cleft lip

1. Pam Kraus, Janelle O’Connell, Jessica Daiker
Amy Barron, Laura Underwood, Jaci Gauna

2.  A cleft lip or palate is an oral-facial birth defects in which the tissues of the mouth
or lip don't form properly during fetal development.
 In the United States, clefts occur in 1 in 700 to 1,000 births, making it one of the
most common major birth defects.
 A cleft lip may be just a small notch in the lip. It may also be a complete split in the
lip that goes all the way to the base of the nose.
 A cleft palate can be on one or both sides of the roof of the mouth. It may go the
full length of the palate.
 The incidence of cleft palate alone is one in 500 live births
 Considering the cleft deformities of all races grouped together, 50% are cleft lip
and palate, 30-35% are palate only, and 15-20% are cleft lip only.

3.  The cleft palate was not recognized as a congenital disorder until
1556.
 For centuries, perforations of the palate were considered to be
secondary to syphilis.
 The first successful closure of a soft palate defect was reported in
1764 by LeMonnier, a French dentist.
 The first closure of the hard palate was performed in 1834.
 Clefts occur more often in kids of Asian, Latino, or Native American
descent.
 More boys than girls have a cleft lip, while more girls have cleft
palate without a cleft lip.
 A child may have one or more of these conditions at birth.

4.  Failure to gain weight
 Feeding problems
 Flow of milk through nasal passages during
feeding
 Misaligned teeth
 Poor growth
 Recurrent ear infections
 Speech difficulties

6.  Cleft lip:
◦ Caused by incomplete fusion of the nasomedial or intermaxillary process during the
2nd month of embryonic development
◦ Cleft causes structures of mouth and face to develop without the normal restraints of
encircling lip muscles
◦ May affect external nose, nasal cartilages, nasal septum, and alveolar processes
also
◦ Usually just beneath the center of one nostril
◦ Can occur bilaterally, symmetrically or asymmetrically
◦ More complete the cleft lip, the greater the chance that teeth in the line of the cleft
will be missing or malformed
 Complete cleft= entire thickness of the lip
 Incomplete cleft= only a portion of the lip is involved

7.  Cleft Palate:
◦ Often associated with cleft lip, but may occur without it
◦ Fissure may affect only the uvula and soft palate (secondary palate, formed ~ 9 weeks), or
may extend forward to the nostril and involve the hard palate and the maxillary alveolar ridge
(primary palate, formed ~ 4-5 weeks )
◦ Complete= involves the primary and secondary palate
◦ Incomplete= involves the secondary palate only
◦ Unilateral= on one side the palatal process of the maxilla is fused with the nasal septum
◦ Bilateral= not attached to the nasal septum, and the septum is visible through the cleft
◦ Cleft occupies the midline posteriorly and can go as far forward as the alveolar process.
Clefts involving the palate only are usually midline
◦ Some cases, the vomer and nasal septum are partly or completely undeveloped
 When these facial bones are involved, the nasal cavity and the oral cavity are open to each other

8.  South Africa:
◦ 2006 study: participants included 35 cleft patients and their families
 Beliefs about the cause:
 God
 Witchcraft
 Ancestors punishing the mother
 Fate
 Genetics and family history of the condition
◦ 2007 study: looked at the beliefs and practices of religious healers
 Most common belief for both Muslim and Hindu healers= it was God’s will or because of an eclipse
 Both also identified evil spirits, witchcraft and genetics as causes
 Hindu group identified karma as being a possible cause
 Both groups reported that their patients came to traditional healers because they were looking for
comfort, or to be relieved of guilt because of their culture and what their ancestors did
 Beliefs of African Americans in US are similar (punishment for something the
mother has done, evil spirits, or displeasing a god)

9.  Nigeria
◦ 2007 study regarding the beliefs of mothers in Nigeria who had a
child with a cleft lip or palate
◦ Identified as Hausu/Fulani (Muslim)= believed cleft was an act of
God
 Other beliefs included the mother going outside during an eclipse while
pregnant or laughing at someone with a cleft lip
 Because of their belief that the cleft is an act of God, may feel less
shame related to the condition and also less likely to have it repaired
◦ Identified as Yoruba (Christian)= believed cleft was due to evil
spirits or punishment from ancestors
 Other beliefs included curses, not having enough food during
pregnancy or hereditary/environment factors

