Pediatric Cleft Lip and Palate
What is Cleft Lip and Cleft Palate?
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A cleft lip is a separation or opening of the lip. Sometimes this includes the base of the nostril and the upper jaw at the gum line. The palate is the roof of the mouth that extends to the back of the throat. There is a hard and soft portion of the palate. The hard palate separates the mouth from the nasal cavity. The soft palate is the muscular part that helps speech and swallowing. A cleft of the palate is an opening in the roof of the mouth in which the two sides of the palate did not join together. Clefts can be unilateral (a cleft on one side) or bilateral (a cleft on both sides). It is possible to have a cleft lip only, a cleft palate only, or a cleft lip and cleft palate together.
Occurrence of Cleft Lip and Palate
Clefts are among the most common birth defects and occur in 1 in 1,000 newborns. There is a 2 percent to 5 percent chance that parents of one child with a cleft will have another child born with a cleft. The risk of having a child with a cleft increases if there are other family members with clefts.
The lip segments usually join together during the seventh week of pregnancy and the palate usually closes by the eleventh week. When this process does not occur, the result is a cleft lip and/or cleft palate. There may be genetic or environmental reasons for the clefts, including:
- A genetic link is suspected when other family members have clefts
- Some clefts can be linked to certain syndromes
- 85% of cases of cleft lip with or without cleft palate are isolated and not related to other medical conditions.
- When a cleft palate occurs alone without a cleft lip, there is a greater likelihood that it is related to a syndrome.
It is recommended to have a genetic evaluation performed to identify possible causes, particularly if an additional anomaly is identified.
Treatment of Cleft Lip and Palate
There are no fetal treatments for cleft palates; however, your maternal-fetal medicine specialist, along with the pediatric plastic and reconstructive surgery team, will work with you to develop a coordinated delivery and postnatal treatment plan.
Once your child is able to eat, preparations for lip surgery are made, which is typically done at 3 to 4 months of age. Before surgery, the pediatric dentist performs nasoalveolar molding (NAM), a nonsurgical procedure that uses an oral splint and taping of the lip to make a wide cleft lip smaller and easier to repair. This device helps to reshape the lip, nose and palatal bones. When prenasal alveolar molding is completed, the child will be ready for surgery.
Typically around 12 months of age, your child’s palate repair is performed. Before surgery, your child's hearing will be checked. For infants with persistent infection or fluid in their ears, an otolaryngologist will place ventilation tubes before surgery. Most children remain in the hospital for at least a day following surgery or until they are eating and drinking well.
At 7 to 12 years of age, repair of the bony cleft in the child's gum ridge is typically performed. In this surgery, called an alveolar bone graft, bone is taken from the hip and placed into the gum ridge to create a solid area of bone for the adult teeth to grow into. Frequently, presurgical orthodontic work is necessary before bone grafting of the bony cleft. Children typically stay in the hospital for one night after the surgery.
The final step in treatment for cleft lip and palate involves surgery on the nose and midface, which is usually done when children have completed their growth (age 14 to 16 for girls and 16 to 18 for boys). Preparation for surgery at the midface often involves several years of orthodontic treatment. Nasal surgery is normally done following the midface bone surgery
All children with clefts of the palate have issues with speech and are enrolled in speech therapy at an early age. A cleft-specialized speech therapist will see the children annually at the cleft team visit to assess their progress with development and issues with speech. Additional therapy for children is also available through the schools if needed. Sometimes, additional surgeries for improving speech are recommended if the child continues to have poor speech following the cleft repair, but only after maximizing the speech therapy.
Cleft Lip and Palate Pre- and Post-Childbirth
Typically, there are no special requirements for delivering an infant with a cleft lip and/or palate. The team of physicians will work with you and your obstetrician to determine your delivery plan. However, you should select a hospital that is well prepared to assess your baby's needs and has a feeding specialist experienced in feeding infants with clefts. Some babies may be transferred to the neonatal intensive care unit for closer observation. Once the baby is born, the pediatric team will conduct a physical assessment to assure the baby has no other medical problems
Most babies with a cleft lip and cleft palate have difficulty breast-feeding due to poor suction and difficulty latching on to the breast. However, breast milk is encouraged and mothers are usually able to pump and feed using nipples specially designed for clefts. A feeding assessment is initiated while your baby is still in the newborn nursery. The feeding specialist can select the right system and establish a successful feeding program.
Long-Term Outcomes and Considerations
The Texas Cleft-Craniofacial Team meets monthly to evaluate each patient. The team is composed of clinical specialists, including plastic surgery, oral maxillofacial surgery, ENT or otolaryngology surgery, cleft orthodontist, speech therapy, nursing coordinator, and genetic counselors. Each patient is seen once a year to assess your child’s appearance, speech, dental needs, and overall wellbeing until full facial growth is achieved. This annual assessment allows you to see all the specialists that you need in one visit. It also allows the physicians to coordinate your care and determine the best clinical plan for your child.
Daniella Coca’s son Anthony was born with both a cleft lip and palate. Coca was five months pregnant when she received the diagnosis after a 3-D ultrasound, which afforded her and Anthony’s father several months to meet John Teichgraeber, M.D., and his team, determine a plan of action and better prepare themselves emotionally for the journey ahead.
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As Kenzie and Ricky attended their routine 18-week ultrasound, they expected everything to go smoothly; however, they received unexpected information about their baby girl, Macy.
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About the Host
Matthew Greives, M.D.
- Fellowship-trained in pediatric craniofacial surgery and Board Certified in plastic surgery
- Assistant Professor, Division of Pediatric Plastic Surgery at UTHealth McGovern Medical School
- Clinical interests include cleft lip and palate care and surgery, craniosynostosis, orthognathic surgery, neonatal airway surgery, craniofacial distraction and ear reconstruction
- Dr. Greives’ professional recognitions include the Huggins Surgical Research Symposium: Best Clinical Presentation (2011) and the ASPS Senior Resident Conference: Best Microsurgery Paper (2012)
- Member of the Texas Cleft-Craniofacial Team and Director of the Vascular Anomalies Clinic
Texas Cleft-Craniofacial Team and Pediatric Plastic Surgery Clinic
The University of Texas Health Science Center Professional Building
6410 Fannin, Suite 950
Houston, Texas 77030
Phone: (713) 500-7302
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