Cleft lip and Cleft palate

Introduction
Cleft lip and palate are congenital (present from before birth) abnormalities that affect the upper lip and the hard and soft palate of the mouth. That may occur separately or together. Cleft lip: It results from the failure of maxillary processes to fuse with the nose elevation on the frontal prominence. This defect varies from a notch in the lip to complete separation of the lip into a hare. The cleft lip may be unilateral or bilateral.

Unilateral Cleft lip

Bilateral Cleft lip

Cleft palate (isolated): Isolated cleft palate results from a failure of the fusion of secondary palate with each other, and with the primary palate. It can be unilateral or bilateral. Cleft lip and palate: This condition results from a combined defect of cleft lip and cleft palate.

Incidence
Cleft lip occurs in approximately 1 in 800 births. It is more common in Asians and American Indians and less common in African-Americans. Cleft palate occurs in approximately 1 in 2000 births. There are various degrees of
severity with each defect.

Etiology
Idiopathic (exact cause are unknown). Suspected causes include- mutant genes inherited from one or both parents, and teratogens (drugs, viruses, or other toxins that can cause abnormalities in a developing fetus).

Clinical manifestations
Separation of the lip alone. Separation of the palate.

 Separation of the lip and palate. Varying amounts of nasal distortion. Recurrent ear infections. Failure to gain weight. Nasal regurgitations during bottle feeding. Growth retardation. Misaligned teeth. Poor speech. Feeding problems.

Investigations
Cleft lip with or without the cleft palate is easily apparent at birth. Only cleft palate may be identified when thorough assessment of the mouth is done or when the infant has difficulty with initial feeding.

Complications
Recurrent ear infections Hearing loss Dental cavities Displaced teeth Poor speech Lip deformities Nasal deformities

Management
Treatment of cleft lip and cleft palate may require joint efforts of pediatrician, plastic surgeon, nurses, orthodontist, prosthodontist, and speech therapist. Surgical Management The cleft lip is usually repaired by about 2-3 months of age and cleft palate is usually repaired by about 18-24 months of age of the baby. Closure of the cleft lip is done firstly then the closure of the cleft palate. Cleft lip is generally repaired by Z-shaped sutures, to reduce notching of the lip. After the surgery, the suture line is protected from tension by an arched metal device taped to the cheek. Cleft palate surgery is postponed later in order to wait for the changes in the palate. Orthodeontic and prosthodontic treatment may be required to correct malposition of the teeth and maxillary arch.

 Children with cleft palate may have speech problem and may require speech therapy. The baby is anesthetized and asleep (general anesthesia), the tissues around the defect are trimmed and sewn together with several layers of stitches (absorbable sutures). The skin is sewn together with very small; fine stitches (sutures) to make the scar as small as possible. In cleft palate repair, tissue from the back of the mouth (pharynx) may be taken to add tissue to the deficient soft palate (this is called a pharyngeal flap). Occasionally more than one surgery is required for complete palate closure

General instructions Soon after the birth, the baby may look unattractive but the nurse should not show her reactions. The disfiguring defect may cause negative reaction and shock in the parents. The nurse should explain the positive aspects about the correction of the defect and other possible treatment. Feeding of an infant: The immediate problem faced is the feeding an infant with the cleft lip and palate, because this defect reduces the ability of the infant to suck. While feeding, the infant should be hold in upright position. A special cleft palate nipple can be used. A large and soft nipple with the large hole or a long and soft lamb's nipples are useful. When the infants have the problem to take feeds with the nipple, a syringe with the rubber tube may be used to feed.

Nursing Management

NURSING CARE PLAN

GOAL INTERVENTIONN RATIONALE

Pre-operative Care
1. Risk for Aspiration (Breast Milk or Mucus) related to anatomic defect.

The of

infant gagging

will or

Assess

respiratory

status

Allows problems.

for

early of

have no episodes aspiration.

and monitor vital signs at least every 2 hours. Position feedings. Feed needed. Burp frequently (after every 15-30 ml of fluid). Position feedings. Keep suction equipment and bulb syringe at bedside. upright for slowly and use as adaptive equipment on side after

identification

Prevents aspiration of feedings. Facilitates intake while minimizing aspiration. Helps to prevent and regurgitation aspiration. Minimizes passage of feedings through cleft. Suctioning necessary may to be remove risk of

milk or mucus.

