Every year children are born with minor or major birth defects. The doctors and surgeons carry out extensive health practices and surgical procedures to ensure these children live a happy and healthy life with their families. Statistically, in every 700 childbirths in the US, 1 child is born with a cleft defect. This oral malfunction occurs due to insufficient tissues in the mouth during fetal development in the uterus (1). It occurs in two forms – the cleft lip and cleft palate. Let’s look at these defects, the correction procedures, treatment, and lifestyle process of children born with these issues.
Birth Defects
There are different forms of birth defects, and one of the most common is the cleft defect. This oral malfunction occurs when a child is born with an opening (cleft) in the palate. The palate is the roof of the mouth and has two parts – hard palate and soft palate. The soft palate is the soft front portion of the skin covering the tissues and muscle components of the mouth. The hard palate is the bony body structure, the back portion, which is a part of the skull. This split opening of the palate can occur on both palates, only on the soft palate or on the hard palate.
What is a Cleft lip defect?
The cleft lip appears as a physically visible open split of the lip skin, dividing the upper lip into two places. The resulting gap may be small or run extensively to the base of the nose and as far back as the upper jaw and gum bones. This defect occurs during the early stages of fetal development. Specifically, during the first 6 to 10 weeks of pregnancy, the roof of the mouth and lips are formed in the uterus (2). This formation involves the fusion of the bones and skin around the nose, upper jaw, and mouth. The defect results from insufficient tissues available for this fusion; it may also occur when the available tissue does not stretch into joining together.
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What is a Cleft palate defect?
The cleft Palate appears as a physically visible open split on the palate – roof of the mouth. The resulting gap runs as far as the hard palate.
The cleft defect can occur as
- Cleft lip
- Cleft palate
- Or a combination of cleft lip and cleft palate.
Because the cleft palate and cleft lip occur separately, it is possible to occur on one side or both sides of the mouth.
- Unilateral cleft lip – on one side of the lip
- Bilateral cleft lip – On both sides of the lip
The size of the cleft may also vary
- Incomplete cleft lip – a small visible notch on the upper lip
- Complete cleft lip – a wider gap that runs through the lip to the gum and extends to the nostrils
- Cleft lip and cleft palate – The visible opening runs through the hard palate onto the gums and the upper lips.
Causes of Cleft Lip and/or Cleft Palate Defects
There is no exact known cause for this oral malfunction. But its occurrence may be attributed to certain factors which have been found reoccurring in the children born with these defect. Some of which includes
- Genetics – a repeated occurrence if a parent or relative had a cleft
- Environmental factors – These may include exposing the fetus to harmful chemicals and substances during pregnancy
- Taking certain medications during pregnancy – including anti-seizure medicines, acne drugs containing Accutane, and methotrexate.
- Exposure to viruses during fetal development
- Not taking sufficient prenatal nutrients during pregnancy for fetal development.
- Smoking cigarettes during pregnancy
- Taking hard drugs and narcotics during pregnancy
- Excessive alcohol consumption during pregnancy
Problems Associated With the Cleft Defect
The cleft defect results in some challenges for the child. Some of these problems include
1. Difficulties in feeding – The food taken in goes through the cleft to the nasal opening instead of going through the throat to the stomach for digestion. The child with a cleft defect will have problems in breastfeeding, and utmost care should be taken while feeding. This can only be corrected by sealing the cleft covering the passage of the nose from the throat.
2. Difficulties in Speaking – Speech development problems
3. Ear Infections and Difficulties in Hearing – The muscles in the palate are connected to the middle ear, and because of the cleft, sticky secretions may buildup within the middle ear, a condition called glue ear (3).
4. Poor Growth and Development – The child may struggle to put on body weight during the first few months.
5. Sleeping Problems – The baby may have difficulties sleeping and may be required to lay in certain positions.
6. Dental Problems – Children with cleft lips are prone to dental problems like cavities, irregular teeth alignment, etc.
The only way to close a cleft – cleft lip or cleft palate, is by carrying out surgery. The surgery is intended to close the opening in the roof of the mouth. It is completed within few hours and the post-surgery hospital stay is 3 to 5 days.
