Cleft lip/palate clinic

What is cleft?

Cleft is congenital separation of lip and/or the palate. Sometimes alveolus and maxillary bone are also involved. Congenital separation of the lip is called 'cleft lip', and that of the palate is 'cleft palate'. 'Alveolar cleft' implies the separation of the alveolus. Actually baby has little discomfort with this condition. This congenital anomaly is known to appear in 1st trimester. Etiology is thought to be the genetic and environmental factors. Therefore, no parents should be blamed or feel guilty. Incidence is different among the ethnic group, about 1 of 700~750 babies have this condition when he or she is born
 

What can we do to manage the cleft baby?

Special care should be taken to the cleft baby from the birth. Although there is individual difference, several times of admission and surgery are necessary. We’ll show you the sequential management of this cleft baby.

What can we do to manage the cleft baby?

1~2 years old : Around age of 1, palatoplasty and follow up for the cheiloplasty is planned. The main purpose of the palatoplasty is closure of the palate so that the patient can eat, drink, and pronunciate with normal articulation. Cooperation with dentist at this time includes the molding the dental cast and taking cephalogram. ENT specialist inserts the tube in the tympanic membrance if there is evidence of otitis media. Speech therapist analyses the speech and pronunciation.

2~6 years old : Follow-up of the surgical outcome of cheiloplasty and palatoplasty is tried. If there is nasal sound with speech problem following the palatoplasty, velopharyngeal surgery is considered. In case of cleft lip, severe nasal deformity can be corrected at the age of 5~6 with primary rhinoplasty. With the bilateral cleft lip patient, surgery for the elongation of the columellar may be needed. At the age of 2~5, ENT specialist should make an auditory examination. Dentist makes 2~6 years old : Follow-up of the surgical outcome of cheiloplasty and palatoplasty is tried. If there is nasal sound with speech problem following the palatoplasty, velopharyngeal surgery is considered. In case of cleft lip, severe nasal deformity can be corrected at the age of 5~6 with primary rhinoplasty. With the bilateral cleft lip patient, surgery for the elongation of the columellar may be needed. At the age of 2~5, ENT specialist should make an auditory examination. Dentist makes a regular examination for the dentition and gummy state. When these children grow up to the age of 2, they are aware of the reaction of others and have interest in their appearance and pronunciation, And at the age of 3, they respond and answer to others’ reaction and have some fear about the hospital and surgery. For the appropriate adaptation at this age, consultation to the psychological specialist is necessary.

6~12 years old : For the enhancement of the aesthetic property, cheilorevision and 2ndary rhinoplasty are planned. These procedures are inevitable because the muscles around the mouth are not able to grow in normal pattern even after the successful primary lip and nose surgery. Obtaining the symmetry and balance of the nose can make the child look better. It is highly desirable if the scar can be removed, however this is not possible. Instead of this attemption, symmetry and balance of the core structure of the lip should be restored. Problematic articulation and nasal sound should be corrected with velopharyngeal surgery. If there is alveolar cleft, alveolar bone grafting from the iliac crest and orthodontic treatment should be considered following the dental radiologic evaluation. ENT specialist continues to examine the auditory function. Speech therapy and psychological support should be caught up with this treatment as well.

12~18 years old : If there remains the developmental abnormality in the face, orthognathic surgery should be considered. Orthodontic treatment is mandatory if there is necessity of orthognathic surgery. Speech and psychological evaluation should be continued.

After the 18 years old : If needed, another orthognathic surgery can be considered, and the orthodontic treatment is completed.

Breast feeding and postoperative care of clef lip / palate

Parents get to know that there is little difference in breast feeding between the cleft and the non-cleft baby though they are somewhat embarrassed at first. Cleft baby need same amount of the caloric uptake and nutritional support. Cleft baby has weak suckling power due to the cleft lip and/or palate, therefore the food tends to regurgitate over the nose. They are easily tired before the completion of the lactation because of this difficulty in sucking. In fact, it is very hard for the cleft baby to suckle via the nursing bottle. Therefore, cruciform hole on the nipple and squeezing a little during the breast feeding may be needed to help the cleft baby. It is recommended that breast feeding should not last more than 30 minutes. As they swallow air during the lactation, parents should make them belching intermittently. They have a tendency of sneezing and swallowing the wrong way, so they should be orthostatic in some degree during the milk feeding and with the slower rate than the non-cleft baby.

Issue of health insurance

Primary cases of cleft lip and palate are covered with health insurance. However, all other cases except the primary cases are beyond the coverage of health insurance. For financial support or more information, call 02-3101-4090, department of public welfare service in Asan foundation.

Postoperative care

Following the palatoplasty, cleft baby should be in the prone position so that the intraoral bleeding should not be aspirated and discharged naturally. Immediately after the surgery, some bleeding is natural and parents don’t have to be worried about this. It is important for the cleft baby to leave the intraoral suture untouched. They should not put their hands into the mouth or suck their finger. If needed, restriction of the hands may be needed. Crying may cause the tension to the suture site and may result in the wound dehiscence so the parents should make them calm down and asleep. Although breast feeding is possible from the day after the surgery, syringe or spoon is recommended other than the nurse bottle nipple. After the milk feeding, water intake should be followed to remove the remainder of the milk on the suture site. Though stitches disappear in 2 to 3 weeks spontaneously, special care should be taken until this period and parents should not make them cry.
Without other problems, patient is planned to be discharged next day after the surgery. Immediately after the surgery, NPO is needed for 4hours and later on, patient can drink water or milk. If patient has fever, discharge may be delayed one to two days. Parents should keep in mind that baby should not touch the surgical site. Stitch out is planned on the 4th to 5th day after the surgery and taping should be maintained for 2 to 3 weeks. At postoperative 3rd week, re-visit for the outpatient clinic and evaluation is planned. Nasal retainer should be worn for 6 months after the surgery. Initially, the surgical scar becomes reddened and protruded, but it grows lightened and flattened. Surgery on the scar, deformity of lip and nose is planned at the age of 4 to 5.

Development of the teeth

Cleft lip / palate patient has different teeth structure from that of non-cleft patient. Lack of the number of teeth or excess of the number of useless teeth is not infrequent. Shape of the tooth adjacent to the alveolar cleft is unusual and crooked. Dental specialist for the cleft paitent may help this patient with the specillay designed orthodontic treatment.

Secondary deformity of cleft lip and nose

Clef lip patient has typical structural deformity of nose. In case of unilateral cleft, nose is deviated to the non-cleft side, ala of cleft side is drooped and depressed, nostril of cleft side is widely opened, and nasal floor of the cleft side is depressed so that the apparent asymmetricity is prominent. Surgery for this deformity is planned at preschool age; 1 to 1 and half year before admission. Adequate timing of definite corrective rhinoplasty had better be postponed until the growth of bone and cartilage is completed. This is planned after the adolescent period. Secondary cheilorevision is planned with the secondary rhinoplasty. However, if the scar around the philtrum is widened abnormally, line of lip is severely interrupted, notching or bulging of vermilion is prominent, cheilorevision can be planned at appropriate time.