Timing and Care for Patients with Cleft Lip and Palate

Three percent of neonates are diagnosed with congenital anomalies, with a delayed recognition of more subtle anomalies raising the incidence to 7 to 10% by five years of age. Facial clefting represents the most common facial congenital anomaly. Patients born with cleft lip and/or palate have a wide range of needs depending on the severity of the clefting. While most clefts are isolated events and independent of syndromes, the needs of a patient with an isolated cleft palate can require the attention of multiple subspecialists. Additionally, there exist more than 300 syndromes that may be associated with facial clefting. For these reasons, patients born with cleft lip and/or palate are best treated by using a multidisciplinary team approach (Figure 1). In addition to requiring multiple subspecialists, the correct timing that these subspecialists provide care is imperative as well (Figure 2).

Figure 1. Multidisciplinary team approach

Figure 2. Cleft patient treatment timeline (click for larger image)

Timing of treatment for a patient with a cleft lip and/or palate greatly depends upon the individual's needs. However, there are generalized functional needs that dictate patient care at various stages of life. These functional needs include an emphasis on growth and feeding in the newborn, followed by a shift towards speech development and, lastly there is an emphasis placed on dental and skeletal growth and alignment.

Figure 3.

In the setting of a child born with a cleft palate, an important first goal is to teach the family how to properly feed their child. Because the newborn is unable to suck, feeding a cleft palate baby can be frustrating and cause anxiety for the family. The speech therapist often plays the largest role in educating the family on feeding and introduces nursing bottles designed for cleft infants

(Figure 3). Additional team members that are important in the early stages of treatment include the geneticist, who evaluates the newborn to rule

Figure 4.

out other anomalies or syndromes and provides accurate genetic counseling for the family. Emphasis of treatment on proper feeding ultimately allows for good nutrition and healthy growth of the infant. This in turn allows for safer surgical correction of the cleft anomaly. Ideally, the cleft surgeon should evaluate the patient in the first week of life in order to determine if the newborn would benefit from other interventions, such as nasoalveolar molding. Nasoalveolar molding (NAM) is initiated within the first weeks of life and narrows the cleft through passive molding of the alveolus (Figure 4). Classically, infants with a cleft lip and palate undergo surgical correction of the cleft lip around three months of age and surgical correction of the cleft palate around nine months of age (Figure 5). Therefore, the cleft surgeon also plays a large role in the child's first year of life.  Other important issues include possible placement of ear tubes in cleft palate children, who are more

Figure 5.

susceptible to chronic otitis media.

  

Speech development becomes the next functional goal emphasized in patients with cleft palates. Early evaluation of the child's hearing is important in order to allow for proper speech development; this often involves care provided by an audiologist and an otolaryngologist. Speech therapists, again, are important team members in this period of the patient's life, which spans for the first decade. Pediatric dentist become involved in the dental hygiene of the patients, which is crucial for proper cleft care. If velopharyngeal insufficiency (VPI) exists, and intense speech therapy has failed, the cleft surgeon may perform surgical repair of the VPI. VPI surgery is often performed around age four to five, after time has been allowed for adequate speech therapy, but before school matriculation occurs. Additionally, aesthetic revisions of the cleft lip repair or needs to surgically address mild nasal tip deformities are also performed before the child matriculates through school.

Figure 6.

After approximately age eight and extending into adulthood, the emphasis of care shifts toward dental and facial skeletal alignment (Figure 6). The pediatric dentist, orthodontist, oral surgeon, and cleft surgeon all actively participate in the treatment plan. The treatment plan requires careful coordination of the patient's needs that may include placement of dental expanders, surgical bone grafting of the alveolus, alignment of teeth with orthodontic devices, alignment of the skeletal bones through distraction or orthognathic surgery and correction of nasal obstruction through rhinoplasty surgery. Major surgeries correcting the facial skeleton and nose are reserved until the patient has reach mature facial skeletal development. Therefore, while the patient's needs are complex, taking a multidisciplinary team approach and utilizing a team coordinator who oversees the collaboration of the multiple subspecialists, provides the best means of providing excellent cleft patient care.

About Dr. Patel...

Assistant Professor

Director, Facial Plastic and Reconstructive Surgery 

  M.D./Ph.D: Medical College of Georgia

Residency: University of North Carolina,

Chapel Hill

Fellowship: University of California, Davis 

Special interest: Facial plastic and reconstructive surgery, cleft lip and palate repair, facial trauma

 Read more about Dr. Krishna Patel