What Does the Repair Surgery Involve?
Cleft lip and cleft palate defects are reversible. They are repaired by surgeries called “Cleft lip repair” and “cleft palate repair,” respectively. The surgery focuses on
- Restoring the lips and mouth function.
- Improving the growth and appearance of the face.
Who Treats a Child with Cleft Lip and/or Cleft Palate?
Because of the complexity of this oral malfunction, the surgery process requires the consultation and presence of various experts and specialists to repair the defect and improve the condition. They include
- Plastic Surgeon -To evaluate the defect and carry out the necessary surgery process.
- Oral surgeon – To reposition, repair, and improve the appearance of the lips and upper jaw (4).
- Pediatrician – To check on overall health.
- Pediatric Dentists – To carry out routine follow-up dental care.
- Otolaryngologist – Ear, throat, and nose doctor. To evaluate the resulting hearing problem and treat the problem.
- Orthodontists – To arrange and straighten the teeth.
- Psychologists – To assist the family through the process.
- Nurses – To supervise the child’s health and healing process.
- Speech Pathologist – To evaluate feeding and speech problems.
- Speech Therapist – To help improve speech coordination.
- Prosthodontist – To design artificial teeth and dental appliances for functional improvement in eating, speaking, and appearance.
- Genetics Counselor – To analyze possible causes of the defect.
- Audiologist – Auditory and hearing specialists. To evaluate and monitor hearing problems.
- Social Workers – These experts develop strategies and plans of action to care for the child through the treatment process. Treatment for Cleft defects starts in childhood and extends through early adulthood.
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Cleft Lip Repair Surgery
The cleft lip surgery is preferably performed during the first three months of the child’s birth. This timing is important because the defect alters the child’s primary activities and functions required for proper development. This includes feeding, speaking (crying), and hearing functions. Hence, the plastic surgeon carries this surgery alongside the pediatrician, speech pathologist, ear nose throat specialist, and hearing counselor.
General anesthesia is administered during this surgery to manage the pains and reduce discomfort.
During the surgery procedure, the lip tissues – soft palates are trimmed and incisions made on both sides of the cleft to create flaps of tissues. These flaps of tissues are stretched and connected, then sutured thinly to leave a minimal scar. This repair improves lip appearance, function, and structure.
A nasal repair may be carried out alongside cleft lip repair surgery. This involves realigning the nasal elements using stents and sutures into a normal configuration. And the nasal alveolar molding procedure is used to maintain this correction.
The post-surgery hospital recovery time lasts about a week to watch for possible after-effects and complications.
Cleft Palate Surgery
The child needs to be older for the cleft palate repair surgery procedure. This repair surgery is performed during the 9th to 12th month of birth. The surgery process repairs the soft or hard palate or both palates.
A team of specialists also carries out the surgery, the plastic surgeon alongside the pediatrician, speech pathologist, ear nose throat specialist, and hearing counselor. The surgeon makes incisions on both sides of the cleft, then rearranges and repositions the muscles, tissues, and lining of the palate. And the incision is closed in dissolvable stitches. The scar from this repair procedure is hidden inside the mouth.
The cleft palate repair procedure creates a separation between the oral and nasal cavities. During the procedure, an airtight and watertight valve is formed, necessary for normal speech development. The repair also stabilizes facial growth processes and enhances proper dental development. This aligns the muscles into proper positions and improves palate function for feeding, swallowing, and speaking.
Cleft palate repair may need follow-up as the child grows and develops. The child may also need braces as soon as permanent teeth develop and may need consultation sessions with the speech pathologist to improve speech.
The Processes – What to Expect During the Repair Surgery
- The child may be put through consultation sessions with various specialists to ascertain the extent of cleft complications and develop a treatment plan.
- The surgery process will be carried out in the hospital and under general anesthetics (5).
- Depending on the repair process (cleft lip or/and cleft palate), various surgical techniques may be used to achieve the desired goals.
- All procedures aim to reconstruct, connect, and improve the symmetry of the affected areas and treat the complications of the defect.
- After the surgery, the affected areas may be repaired and closed with thin stitches.