10.  Asia:
◦ 1990 paper discussing the beliefs of people of Asian/Pacific Island descent
living in the United States:
 Some view a cleft as a gift from God, while others view it as a curse
 Many beliefs exist about the role different foods play in causing or healing physical
problems
 Ex/ eating hare while pregnant could cause a cleft lip
 Members of some religions, such as Buddhism, may view a cleft as part of a
person's karma and not treat it at all
 Beliefs regarding the cause include spirits, negative forces, punishment for the
actions of ancestors and eating certain foods
 Depending on the belief regarding the cause of the cleft, patient may feel shame

11.  Latino
◦ Article focused on Latino people (from Mexico, Central and South
America, and the Caribbean) who are living in the United States
 Eiology of a cleft lip or palate may be accounted for by folklore or
mythology
 Some beliefs include that cleft is due to natural events (eclipse),
actions of the parent (drinking alcohol or having a STD), or emotional
factors (stress during pregnancy)
 Witchcraft or evil spirits also believed to be a cause
◦ Health care underutilized due to lack of insurance and/or fear of
not being a legal citizen of the US

12.  Nurses need to remember:
◦ to be sensitive when dealing with the family of a baby with cleft
lip and palate
◦ Try to remember this may be quite a shock and they may be
grieving the “healthy & normal” baby they wanted
◦ Encourage parents to do cares for the baby as you normally
would
◦ Sometimes listening is the best way to show empathy, just let
them know you’re there and you’re someone they can confide in

13.  Beyond the cosmetic abnormality, there are other possible complications that
may be associated with cleft lip and cleft palate, including the following:
◦ feeding difficulties
Feeding difficulties occur more with cleft palate abnormalities. The infant may be unable to
suck properly because the roof of the mouth is not formed completely.
◦ ear infections and hearing loss
Ear infections are often due to a dysfunction of the tube that connects the middle ear and the
throat. Recurrent infections can then lead to hearing loss.
◦ speech and language delay
Due to the opening of the roof of the mouth and the lip, muscle function may be decreased,
which can lead to a delay in speech or abnormal speech. Referral to a speech therapist
should be discussed with your child's physician.
◦ dental problems
As a result of the abnormalities, teeth may not erupt normally and orthodontic treatment is
usually required.

14.  Infant with a Cleft Lip and Palate using a Pigeon system bottle, which encourages “active” feeding.
 The baby still has to suck, but not as hard and there is a one way valve that doesn’t allow milk to go back
into the bottle after it has been sucked through.
 This helps the child later on with feeding after surgery has been complete since the baby has already
taken an active roll in eating.
 Corpak’s are also utilized to provide the baby nutrition without burning so many calories.
 Most NICU protocols will not allow the nurse to try to feed for more than 20 minutes.
 The remainder of the bottle is then corpaked.
 Breastfeeding can still be accomplished but it is recommended to consult a lactation educator before
attempting.

15.  There may be many people involved in management of a cleft abnormality, because the
skills of many different areas are needed to help with the problems that can occur with
cleft abnormalities. The following are some of the members of the team:
◦ Plastic/craniofacial surgeon - a surgeon with specialized training in the diagnosis and
treatment of skeletal abnormalities of the skull, facial bones, and soft tissue; will work closely
with the orthodontists and other specialists to coordinate a surgical plan.
◦ Pediatrician- a physician who will follow the child as he/she grows and help coordinate the
multiple specialists involved.
◦ Orthodontist - a dentist who evaluates the position and alignment of the child's teeth and
coordinates a treatment plan with the surgeon and other specialists.
◦ Pediatric Dentist - a dentist who evaluates and cares for the child's teeth.
◦ Speech and language specialist - a professional who will perform a comprehensive speech
evaluation to assess communicative abilities and who will closely monitor the child throughout all
developmental stages.

16. ◦ Otolaryngologist (Ear Nose Throat specialist) - a physician who will assist
in the evaluation and management of ear infections and hearing loss that may be
side effects of the child's cleft abnormality.
◦ Audiologist (hearing specialist) - a professional who will assist in the
evaluation and management of hearing difficulties the child may have.
◦ Genetic counselor - a professional who reviews the medical and family history,
as well as examines the child to help in diagnosis. A genetic counselor also
counsels the family regarding risk for recurrence in future pregnancies.
◦ Nurse team coordinator - a registered nurse who combines experience in
pediatric nursing with specialization in the care of the child and acts as liaison
between the family and the cleft team.
◦ Social Worker- a professional who provides guidance and counseling for the
child and family in dealing with the social and emotional aspects of a cleft
abnormality and assists the family with community resources and referrals (i.e.,
support groups).

