before Birth
A ‘prenatal ultrasound’ can be conducted to detect the growing baby’s cleft deformity. For proper cleft lip identification, this test can be performed after the 13th week of pregnancy. If a cleft lip is detected after performing a prenatal ultrasound, the doctor may also perform another test by collecting amniotic fluid from the uterus as a sample. Through this test, it can be determined whether the cleft lip occurrence is congenital or not.
Problems Associated With Cleft Lip and/or Palate
Due to abnormality occurring in the joining of the lip and/ or palate, feeding a cl;eft baby becomes a concerning issue for the parents. In fact, while trying to feed food/ liquid often spills out from the mouth and enters the nose of the baby. So the parents have to be very cautious during feeding. Moreover, as cleft babies cannot feed fully they mostly suffer from malnutrition and if not intervened timely, it can be fatal. Specially designed feeding bottles and nipples for cleft babies are available that ensure the safe flow of the liquid down the food pipe without interfering with their breathing.
Trouble in Swallowing
Cleft babies often experience trouble swallowing food. Even when, the food intake is through specially designed feeding bottles and nipples, the food/ liquid can flow back into the nose causing blockage in the air passage. Babies with cleft palate deformities may need to wear an artificial palate protection cap to help them swallow food, without interfering with their breathing.
Improper Speech with a Nasal Voice
The untreated cleft palate can lead to speech problems resulting in nasal-voiced speech and/ or unclear vocal sound when the baby turns a little older. After cleft lip and cleft palate repair, speech therapy needs to be given to the patient so that he/she can speak clearly.
Prone to Ear Infections
Sometimes, cleft afflicted children are found suffering from ear infections. The accumulation of fluids in the middle ear blocks their auditory perception, and if not treated timely can lead to deafness. Even after cleft lip repair, the patient can experience such problems of ear, nose, and throat. That’s why regular check-up following clip surgery is essential to determine any problems occurring in the patient. If diagnosed on time, ear fluid build-up can be treated by doctors by draining off the fluid from the ear, thereby restoring hearing loss.
Cleft afflicted children commonly experience dental problems. Their dental problems can be varied; ranging from missing teeth, small teeth or extra teeth occurring as a result of cleft lips and palate (these are called supernumerary teeth) as well as teeth that are misaligned/ improperly formed resulting in tooth line deformity. Among other dental problems occurring in children with cleft lip and cleft palate are – gum (alveolar ridge) defects which can dislodge, rotate or tip a permanent tooth or prevent the new tooth from growing out properly. Children having clefts are also vulnerable to cavities and need orthodontic treatments.
Who Treats Children With Cleft Lip and/or Palate?
Cleft lip and palate deformities occur in the mouth (oral) and maxillofacial regions which have numerous nerve endings and muscles. Even the slightest of mistakes can become life-threatening for the patient and might cause a permanent damage. Thus, while conducting the surgical procedure to treat children with cleft deformities, specialists are deployed to address issues specific to the facial location where the cleft deformity has occurred/ extended. A team of physicians consisting of maxillofacial surgeons (plastic surgeons), oral wellness specialist (dentists), ENT specialist, anesthesiologists and other medical support staff work together to correct cleft lip and cleft palate through surgical means. A usual team consist of –
- Plastic Surgeon – To evaluate and participate in crucial surgeries on the lip and/or palate
- Otolaryngologist – An ENT (ear, nostril, and throat) specialist to assess treatment choices for hearing issues
- Oral Surgeon – To reposition segments of the higher jaw when necessary, to support, operate and to repair the cleft of the gum
- Orthodontist – To straighten and reposition the teeth
- Dentist- To perform constant dental care
- Prosthodontist – To make synthetic teeth and dental home equipment to enhance the appearance and to satisfy sensible necessities of the patient for eating and speaking post-surgery and recovery
- Speech Pathologist – To assess speech and feeding problems
- Speech Therapist – To work with the patient to strengthen his/her speech post-surgery or treatment
- Audiologist – A professional in communication problems stemming from a hearing impairment. They investigate and offer consultation for the betterment
- Nurse Coordinator – To provide ongoing supervision of the child’s health
- Psychologist – To aid any adjustment issues arising in the household of the child suffering from cleft lip and palate deformities
- Geneticist – To help parents with a genetic history of cleft occurrence understand the chances/ risk of getting a cleft appearance in their future progenies and counseling them for deterrence.
