What is a cleft lip?
A defect in the lip leading to a gap in the lip is called as cleft lip. It is usually a birth defect and can be seen in 1 in 700 people at time of birth.
Why does cleft lip occur?
Though the exact cause why a cleft lip occurs is not known, it is suspected that certain genetic and external causes can lead to clefting. Use of anti seizure medications, smoking during pregnancy and various genetic disorders have been associated to cleft lip.
What is cleft palate?
A gap in continuity of either the hard palate or the soft palate is called as cleft palate. It can occur isolated or along with cleft lip. It is seen in about 1 in 1000 live births. The exact cause is not known but similar genetic and external causes are suspected as in cleft lip.
What are the types of cleft lip and cleft palate?
Cleft lip can be incomplete (only cleft of lip is present) or complete (lip as well as jaw underneath has a cleft). Cleft lip can be one sided on either right or left or may be on both sides. Cleft palate can involve the hard palate or soft palate or both soft and hard palate. Sometimes cleft may only be submucosal (a small hole in the back portion of the palate). Cleft palate can lip can co-exist together.
What are the symptoms of cleft lip and cleft palate?
Figure 1: Cleft lip and palate
Patients with cleft lip and/or cleft palate may present with obvious noticeable defect. Occasionally babies with cleft soft palate or submucosal cleft may have nasal voice or may have milk regurgitating though nose when they vomit.
What is the treatment of cleft lip and cleft palate?
The treatment of cleft lip and cleft palate is obviously surgical closure of the gap. When to do the surgery is of the most paramount importance. Surgery should be timed such that the child can achieve normal speech, normal hearing and optimum development of the face. Normally cleft lip is repaired at around 2-3 months of age. Cleft palate is usually operated around 1 year of age (surgery is usually done before child learns to speak) so that child can articulate properly.
Sometimes a child with cleft palate may need multiple surgeries to ensure adequate cosmetic, speech and facial development.
What are the long term outcomes seen in a patient with cleft lip and cleft palate?
Patients with cleft soft palate tend to have middle ear problems due to disruption in the Eustachian tube (tube that connects middle ears to the nose). Thus, they can have middle ear fluids, hearing problems and recurrent episodes of ear infections (otitis media). This can lead to significant delay in speech and language development if closure is not done early. Unrepaired cleft can lead to articulation problems and faulty speech. Nasal tone to voice occurs.
Defect in tooth development can occur and patients can have either multiple teeth (at same area), peg shaped teeth, absent tooth or missing tooth if the upper jaw is also having a cleft. Thus children with cleft lip and cleft palate are move prone to get gingivitis (infection and bleeding gums), cross bite and crowding of teeth. They are at higher risk of dental caries. Thus orthodontic treatment may be needed along with the cosmetic surgery. Children may require palatal expansion to prevent crowding at 5-6 years of age. Once permanent teeth erupt, conventional braces and prosthetic tooth replacement may be needed.
If one child has cleft lip and/or cleft palate, what are the chances of other siblings being affected?
Cleft lip or cleft palate occurring due to a genetic problem or a syndrome have risk of occurring in next child to the same extent as the chance of that genetic defect or syndrome occurring in next child.
If more than 2 people in the family (cousin, aunt or uncle) are affected than chance of the next child being affected is 16%. If no genetic cause is identified and nobody else in the family is affected, the chance of recurrence in next child is 1-3%.
How can a baby with cleft lip or cleft palate be fed?
Poor feeding and inability to gain weight may lead to delay in lip closure till appropriate weight gain is achieved. Thus it is very essential to have adequate feeds. Generally children with cleft lip alone and children with isolated cleft soft palate have little trouble with breast or bottle feeding. However children with cleft lip together with cleft palate are unable to suck at either breast or bottle and thus seem to need mechanical assistance. “Bondla” feeds (feeding with a wide cut long spout spoon) (Figure 2) or cleft palate plastic squeezable bottle can help to control milk volume and flow rate.
Figure 2 - Bondla