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Cleft Lip and Palate in Children

Cleft Lip and Palate in Children - What it is

Cleft lip and/or palate (CLP) is one of the most common types of birth defects occurring in approximately 2 in 1,000 live births in Singapore. The most common type of cleft deformity is complete cleft lip and palate.

Most babies with cleft lip and/or palate are otherwise healthy with no other birth defects. Some babies who have clefts may have other medical conditions.

Cleft Lip and Palate in Children - Symptoms

Cleft lip and/or palate are congenital conditions characterised by an opening or split in the upper lip, the roof of the mouth (palate) or both, that are present from birth.

A cleft lip can be on one side (unilateral) or both sides (bilateral) of the upper lip. Cleft lip can occur alone, or can occur with a cleft palate. Similarly, a cleft palate may occur in isolation without a cleft lip deformity.

Unilateral Incomplete Cleft Lip
Unilateral Complete Cleft Lip
Bilateral Cleft Lip
Cleft Palate

 

Cleft Lip and Palate in Children - How to prevent?

Cleft Lip and Palate in Children - Causes and Risk Factors

The causes of CLP among most babies are unknown, but several factors have been known to increase risk such as genetics, the environment and certain drugs (phenytoin, isotretinoin). Most of the evidence points to a multifactorial cause. It is unlikely that parents did anything that would have directly caused a cleft.

Cleft Lip and Palate in Children - Diagnosis

Cleft lip can usually be diagnosed during the first trimester of pregnancy by a routine ultrasound. Isolated cleft palate is generally diagnosed after the baby is born, however, certain types of cleft palate (for example, submucous cleft palate) might not be identified until later in life.

Cleft Lip and Palate in Children - Treatments

Feeding

There is no single/ best method of feeding your baby. The principles to follow are to:

  1. Encourage your baby to learn normal reflexes such as sucking and swallowing
  2. Treat your baby as normal as possible if there are no further medical complications requiring special attention/management
  3. Prevent regurgitation

Typically, a combination of reflexes is used to achieve effective feeding. Two processes occur simultaneously. The first is the ability to create an adequate vacuum by creating a seal around the nipple/teat, and second, is the ability to position the tongue properly below the nipple.

Babies with a cleft usually have difficulty forming a good seal around the nipple to create a vacuum for suction. Fortunately, there are several ways of solving this problem:

  1. Assisted squeezable bottles for feeding
  2. Modified breastfeeding
  3. Spoon feeding

Upon referral to the Cleft Team, the Plastic Specialty Nurse will meet you to assess your baby’s sucking and swallowing skills in order to determine the most suitable mode of feeding for your baby (e.g., positioning, type of bottle and teat).

It is important to position your baby at a 45 degree angle in an upright position while feeding to prevent choking or having fluid flow back up through the nose. During and after each feed, you are encouraged to burp your baby more often than a baby that does not have a cleft. This is because your baby may swallow more air than normal during feeding.

It is normal for a newborn baby to lose up to 10% of their body weight within the first week. This lost weight is usually regained within 2-3 weeks. Your baby is considered well fed if he/she has 6-8 wet nappies a day, has regular bowel movements and is healthy and alert.

Cleft Lip and Palate in Children - Preparing for surgery

Cleft Surgery

Surgical intervention aims to:

  1. Repair affected structures and restore facial aesthetics
  2. Establish adequate function of the lip and palate
  3. Identification and treatment of other abnormalities

The treatment required for a child with a CLP depends on the severity of his /her condition. He /she may need several surgeries. Your child's Plastic Surgeon will explain your child's surgical plan to you.

Your child will be followed up with by a multidisciplinary cleft team from birth to adolescence, which usually comprises the following professionals:

  • Plastic Surgeon (Primary physician overseeing management of your baby’s care)
  • Clinical Coordinator
  • Plastic Specialty Nurse
  • Ear, Nose and Throat (ENT) Surgeon
  • Speech and Language Therapist
  • Orthodontist
  • Geneticist
  • Psychologist

Clinical Coordinator

The Clinical Coordinator helps to coordinate interdisciplinary care for your child. He/she conducts antenatal counselling and provides support to families expecting a child with a cleft.