The healthcare crew works together to build a plan of care to meet the special needs of every cleft affected patient once they’re inducted into a comprehensive cleft care program.
Treatment for cleft lip and cleft palate
- A cleft lip may just require one or two surgical procedures depending on the extent of the deformity. The preliminary cleft lip surgery is more commonly performed by the time an infant is three months old.
- Repairing a cleft palate completely, requires a couple of surgical procedures spread over the period of 15-18 years. The very first surgical procedure to repair the cleft palate normally happens when the baby is between 6 and 12 months old. The preliminary cleft palate surgery forms a sensitive palate, decreases the possibilities that fluid will increase within the middle ears, and aids in the proper development of teeth and facial bones.
- Children exhibiting deformity of the jaw-line, occurring as a result of the cleft, may require a bone graft. However, that may only be done when the child attains 8 years of age. ‘Bone graft’ once done fills up the gum-line so that it can support permanent teeth and stabilize the upper jaw-line. As per findings, about twenty percent of children with cleft palate deformities, having undergone preliminary cleft palate surgery, require follow-up surgical procedures to improve/ correct their speech. Moreover, they might need dental braces to support their growing teeth and restore their dental composure and alignment.
- Additional procedures are recommended in the course of their growing years to close the openings occurring between nose and mouth, improve the appearance of lips and nostrils, and mend the final facial scars left by the preceding surgical operations of cleft lip and palates.
In a nutshell, after preliminary identification of cleft occurrence, the child’s health condition is thoroughly monitored, i.e. whether the child has proper body weight and is fit enough to undergo the cleft surgery procedure or not. If the cleft child is found to be suffering from nutritional deficiency and exhibits signs of physical weakness/ exhaustion, he/she is recommended for the nutrition program. Under the guidance of a nutritional counselor, the cleft child is fed with nutritional supplements; a few months of care results in health improvement. Once the child attains set parameters (proper weight and health condition), the surgery is conducted on the cleft child gifting him/her with a lifelong smile! A surgical procedure to correct a cleft lip is almost always carried out at 3-6 months and an operation to repair a cleft palate is regularly carried out at 6-12 months.
In this connection, the importance of a few other supportive procedures following up to the rectification surgeries is worth a mention.
Feeding Support -Cleft babies cannot feed normally like normal babies. As breastfeeding is of vital importance for the early development of a child, it becomes a necessity for the parents of a cleft child to learn the proper feeding technique to aid their cleft afflicted new-born in breastfeeding. Alternatively, a feeding bottle with an extended nipple designed to feed babies with cleft deformities is recommended by nutritionists.
Monitor Hearing -Newborns affected with cleft palates often suffers from ‘glue ear’ a condition in which there is a fluid build-up in the space of the middle ear behind the ear drum leading to loss of hearing and even to deafness. Close supervision (through auditory tests, ear exams) can help diagnose the problem. A grommet (a surgically implanted tube placed in the eardrum of the patient to drain off the fluid build-up in the middle ear) is used by ENT (Ear-Nose-Throat) physician to aid babies with glue ear.
Speech and Language Therapy -This recovery procedure is used as a follow-up to the cleft rectification surgeries. Once the cleft lip and palate surgeries are successfully conducted, the child recovers gradually. He/she, then, needs to be taught proper speech and pronunciation. Early intervention and speech and language therapy enable the speaker to learn fast by overcoming his/her difficulty occurring due to surgery. Gradually the child not only smiles like others of his/her age but also learns to speak properly without hesitation/ stuttering.