Cleft Lip
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Postoperatively, these patients are followed by multiple specialties from
infancy into adulthood. Concomitant cleft palate repair is ideally performed
from 9 to 12 months followed by close speech evaluation and follow up at 2
to 3 years of age to rule out any concomitant issues with swallowing or
speech. A concomitant cleft palate can result in speech and swallowing issues
as a result of anatomic abnormalities that result from the inability of the soft
palate to rise against the posterior pharyngeal wall and separate the
nasopharynx from the oropharynx (referred to as velopharyngeal
insufficiency). Alveolar bone grafting, generally using cancellous bone from
the iliac crest to close the alveolar gap is performed at 7 to 9 years of age per
the discretion of the orthodontist when the permanent maxillary canines erupt.
Following this, surgeries with ear, nose, and throat specialist or plastic
surgeon for correction of nasal cleft deformity and scar revisions as well
as orthodontics are done at various ages depending on the patient's needs.
Final evaluation at the age of skeletal maturity, generally from 16 to 18 years
of age, will evaluate the need for orthognathic surgery to create different
pattern osteotomies in the mandible or midface/maxilla to correct various
skeletal abnormalities associated with cleft lip deformity.
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Complications
Hypertrophic scarring
Poor cosmesis
Postoperative and Rehabilitation Care
Postoperative feeding in infants with cleft lip needs special attention.
Conventional feeding strategies i.e. breastfeeding or bottle-feeding are
generally avoided in the post-operative period to minimize the tension on the
wound. [12] Surgeons more often advise spoon-feeding as an alternative
feeding strategy. Apart from spoon-feeding, various other modes including
syringes, cups, soft nipples, etc have also been tried by clinicians across the
globe. Although a considerable proportion of surgeons support the idea of an
alternative feeding strategy, there are some that oppose this practice. There is
sufficient literature highlighting the inconsolable crying and wriggling of the
infant after the introduction of alternative feeding methods in the post-
operative period. [12] This results in poor feeding and in turn affect wound
healing. Thus, major changes in feeding may cause weight loss in the infant
making a particular alternative method counterproductive. Therefore,
alternative feeding methods must be encouraged in children who have
undergone cleft lip repair to avoid unnecessary tension on the operated area,
but the issue of increased wound dehiscence due to the continuation of
conventional feeding strategies is still not proven.
Enhancing Healthcare Team Outcomes
Overall, it cannot be stressed enough that proper care of each cleft lip patient
takes a collaborative effort between multiple specialties. The techniques and
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timing of medical interventions and surgeries mentioned here are a consensus
in the current practice, but there is a wide variation based on geographic
location and resources. Ultimately, treatment must always be tailored to the
individual. In all cases, treatment of cleft lip requires an interprofessional
team from many disciplines; and often these children need to be followed for
many years.
Nurses who look after these infants should be fully aware of the risk of
aspiration, airway obstruction, and difficulties with feeding. There is no single
method of feeding that works in all children and the mother should be
educated on the different techniques to help the infant latch on the nipple.
Similarly, there is no one ideal bottle or nipple that can help infants with cleft
lip suck. In general, the recommendations are a soft nipple that may need to
be angled.
As the child grows, he or she may require training from a speech therapist. A
nurse practitioner should follow the child as an outpatient and if any issues
come up, the interprofessional team should be notified. Most children need
countless dental visits to assess dental growth and alignment.
Because of the cost of cleft lip repair easily runs into 6 figures, a social
worker should be involved to ensure that no child is denied care and is
provided with all support necessary.
Since facial aesthetics are compromised, most children need some type of
emotional support; hence a mental health nurse should provide counseling.
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Finally, the mother should be taught about the potential for aspiration and
choking. If the infant fails to gain weight, a visit to the pediatrician is highly
recommended.[13][14]