2. Altered Nutrition: Less than Body Requirements related to the infant's inability to form an adequate seal for sucking

The

infant

will

Assess fluid and calorie intake daily. Assess weight daily (same scale, same time, with infant completely undressed).

Provides an objective measurement receiving mote of sufficient Using whether the infant is caloric intake to progrowth.

gain weight.

the

same

scale the

and when infant for

procedure weighing provides daily weights. Observe for any respiratory impairment. Any symptoms

comparability between of

respiratory compromise will interfere with the infant's ability Feedings are no to should signs suck. be of

initiated only if there respiratory distress. Facilitate breast-feeding. Breast milk is recommended as the best food for an infant. The process feeding promote between infant. Give the mother information on breast-feeding the infant with a cleft lip and/or palate such as plugging the cleft lip and eliciting a let-down reflex before nursing. If the mother is unable to breast-feed (or prefers not to), initiate bottle feeding: Hold infant in an upright or Facilitates swallowing Information specific may encourage and suggestions the of breastto and bonding mother helps

mother to persist with breast-feeding.

semisitting feeding.

position

for

and

minimizes

the

amount of fluid return from the nose. Small tire amounts the as infant do given at and as a

Feed small amounts slowly.

allow feeding do not quickly amounts larger

faster rate. They also decrease the calories used during feeding. Initiate nasogastric feedings if the infant is unable to ingest sufficient calories by mouth. Adequate must be nutrition maintained.

Use of a feeding tube allows the infant who has difficulty with oral feeding to receive adequate growth. nutrition for

Post-operative Care
3. Risk for Infection related to surgical procedure and accumulation of formula and secretions the oral cavity Assess vital signs every 2 The mucosal infection. infants tissue hours. Assess oral cavity every 2 hours or as needed for tenderness, of secretions. reddened Elevated Aids in temperature identifying

may indicate infection infection.

will heal without

areas, lesions, or presence

Cleanse normal

suture saline

line or

with sterile

Helps

decrease

the

presence of bacteria.

water if ordered. Cleanse the cleft areas by giving 5-15 ml of water after each feeding. If a crust has formed, use a cotton swab to apply a halfstrength peroxide solution. Apply antibiotic cream to suture line as ordered. Use careful hand washing and sterile technique when working with suture line Counteracts the growth of bacteria. Prevents the spread of microorganisms other sources from Prevents accumulation of which carbohydrates, encourage

bacterial growth. Helps loosen the crust, aiding in removal.

4. Ineffective Breathing Pattern related to anesthesia and increased secretions The infant will an Assess respiratory Allows problems. Enables early detection of abnormal respirations, facilitating prompt intervention. Keep suction equipment and bulb syringe at bedside. Gently suction and mist for if 2 oropharynx Provide first ordered. Reposition hours. every cool 24 Gentle suctioning will keep the airway clear. Suctioning that is too vigorous can irritate the mucosa. Moisturizes secretions to reduce pooling in lungs. Moisturizes oral cavity. Ensures expansion of all lung fields for early of

maintain effective

status and monitor vital signs at least every 2 hours. Apply a cardio respiratory monitor.

identification

breathing pattern.

nasopharynx as needed. hours

postoperatively

5. Altered Nutrition: Less Than Body Requirements related to surgery and feeding difficulties Maintain intravenous infusion as ordered. Begin with clear liquids, then give half-strength formula or breast milk as ordered. Use Asepto syringe or dropper in side of mouth. Avoids sulure line and resullant accumulation of formula in Ihat area. Do not allow pacifiers. Give high-calorie soft foods after cleft palate repair. Sucking can disrupt Provides NPO. Ensures adequate fluid when

The

infant

will

receive

adequate

nutritional intake. fluids and nutrienls.

sulure line. Rough foods, utensils, and disrupt site. slraws the could surgical