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CLEFT PALATE
Jyoti Gupta, M.Sc. Foods and Nutrition
BACKGROUND
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,
Incidence
More
1 in 500
Less
1 in 2000
Prevalence
1 in 750
*Prevalence
in Pakistan:
1 in 523
India: 27,000 to 33,000 per year
*Elahi MM, Jackson IT, Elahi O, Khan AH, Mubarak F, Tariq GB, Mitra A.
Epidemiology of cleft lip and cleft palate in Pakistan. Otolaryngol Clin
North Am. 2007 Feb; 40(1):27-60
Incidence
Boys
EMBRYOLOGICAL
DEVELOPMENT OF
CLEFT LIP
EMBRYOLOGICAL
DEVELOPMENT OF
CLEFT PALATE
Classification
It
or bilateral
CLASSIFICATION
A mild form of a cleft lip is amicroform cleft. A
microform cleft can appear as small as a little
dent in the red part of the lip or look like a scar
from the lip up to the nostril.
Incomplete cleft lips can take on a variety of
appearances. There may be just a small gap or
cleft in the vermillion or it may slightly extend
into the skin above
the lip or extend almost to the nostril.
As with a complete cleft lip deformity, the nose
has some distortion. The distortion is usually to
a lesser degree. The nostril may be widened, but
the floor of the nostril is
Classification Systems
Kernahan Striped Y
Millard Modification of
Kernahan Striped Y
Kriens LAHSHAL
Veau classification
Lip
Alveolus
Primary
Palate
Hard Palate
(Maxillary)
Hard Palate
(Palatine)
Soft Palate
Karnahans Classification
Millards Modification of
Karnahans Classifcation
Kriens LAHSHAL
L = Lip (right)
A = Alveolus (right)
H = Hard Palate
(right)
S = Soft Palate
(median)
H = Hard Palate
(left)
A = Alveolus
Capital
letter(left)
= complete
L = Lip (left)
cleft
Lowercase letter =
incomplete cleft
Examples
.
or - = normal
LA.l = complete right cleft lip and
alveolus, incomplete left cleft lip
LAHS = complete right unilateral cleft
lip, alveolus, hard, and soft palate
T
A
P
H
P
O
H
O
I
YS
Y
G
O
L
PATHOGENESIS/CAUSES
ABCA4 on chromosome 1
a region on chromosome 8
Environmental factors
Drugs: corticosteroids (anti-inflammatory), phenytoin
(anticonvulsant), retinoid.
Infections: like rubella during pregnancy.
Maternal smoking
Alcohol consumption, smoking, hypoxia during pregnancy, some of
dietary and vitamins deficiencies (like folic acid and vitamin A
deficiency)
Maternal Age
Women with diabetes diagnosed before pregnancy
GENETICS
CL/P
Normal parents, one child with CL/P 4% risk CL/P in next child
Normal parents, two kids with CL/P 9% risk CL/P in next child
One parent CL/P, no affected kids
4% risk CL/P in next child
One parent CL/P, one child CL/P 17% risk CL/P in next child
Risk of CL/P in siblings increases with severity of deformity
- child with unilateral CL risk CL/P next child 2.5%
- child with bilateral CL/P
risk CL/P next child 5.7%
CP
DIAGNOSTIC TEST/
EXAMS
Orofacial clefts
can beDiagnosis:
detected during
Advantages
of Prenatal
preparation
3.Usually,
Opportunity
to investigate
other
orofacial
clefts are diagnosed
anomalies
whenassociated
the baby is
born.
4.
Gives parents the choice of
Minor
clefts might
not be diagnosed
continuing
the pregnancy
until
later in life.for fetal surgery
5.
Opportunity
Diagnosis can also be
PHYSICAL EXAMINATION.
made
by
PROBLEMS &
COMPLICATIONS
Feeding
Difficulties
Cleft
Dental Problems
A
Speech Problems:
MANAGEMENT OF CLEFT
LIP AND PALATE
Genetic Scientist
Pediatrician
Pedodontist
Orthodontist
Oral and Maxillofacial Surgeon
Prosthodontist
ENT Surgeon
Plastic Surgeon
Psychiatrist
Psychometrist
Speech Therapist
Social Worker
Neonatal Period
Parents counselling about immediate & long term
implications of cleft defect & necessary surgery.
