Cleft lip and palate are congenital conditions that affect a child’s facial and oral structure. They occur when the tissues of the lip or palate (roof of the mouth) do not form properly during foetal development. While these conditions may feel overwhelming for parents, modern medical advancements have made it possible to effectively treat cleft lip and palate through surgery.

This comprehensive guide provides insights into the surgical process, the ideal cleft palate surgery age, and preventive measures during pregnancy.

Causes of Cleft Lip and Palate

Cleft lip and palate result from facial and mouth formation issues before birth due to factors like genetics and lifestyle choices.

Genetic Factors

Genetic factors and inherited mutations can increase the likelihood of a child being born with a cleft lip or palate, with certain syndromes like Van der Woude syndrome or Pierre Robin sequence also including cleft conditions as part of their characteristics.

Nutritional Deficiencies During Pregnancy

Lack of important nutrients during early pregnancy can lead to cleft lip and palate development. Not having enough folic acid, as well as vitamins B6, B12, and zinc, can increase the risk of these birth defects.

Maternal Health Conditions

Diabetes and obesity in pregnant women can raise the risk of cleft formation in babies due to their impact on foetal development.

Exposure to Teratogens

Teratogens are substances that can harm foetal development, including medications, alcohol, tobacco, and viral infections like rubella, which can cause birth defects or developmental abnormalities.

Environmental Factors

External influences such as pollution and radiation can contribute to cleft conditions in babies. Pollution, such as exposure to pesticides, and radiation during early pregnancy can disrupt normal foetal growth.

Unknown Causes

In some instances, cleft lip and palate occur without identifiable risk factors, making it difficult to pinpoint a specific cause. These cases are often categorized as “isolated clefts.”

How to Prevent Cleft Lip and Palate During Pregnancy

While not all cases are preventable, taking proactive steps can reduce the risk of a cleft lip or palate in a baby.

• Take at least 400 micrograms of folic acid daily before conception and during early pregnancy.
• Include folic acid-rich foods in your diet such as leafy greens, citrus fruits, beans, and fortified cereals.
• Consume a diet rich in vitamins, minerals, and essential nutrients like vitamin B6, zinc, and iron.
• Focus on whole grains, fresh fruits, vegetables, lean proteins, and dairy products.
• To prevent cleft conditions in your baby, stop smoking, avoid alcohol during pregnancy, only take medications approved by your doctor, and steer clear of teratogenic drugs.
• Keep conditions such as diabetes and obesity under control with medical guidance.
• Schedule regular prenatal checkups to monitor health and manage any risks.
• Stay updated on vaccinations to prevent infections like rubella.
• Practice good hygiene to avoid viral and bacterial infections during pregnancy.
• Avoid exposure to harmful chemicals, pollutants, and pesticides.
• Use safe household cleaning products and limit radiation exposure.

When to Consider Surgery: Cleft Palate Surgery Age

Cleft palate surgery is ideally performed between the ages of 9 and 18 months to ensure optimal outcomes for the child’s development. This timing is critical as it allows the palate to be repaired before the child begins to develop speech, minimising the risk of speech delays or articulation issues. Early intervention also helps to address feeding difficulties and reduces the chances of middle ear infections, which are common in children with cleft palate.

However, the exact timing of the surgery may vary depending on the child’s overall health, weight, and the severity of the cleft. Parents should work closely with a multidisciplinary cleft care team to determine the best timeline for their child’s surgery.

Diagnosis of Cleft Lip and Palate

The diagnosis of cleft lip and palate is typically made during pregnancy or shortly after birth. It involves a combination of physical examinations, imaging tests, and sometimes genetic evaluations. Here’s how cleft lip and palate are typically diagnosed:

Prenatal Diagnosis

During the second trimester, ultrasounds can sometimes show a cleft lip or palate in the baby. Cleft lips are usually easy to see, but cleft palates may need further imaging, such as high-resolution 3D or 4D ultrasound, for a better view. Prenatal tests can show a higher chance of birth defects like cleft lip or palate. If risk factors are found, more tests or a specialist visit might be suggested.

Postnatal Diagnosis (After Birth)

A cleft lip is a visible gap in the upper lip at birth, while a cleft palate may cause feeding difficulties and can be detected during a physical exam. The doctor may also look for related birth defects affecting teeth, hearing, or facial structures.

Imaging Tests

After birth, X-rays or a CT scan may be used to see the cleft’s size, shape, and location. This helps the medical team plan for surgery and check for related conditions. In some cases, 3D imaging or MRI scans may be used for more detailed visualization of the palate and surrounding structures.