Plastic Specialty Nurse

The Plastic Specialty Nurse is a Registered Nurse who specialises in the care of children with cleft and/or craniofacial anomalies. The nurse will work closely with you and your child by sharing information and assisting you with feeding techniques, and pre and post-surgery wound care management.

Ear, Nose and Throat (ENT) surgeon

Babies born with a cleft palate are more prone to have fluid build-up in the middle ear that may lead to ear infections, or some degree of conductive hearing loss. The ENT Surgeon assists with management of your child’s hearing, and may recommend draining the middle ear fluid by inserting ventilation tubes (grommets).

Speech and Language Therapist

The Speech Language Therapist (SLT) is responsible for the assessment, identification and management of communication disorders in individuals with cleft and/or craniofacial anomalies. The SLT will also provide advice as to the need for and timing of therapy, or surgical repair of the palate to facilitate speech if required.

Orthodontist

For newborn infants right after birth, the Orthodontist performs nasoalveolar molding (NAM) using a non-surgical device that helps to shape the gums, lip and nose. This prepare the babies for lip repair surgery by the Plastic Surgeon.

When your child is older (7-13 years old), orthodontists provide early orthodontic treatment to prepare your child for bone grafting at the nose and upper jaw areas.

For patients requiring jaw surgery, the orthodontist monitors them until they are skeletally mature (usually late teens and early adulthood), whereby they then commence orthodontic treatment in conjunction with jaw surgery.

Geneticist

A referral to a Geneticist for further genetic testing may be required to identify any underlying cause of the cleft. The Geneticist will then be able to counsel parents regarding the risk of clefting in subsequent children.

Psychologist

Your child may be referred to a Psychologist to support him/her and your family through any psychological and/or emotional stressors.

Recommended schedule for surgery

  • Cleft lip repair at 3 – 6 months
  • Palate repair at 6 –12 months
  • Speech surgery at 5 – 6 years
  • Alveolar bone grafting at 7 –13 years
  • Maxillary advancement (i.e., jaw surgery) at 17 year old and above
  • Secondary soft tissue surgery and/or rhinoplasty at 17 – 18 years

Preparation for operation

Your child will likely be hospitalised for three to five days. You may stay with your child throughout their hospitalisation.

We advise that you keep your child away from individuals who have cough, flu or other infections in the weeks leading to the operation. This reduces the chance that the surgery may have to be postponed in the event that your child is unwell. Your child will be admitted the day before the surgery at the Admission Office between 12pm to 2pm. You are required to bring along the KKH Admission Authorisation Form and your child’s Birth Certificate.

Your child’s Plastic Surgery Team will meet you in the ward to explain the surgical procedure in detail, discuss any worries you may have, and obtain your consent for surgery. If your child is planned to undergo multiple procedures within the same surgery (e.g., grommet insertion or dental extractions), the respective medical professionals will meet you as well.

An anaesthetist will visit you the day before the surgery to explain the procedure for undergoing general anaesthesia and instructions for fasting.

For general information about preparing your child for surgery, you may log on to: http://www.kkh.com.sg/patient-care/conditions-treatments/preparing-for-operation

Cleft Lip and Palate in Children - Post-surgery care

Your child may be offered a bottle of glucose water as soon as he or she is awake after Cleft Lip Surgery.

If your child had undergone Cleft Palate Surgery, this may be provided using a spoon/cup/spout feeder/syringe.

When he or she can tolerate clear fluids (e.g., water, glucose water) well, breast or formula milk may be given. Your baby will also be given fluids through an IV drip which may be removed once he /she is drinking well again.

Your child will be reviewed by the cleft team in the ward. The Plastic Specialty Nurse will teach you how to care for the surgical site. You will have to ensure that your child’s wound is kept clean. Further instructions will be given to you together with an educational leaflet.

After surgery, your child may be discharged only when his or her appetite has improved.

When to seek medical attention

  • Continuous bleeding / swelling / discharge seen from surgical site
  • Fever of 38.5°C and above
  • Not drinking / eating well

Follow up Care

Your child will need to return to the Cleft and Craniofacial Centre 7 days after surgery to be reviewed by his/her Plastic Surgeon.

Cleft Lip and Palate in Children - Other Information

Please write to: ccrc@kkh.com.sg or call: +65 63941521 (CCRC Counter)

The information provided is not intended as medical advice. Terms of use. Information provided by SingHealth

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