- The procedure is completed in 1 to 2 hours.
- The repair improves lip appearance, function, and structure.
- A nasal repair may be carried out alongside this repair surgery.
- Also, the Otolaryngologist may be present for the ear tube surgery to place tiny bobbin-shaped ear tubes in the eardrum. These ear tubes create an opening that stops the buildup of fluids, reducing the possible risk of chronic ear fluid. A condition that may lead to loss of hearing abilities.
- Other surgeries may be carried out alongside the cleft surgery to improve the overall appearance of the affected areas, including the mouth, nose, lip, and upper jaw.
- As soon as the anesthetics wear out after surgery, the child may experience pain and discomfort and become irritable.
- There may be swellings, bruising, and minimal bleeding around the affected areas.
- Also, there may be an appearance of a small amount of blood in the mucous or saliva for days after the surgery.
- The child may be required to stay in the hospital for days so that the specialists can watch and monitor the surgery process. They also watch out for possible complications and reactions.
- The stitches from the surgery may dissolve or be taken off in 5 to 7 days.
- There may be a tiny scar for cleft lip, probably tucked in the natural lines of the face. The scar fades as the years go by.
- The child may be restricted to a liquid diet plan for the first two weeks and then to soft food for several weeks before adjusting to regular meal plans.
- The child will be fed with fluids using an intravenous catheter.
- There may be a strict guideline to dress the child in certain outfits and pads that prevent elbow movement. This is intended to restrict hand movement to the mouth to prevent infections and complications.
Additional Surgery
- Some procedures such as nasal alveolar molding or lip adhesion may be carried out before the cleft repair for wider clefts. These procedures will reduce the width of the gap, bring the lips closer, and improve the shape of the nose.
After the cleft lip and cleft palate repair surgery process, the treatment procedure may require further surgeries such as
- Alveolar bone grafting in the gum – This is carried out through a bone graft method, inserting a piece of bone. This procedure is carried out at 8-12 years.
- Extended lips and palate surgery – This is carried out if there is poor healing from the previous surgery. Also, if the child shows continuous challenges with speech formation, it improves the functions and appearance of the lips and palate.
- Rhinoplasty – To improve the shape of the child’s nose
- Orthognathic. To improve the appearance of the jawline
- Speech surgery and therapy
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Benefits of Cleft Lip and/or Cleft Palate Repair Surgery
The cleft lip and cleft palate repair surgery processes have immense benefits. They include
- Improved child’s appearance – shape and symmetry of the lips, nose, and jawline.
- Improved feeding ability.
- Improved ability to talk.
- Improvement in a child’s quality of life.
What are the Side Effects?
Possible complications and side effects include
- Infection – This may occur during the post-surgery healing time.
- Bleeding
- Poor healing
- Malformation of bone in the middle of the face
- Clogging of water in mouth roof
- Elevation of surgery scars
- Widening of surgical scars
- Inability to wet diapers
- Heavy bleeding from the nose or mouth
- Fever above 101.4°F
- Damage to blood vessels and nerves – could be temporary or permanent
Summary
There are different forms of birth defects, and one of the most common is the cleft defect. This oral malfunction occurs when a child is born with an opening (cleft) in the palate. It occurs in two forms – the cleft lip and cleft palate. There are no exact known causes for this oral malfunction. But its occurrence may be attributed to a complex interaction between genetic and environmental factors. The only way to close a cleft – cleft lip, or cleft palate, is by carrying out surgery to close the opening in the roof of the mouth. All procedures aim to reconstruct, connect, and improve the symmetry of the affected areas and treat the complications of the defect. The surgery procedure is completed in 1 to 2 hours and the post-surgery hospital stay is 3 to 5 days. There may be a need for additional surgical procedures as the child grows and develops.
References –
- “Cleft Lip and Cleft Palate” – webmd.com
- “Cleft Palate With Cleft Lip” – kidshealth.org
- “Treatment -Cleft lip and palate” – nhs.uk
- “Cleft lip and cleft palate” – mayoclinic.org
- “Cleft Palate Repair: The Surgery” – nationwidechildrens.org