Genetic Testing

Genetic testing may be recommended if a cleft lip and palate are suspected to be part of a genetic syndrome. Syndromes like Van der Woude syndrome and Pierre Robin sequence can be linked to clefts, so family history is examined to see if there is a genetic predisposition.

Multidisciplinary Evaluation

After a cleft lip and/or palate diagnosis, a team of specialists will evaluate the child’s health and develop a treatment plan that may include surgery, speech therapy, orthodontics, and audiology to address feeding, speech, hearing, and dental concerns.

Treatment of Cleft Lip and Palate

Treatment for cleft lip and palate involves multiple surgeries and therapies throughout childhood, coordinated by a team of specialists to improve appearance, function, and growth.

Cleft Lip Surgery

Cleft lip repair surgery is typically performed on infants aged 3 to 6 months to improve feeding, appearance, and non-verbal communication by closing the gap in the upper lip using nearby tissue. The procedure often leads to significant improvements in appearance and feeding for most children.

Cleft Palate Surgery

Cleft palate repair surgery is done on infants to fix the roof of their mouths, prevent speech problems, and improve feeding. Additional surgeries may be needed later to address any remaining issues.

Speech Therapy

After cleft palate surgery, children may require speech therapy to help with speech delays or articulation problems caused by the cleft. Therapy typically starts after surgery and aims to improve speech clarity and eliminate nasality and other cleft-related speech issues in the early years of life.

Orthodontic Treatment

Orthodontic treatment may be needed as a child grows to align teeth and correct bite issues, starting around age 5-7 and continuing into adolescence. Braces and other appliances are used to enhance dental and jaw alignment, improving chewing, speech, and overall oral health.

Hearing Assessments and Ear Tubes

Children with cleft palate are at risk for ear infections and hearing loss due to fluid buildup in the middle ear. Regular hearing tests are needed to monitor any issues, and ear tubes may be placed to improve drainage and prevent infections.

Challenges Faced by Children with Cleft Lip and Palate

Children with cleft lip and palate may encounter various physical, developmental, and social challenges. Early intervention and a multidisciplinary approach can help address these issues effectively.

Feeding Difficulties

Infants born with a cleft palate may encounter difficulties in generating the necessary suction for breastfeeding or bottle feeding. As a result, specialised feeding bottles and techniques are frequently necessary to guarantee adequate nutrition for these infants.

Speech and Language Delays

A cleft palate can impact the development of typical speech sounds, resulting in difficulties with articulation or a nasal quality of speech. As a result, many children may benefit from speech therapy to enhance their communication abilities.

Dental and Orthodontic Problems

Misaligned teeth, missing teeth, or abnormal jaw growth are frequently observed in children with cleft conditions. To ensure optimal oral health, orthodontic treatments, dental prosthetics, and occasionally jaw surgery may be necessary.

Hearing Loss

Fluid buildup in the middle ear, a condition known as otitis media, is commonly found in children with cleft palate and can lead to temporary hearing loss. It is crucial to conduct regular hearing assessments and, when needed, consider ear tube placement to effectively manage this issue.

Frequent Infections

Children with cleft palate are more susceptible to frequent ear infections because of the abnormal structure of their Eustachian tubes. If left untreated, these infections can have a detrimental effect on their hearing.

Psychological and Emotional Impact

Distinct facial features can have a significant impact on a child’s self-esteem and confidence. These differences may make them vulnerable to bullying, teasing, and social stigma, ultimately resulting in emotional distress.

Social and Peer Interactions

Struggling to speak clearly or feeling self-conscious about one’s appearance can impede social interactions. However, with the assistance of family, counsellors, and peers, children can effectively navigate these obstacles.

Need for Multiple Surgeries

Children may need multiple surgeries throughout their lifetime, including initial repairs, revisions, and secondary procedures for functional or aesthetic enhancements. This process can be emotionally and physically challenging for both the child and their family.

Sources:

• https://www.gillettechildrens.org/conditions-care/cleft-lip-and-palate-repair
• https://www.mayoclinic.org/diseases-conditions/cleft-palate/diagnosis-treatment
• https://www.nicklauschildrens.org/conditions-we-treat/cranofacial/cleft-lip-and-or-palate-surgery
• https://www.myface.org/craniofacial-conditions/cleft-lip-and-or-palate/living-with/
• https://my.clevelandclinic.org/health/diseases/cleft-lip-cleft-palate
• https://www.webmd.com/oral-health/cleft-lip-cleft-palate
• https://www.hopkinsmedicine.org/health/conditions-and-diseases/cleft-lip-and-palate