Pediatric Cleft Lip and Palate
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Dr. Matthew Greives discusses diagnosis and surgical treatment of cleft lip and palate in children:
What is a cleft lip/cleft palate?
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.
The lip segments usually join together during the seventh week of pregnancy and the palate usually closes by the eleventh week. When for some reason 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. A genetic link is suspected when other family members have clefts. Some clefts can be linked to certain syndromes. However 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 a good idea to have a genetic evaluation to identify possible causes, particularly if an additional anomaly is identified.
Clefts are among the most common birth defects and occur in 1 in 600 newborns. There is a 2-5% 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.
What is the treatment of cleft lip/cleft palate?
There are no fetal treatments for clefts. Surgical repair is done in two stages during the first year of life. The lip is repaired at 3-6 months of age and the palate is repaired between 10-12 months. The actual timing depends on the type of cleft, the child's growth and on the pre-surgical treatment plan. The lip repair is generally an outpatient surgery and the baby goes home the same day. Palate repairs require a 2-3 day hospital stay.
What special considerations should be made for delivery?
Typically there are no special requirements for delivering an infant with a cleft lip and/or palate. The Center 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.
Will I be able to breast feed?
Some 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.
What are the long-term outcomes and considerations?
The Cleft Team which includes pediatric plastic surgeons will periodically assess your child's appearance, speech and dental needs until full facial growth is reached. Speech therapy is usually needed following the palate repair and during primary school years. Prior to the development of the secondary teeth (age 7-9), the gap in the alveolar ridge (gum) will be surgically closed. Most children will need orthodontic braces, usually at the same age as many of their classmates. Depending on the severity of the cleft, some children may require secondary surgeries to improve appearance or function as they grow.
Contact The Fetal Center to make an appointment with a high-risk pregnancy doctor.
Note: This information regarding your condition is meant to be a helpful, informative introduction. Because every newborn is different, this may not be applicable to all cases, especially if there are additional defects. Your team of experts at the Center will provide you with information specific to your pregnancy.
Chronology of treatment
Our first concern is the infant's ability to eat, which we ensure through the services of a speech therapist and, if necessary, a pediatric dentist.
The speech therapist instructs parents in the use of various nipples; if the child is unable to eat with a nipple, the pediatric dentist constructs an obturator to seal off the child's cleft palate to improve sucking ability.
Once your child is able to eat, we make preparations for lip surgery, which is usually done at 3 to 4 months of age. Before surgery, the dentist will fashion an obturator with one or two nasal prongs to help reshape the flip, nose and palatal bones. When pre-nasal alveolar molding is completed, the child will be ready for surgery, which normally takes 2 to 3 hours.
The next step is palate repair, which is usually completed at 9 to 12 months of age. Before surgery, we will check your child's hearing. 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.
Repair of the bony cleft in the child's gum is normally the next step in treatment. Surgery is scheduled at 7 to 12 years of age. Frequently, pre-surgical orthodontic work is necessary before bone grafting of the bony cleft. Bone for the graft is usually taken from the child's hip. 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.
University of Texas Health Science Center Professional Building
6410 Fannin, Suite 950
Houston, Texas 77030
Plastic & Reconstructive Surgery Clinic: (832) 325-7234
Texas Cleft-Craniofacial Team: (713) 500-7302
Office Hours: 8:00 a.m. to 5:00 p.m. (Monday-Friday except major holidays)