CLEFT LIP AND CLEFT PALATE

Sharada Pathak
M.Sc. Nursing
Department of Medical Surgical Nursing
2014 Batch
 Session objectives
• Define cleft lip and cleft palate
• State the epidemiology
• Explain the pathophysiology and etiology
• List the clinical features
• Identify the diagnostic investigations
• Describe the management
• Discuss the nursing management
 Introduction
• Congenital anomalies resulting in structural facial malformation
• Openings or splits in the upper lip, the roof of the mouth (palate) or both.
• Usually apparent at birth
 Epidemiology
• The lip, or the lip and palate, fail to close in approximately 1 in every 1,000
neonates.

• Cleft lip (with or without cleft palate) occurs more frequently in males, and
isolated cleft palate is more frequent in females.

• Cleft lip/palate is most prevalent among certain groups of Native Americans (3.6
per 1,000 births) with the next most affected group being Asians (1.7 to 2.1 per
1,000 births)

• Combination of cleft lip and palate occurs in approximately 50% of cases; cleft lip
alone occurs in about 25% of cases; and cleft palate alone occurs in about 25% of
cases.

• Genetic/hereditary predisposition; a fetus with an affected parent or sibling has a

2% to 4% risk compared to 0.15% risk of the general population.
 Pathophysiology and Etiology
• A failure of embryonic development, resulting in
defect syndromes associated with other anomalies.

• Environmental causes:
 anti-epileptic medications taken during pregnancy
 Maternal smoking
 Heavy alcohol intake
 Infections, folic acid deficiency, and vitamin A
intoxication.
 Types of Defect
• Cleft lip prealveolar cleft :
– Varies from a notch in the lip to complete separation of the lip
into the nose
– May be unilateral or bilateral
– Failure of maxillary process to fuse with nasal elevations on
frontal prominence; normally occurs during fifth and sixth
weeks of gestation
– Merging of upper lip at midline complete between seventh and
eighth weeks of gestation
 Isolated Cleft Palate Postalveolar Cleft:
– Cleft of uvula
– Cleft of soft palate
– Cleft of both soft and hard palate through roof of mouth
– Unilateral or bilateral
– Failure of mesodermal masses of lateral palatine
process to meet and fuse; normally occurs between
seventh and 12th weeks of gestation
 Clinical Manifestations
• Physical appearance of cleft lip or palate:
– Incompletely formed lip varies from slight notch in
vermilion to complete separation of lip.
– Opening in roof of mouth felt with examiner's finger
on palate.
• Eating difficulty:
– Suction cannot be created for effective sucking.
– Food returns through the nose.
– Nasal speech.
 Diagnostic Evaluation
• Prenatal ultrasonography
• MRI
• Photography to document the abnormality.
• Serial X-rays before and after treatment.
X ray
 Management
• Interdisciplinary approach begins early and
continues into late adolescence.

• Team of a plastic surgeon, otolaryngologist,

pediatric dentist, prosthodontist, orthodontist,
feeding specialist, speech pathologist,
audiologist, geneticist, psychologist, and
community health nurse.
• The cleft lip is generally repaired before the
palate defect.

• Cleft lip closure early at 6 wk to 6 months followed

by closure of the palate secondarily approximately
6 months later.

• Intraoral or extraoral prosthesis to prevent

maxillary collapse, stimulate body growth, and
aid in feeding and speech development; may be
used before surgical repair.
• Cleft palate repair at ages 6 months and 5 years;
Repair at age 9 to 18 months preferred because
speech patterns have not been set

• If repair is delayed to age 4 or 5, a special denture

palate is used to help occlude the cleft and aid in
establishing speech patterns.
 Post Op Management
• liquids or NPO until the next day
• If NPO, intravenous fluid
• Oximetry for 24 hours
• Prevention of infection
• Pacifiers and toys with sharp edges are avoided
• Usually discharged the day after the operation
 Post-Op Management
• The liquid diet for 2-3 days followed by soft diet
• Alternative methods of feeding if sucking
ineffective e.g soft nipple with crosscut

• Rubber-tipped syringe or dropper; the rubber

extension should be long enough to extend back
into the mouth to prevent regurgitation through
the nose. Direct tip to side of mouth, and feed
slowly
• Feed infant in an upright, sitting position to
decrease aspiration.
– Feed over 18 to 30 minutes.
– Smaller frequent feedings.
– Bubble frequently.
– Avoid repeated removal of nipple due to fear of
choking. This may only frustrate the infant, causing
crying and increasing chances of aspiration.
– Feed infant before he or she becomes too hungry.
 Complications
• Wound dehiscence and oronasal fistula
• Respiratory compromise secondary to obstruction
from the palate lengthening or sedation
Cleft repair