17.  Split in lip or palate
 Symptoms related to location of cleft:
◦ Hard & soft palate: Facial defect
◦ Soft palate: leaking of ingested liquids from the nose
◦ Hard palate: weak, dysfunctional suck, trouble swallowing,
gagging, choking
 Submucous Cleft- only in muscles of soft palate and
hidden by lining of mouth
◦ May not be diagnosed until later in life
◦ Indicated by: trouble feeding, nasal drainage, excessive gas,
nasal sounding voice, increased nasal discharge

18.  Family History: Cleft lip more likely to be inherited than cleft
palate
 Race: More common in Native American, Hispanic & Asian
patients
 Sex: Males 2x as likely to have cleft lip; Females 2x as likely to
have cleft palate
 Environmental factors: exposure of fetus to alcohol, cigarette
smoke, or drugs
 Maternal Nutrition Deficiencies:especially lack of folate
◦ Encourage use of prenatal vitamins.

19.  Physical examination at birth
 Ultrasound: not always visible
 Genetic testing for parents to determine risk of
having additional children with cleft lip/palate

20.  Treatment of the child with CL is surgical and usually
involves no long-term interventions other than possible
scar revision
 However, management of CP involves the care of a
multidisciplinary health care team to provide optimum
results
◦ includes pediatrics, plastic surgery, orthodontics, otolaryngology,
speech pathology, audiology, nursing and social work
 Management of both is directed towards closure of the
cleft, prevention of complications and facilitation of normal
growth and development of the child.

21.  Surgery:
◦ Can make a big difference to the child's ability to grow and develop normally
◦ The baby will usually have an operation to close his or her cleft lip before the age
of three months old.
◦ An operation to repair a cleft palate usually happens a bit later, but usually before
the age of one year.
◦ Under general anesthesia, the surgeon will trim the tissues and sew the lip
together. The stitches will be very small so that the scar is as small as possible.
Most of the stitches will absorb into the tissue as the scar heals, so they will not
have to be removed later.
 Speech and Hearing
◦ A tympanostomy tube is often inserted into the eardrum to aerate the middle ear
◦ Speech problems are usually treated by a speech-language pathologist
◦ Encourage the child's early attempts to make sounds, even before the cleft is
repaired

22.  Prevention
◦ If you have had a child with a cleft lip or palate, the chance of any more children you have being
affected may be slightly increased
 Genetic counseling or testing may provide answers
◦ Daily folic acid supplements in the first month before conception and in the first two months of
pregnancy
◦ Avoid alcohol and drug consumption during pregnancy
 Nutrition
◦ Assess the infant's nutritional intake, adequate amount of nutrients is necessary to maintain growth
◦ Feeding is best accomplished in an upright position
◦ Special nipples or other feeding devices may be needed
◦ Breastfeeding is usually a viable option and sometimes more successful than bottle-feeding
◦ Avoid the use of suction or objects in the mouth such as thermometers, spoons or straws
 Coping
◦ Address parent's emotional needs, answer and acknowledge questions and concerns
◦ Provide support to the child and the family members
◦ Promote attachment/bonding
◦ Emphasize positive aspects of baby's appearance
◦ Express optimism

23.  The exact cause of cleft lip and palate is unknown
but it is believed to be a combination of genetic
(inherited) and environmental factors.
 Certain Drugs, illnesses, and the use of alcohol or
tobacco while the woman is pregnant are thought
to be contributing factors.
◦ restrict alcohol and drug consumption while pregnant

24.  FEEDING
◦ Cleft lip= makes it more difficult for an infant to suck on a nipple
 use special nipples to allow the baby to latch properly (either pump or use formula)
◦ Cleft Palate= may cause formula or breast milk to be accidently taken up into the nasal cavity
 don’t feed baby without palatal obturator (prosthetic palate)
 feed in an upright position to keep milk from coming out of the nose
◦ Babies are more susceptible to altered nutrition (inadequate) related to difficulty eating due to physical
defect
 SPEECH
◦ Muscle function is decreased and cleft lip or palate makes it more difficult for the child to form words
properly
 need to see a speech therapist at 18 – 24 months

25. Mead Johnson/Enfamil Cleft Feeder Special Needs Feeder / Haberman Feeder
Pigeon Feeder Dr. Brown’s Natural Flow to relieve gas

26.  Author Unknown. (n.d.) Lucile Packard Children’s Hospital at Stanford. Retrieved January 28, 2010,
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http://hcd2.bupa.co.uk/fact_sheets/html/cleft_lip.html
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http://kidshealth.org/parent/medical/ears/cleft_lip_palate.html#
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Health Care Delivery Between Patients and Professionals. Knol, 25. Retrieved February 1, 2010,
from http://knol.google.com/k/cultural-considerations-in-cleft-lip- and-palate#
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