Cleft Lip And Cleft Palate

Patient Education

This is a well known and a very obvious deformity that is detected at birth. The cause of this defect is abnormal embryology. In these conditions the right half of the face and the left half of the face do not meet in the midline as they should. In children, this leaves a gap or a cleft called Cleft Lip and Cleft Palate, if the gap is in the lip and palate respectively. In the case of the lip, there are 2 types of clefts - unilateral or on one side only right or left; or bilateral that is both sided lips have a gap. This defect may be also associated with a cleft of the palate in a few cases. In children with a cleft palate only, there are 3 types, but here there may be cleft of the anterior or the hard palate, or cleft of the posterior or soft palate or both. Cleft lip and cleft palate are often associated with certain genetic syndromes, but ~70% of cases, may occur without any underlying genetic disease. Maternal heavy alcohol use in pregnancy may also be linked to these disorders [1].

Problems

In the case of a cleft lip there is only the facial deformity, the child is able to take oral breastfeeds without much difficulty, grows well and has adequate nutrition. However, in children with cleft palates, the child is unable to suck well on the breast or the bottle and the milk given orally may accidentally enter the air passage instead of the food passage. This occurs since the palate is missing, the tongue cannot hit the palate and block the air passage when swallowing. Flooding of the air passage with milk will cause aspiration and may be life-threatening to a newborn. In these children, it is best to avoid breastfeeds, instead, the newborns are fed with a bottle and a long nipple, alternatively, the child is fed by a long spoon or a special container called Bondla that has a long beak to allow the milk to go directly at the back of the oral cavity and swallowing is easier. The feeding is initially done by a trained nurse, who in turn will teach the technique to the mother so that the child can be sent home from the hospital and can be fed at home. In some children, even though this may be difficult and dangerous, we pass a tube from the oral cavity into the stomach and the feeds are given by a syringe directly into the stomach, bypassing the oral cavity. These feeds are given by gravity and never to be forced by the piston of the syringe. The feeds are essential for the nutrition and weight gain in the child. These children are very prone to getting recurrent attacks of respiratory infections due to minimal aspirations of feeds into the air passage and thence to the lungs. Patients of cleft lip and cleft palate may also face speech difficulties [1]. Untreated or uncared for babies with cleft palates often are the doctor for failure to gain weight, poor nutrition, and recurrent infections.

Surgery and management

In children with the cleft of the lips, correction of the deformity is done at the age of 3 - 6 months. The repair is a very delicate surgery to bring the halves together with precise, fine sutures to give an almost invisible scar later in life. The child is kept in the hospital for a few days, feeds are begun the next day with plastic spoons to avoid any injury to the freshly sutured lip. Healing is usually excellent. In children with the cleft of the palates, surgery is done later since this is very major surgery and there may be considerable blood loss during the surgery. The ideal age of surgery in these cases is about 1 ½ years and the child remains in the hospital for a few days and is then sent home on a regular diet. The two halves of the palate are brought in the midline together with 2 or 3 layers of tough sutures so that they do not break apart. These patients may also require speech therapy to improve their speech [1].

Complications

In these surgeries, the most common is either infection or disruption of the sutures. In the case of the former, higher antibiotics are necessary, and in the latter, the repair is done again after a period of 6 months to allow the local tissues to heal before a fresh attempt to close the gap.