The immediate problems of infant with CLP are concerned
with feeding & prevention of aspiration & infection.
Naso-gastric tube feeding
Use of medicine dropper for feeding
Breastfeeding is desirable but may not be successful &
expressing of milk may be most appropriate approach
Bottlefeeding is usually achieved but with some
difficulty due to their inability to generate sufficient
suction.
The nipple of feeding bottle should be positioned on
non-cleft side & moved about or squeezed by parent.
Cutting of a cross in nipple increases the volume of
milk that flows; but only when the nipple is compressed
hence the child doesnt need to create suction.
Here are some tips & tools to help when feeding a baby with a cleft:
Nipples: There are special nipples that can help a baby get the most out
of feeding.
Nipple Shape: There are two main shapesstraight standard nipples
& wide flat NUK or orthodontic nipples.
Nipple Length: The nipple should be long enough for babys tongue to
press against it.
Nipple Pliability: A soft nipple makes milk come out faster, then the
baby will not have to suck as much.
Nipple Hole Size: The size of nipple hole can make milk come out
faster or slower - X shape
Modified Nipples: There are some commercially available bottles
specifically designed for use with infants with CLP. These include Special
Needs feeding (Haberman), cleft palate nurser (Mead Johnson) & Pigeon
bottle. The caregiver provides a gentle squeeze on the bottle as the baby
sucks to get milk.
Mead Johnson/
Enfamil Cleft Feeder
Pigeon Feeder
Natural Flow
Dr. Browns
Oral Care: Clean the area around the cleft using a wet washcloth after
each feeding. Wet cloth with hydrogen peroxide or water (as advised
by your doctor).
Cup Feeding: Most doctors recommend changing from a bottle to a
cup before the palate is repaired. It can cause the scar not to heal if
the baby sucks on a bottle after the surgery. Thicker liquids can be
used to make it easier to drink when the baby is first trying a cup.
Begin offering a cup for small amounts of liquid beginning at 6 months
to help the baby with this transition.
Solid Foods: Solid foods can be given to the baby with cleft palate
at about the same time as with any other baby.
Breast Milk: If attempts at breast feeding are not successful, the
mother can use a breast pump to get milk. Then the baby can drink
the breast milk from a bottle
PREOPERATIVE AND
POSTOPERATIVE MANAGEMENT
CHILDHOOD
Monitoring of hearing & middle ear function to ensure
appropriate language & speech development.
Causes of speech problems---developmental delay
---hearing problems
---oronasal fistulae
---dental malocclusion
---velopharyngeal incompetence (VPI): detected by
nasendoscopy; corrected by pharyngeal flap surgery
which reduces nasal air flow during speech; should be
performed before age of 6 yrs
Speech therapy
Regular dental care to minimize morbidity due to loss of
teeth. It includes oral hygiene instruction & prophylactic
measures to prevent dental caries & periodontal disease;
repair carious & malformed teeth.
Orthodontics- align the teeth in the arch before bone
grafting of residual alveolar cleft prior to the eruption of
SUPPORT GROUPS
Hong Kong Parents Association of Cleft Lip and Palate Children
Canadian Cleft Lip and Palate Family Association
Operation smile, US based NGO provides free reconstructive
surgery & associated services for children born with facial
deformities as well as children in need of surgery due to injury;
presence in more than 60 countries.
Trinity Care Foundation that provides free facial deformities &
CLP surgeries in reputed hospitals in Bangalore, India.
SmileTrain, NGO - US
Transforming Faces, NGO - Canada
The following organization is a good resource for information
oncleft palate:
Cleft Palate Foundation -www.cleftline.org
March of Dimes -
www.marchofdimes.com/professionals/14332_1210.asp
U.S. Centers for Disease Control and Prevention -http://
www.cdc.gov/ncbddd/birthdefects/CleftLip.html