Structural Defects RN , P hD

,
,
C
C
IM
PT T
I, CP

Cleft Lip and Cleft Palate

a h Na ssa r
,
,
R N, P hD
yy alas a
a
Om aila H
S uh
Chapter 8 Page (302-307)

05/07/2023 1
 Objectives
By the end of this discussion, You will be able to:
C PT T
hD , , CP
• Explain the anatomy and formation of , P
palate IM I
, RN , C
a r
s cleft
• Differentiate between cleft lipasand h D
Ppalate
N R N,
• Discuss the etiology ayya h sa ,
m a la
O aila H
• Explain the pathophysiology
S uh
• Identify the diagnostic evaluation
• Discuss the therapeutic management
• Explain the nursing management
05/07/2023 http://www.firsttimeparentmagazine.com/expecting-a-baby-with-a-cleft-lip-or-cleft-palate/
2
 Before we Start
https://www.youtube.com/watch?v=IUr-5Rwy8VY
Explaining Cleft Lip and Palate (1 of 7) T T
CP
hD, I, CP
https://www.youtube.com/watch?v=y0-b6e_pweg
, P M
RN , C I
s a r, hD
s
aPhysiology N, P
Understanding Cleft Lip/Palate
h N , R
y y a la sa
a
m la H a
O a i
https://www.youtube.com/watch?v=iLbqzTlZ6yA
S uh
Development of the Face and Palate

https://www.youtube.com/watch?v=ini6hwyXDQo
Cleft Lip and Cleft Palate: For Students
05/07/2023 3
 Introduction
Formation of the palate
C PT T
• The palate develops from fusion of hD , , CP
, P IM I
the primary and secondary palate , RN , C
s a r P hD
N a s N,
a h a , R
Types of Palate: m ay y la s
O aila H a
• Primary S uh
• Secondary

05/07/2023 4
https://www.slideshare.net/prathyushaent/cleft-lip-and-cleft-palate-embryology-features-and-management
 Introduction
• The primary palate:
• Derived from the C PT T
hD , , CP
intermaxillary segment , P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
• The secondary palate:
a yy alas
Om aila H
• Formed by two palatine
uh
S
processes or palatal shelves
from the maxillary
prominences
05/07/2023 https://www.slideshare.net/prathyushaent/cleft-lip-and-cleft-palate-embryology-features-and-management 5
 Introduction

C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

05/07/2023
https://www.sciencedirect.com/topics/immunology-and-microbiology/secondary-palate
6
 Definition

Clefts of the lip (CL) and palate (CP) ARE: C PT T

hD , , CP
, P IM I
, RN , C
sa r P hD
• Facial malformations that Na s
occur Nduring
, embryonic development
a h a , R
a yy alas
Om aila H
• The most common u h congenital deformity of the head and neck
S

• May appear separately or, more often, together

05/07/2023 7
 Etiology

• Cause Is Unknown
C PT T
• Most cases results from combinationDof: , CP
, P h M I,
RN , C I
sa r , hD
- Genetic a s N, P
h N , R
a
yy alas a
a
m la H
O a i
- Environmental factors
S uh
• CL and CP may be caused by exposure to teratogens such as alcohol,

anticonvulsants
05/07/2023 8
 Etiology

• Use of phenytoin during pregnancy is associated with increase incidence

C PT T
hD , , CP
of CL. , P IM I
, RN , C
s a r h D
as RNwho
• The incidence of CL amongNmothers , P smoke during pregnancy is twice
ya h sa ,
ay inamothers
la
Om aila H
as great as the incidence who do not smoke during pregnancy
S uh
• Toxics: related to pesticides, herbicide and fungicides

05/07/2023 9
 Incidence
• Females have a higher frequency of isolated clefts
T of the secondary palate.
, C P PT
P hD I, C
• Unilateral clefts are nine times moreRN ,
common C IMthan bilateral clefs and occur
a r , hD ,
a ss , P
twice as frequently on theh leftN side.
, R N
a
yy alas a
a
m arelauncommon;
H
• Isolated bilateralOCLs a i approximately 86% present with
S uh
palatal clefts.

• Approximately 68% of unilateral CLs have an associated palatal cleft

05/07/2023 10
 Pathophysiology

• Cleft lip results in a failure of the maxillary C PT processes

T to fuse
hD , , CP
, P IM I
, RN , C
with the nasal elevationsaon s a r
the hD
frontal
P prominence to form
N s N,
a h a , R
ay y la s
Om a(that
the primary palate H ais normally takes place during the 6
ila th

S uh
week of embryonic development

05/07/2023 11
 Pathophysiology
Cleft lip (CL) alone:
C PT T
• Occurs in the midline and may involve the hD , and
soft , CP palates
, P IM I hard
, RN , C
• May vary from a small notch tossaarcomplete P hD cleft extending into the base of
N a R N,
a h
the nose (unilateral or bilateral) a ,
ayy alas
Om aila H
S uh

05/07/2023
https://www.rch.org.au/kidsinfo/fact_sheets/cleft_lip_and_palate_an_overview/ 12
 Types of Cleft lip Deformities

C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

05/07/2023 https://healthrow.net/cleft-lip-and-palate/ 13
 Types of Cleft lip Deformities

C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

05/07/2023 14
 Pathophysiology
Clefts palate (CP) results from:
C PT T
• Failure fusion of the secondary palate (hard hD ,and soft
, CPpalate) that takes
, P IM I
, RN , C
place normally between 7 – a12 s a rweeks P hD
of gestation
th
N s th
N,
a h a , R
ay y la s
O m la H a
• (unilateral or bilateral)a i
S uh

05/07/2023 15
 Pathophysiology
Clefts palate (CP):
C PT T
• Midline defect from bifid uvula to a complete hD , cleft, Cpalate
P
, P IM I that extends from
, RN , C
the soft palate into the hard palates a r P hD
Na s N,
a h a , R
ay y la s
Om aila H a
S uh

05/07/2023 16
 Pathophysiology
Clefts palate (CP) results from:
C PT T
• Failure fusion of the secondary palate (hardD,and soft CPpalate) that(unilateral
, P h M I,
or bilateral) RN , C I
s a r, hD
a s N, P
h N , R
y ya la sa
a a
Om aila H
S uh

05/07/2023 17
 C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

Variations in clefts of lip and palate at birth. A, Notch in vermilion border. B,

Unilateral cleft lip and palate. C, Bilateral cleft lip and palate. D, Cleft palate
05/07/2023
https://healthrow.net/cleft-lip-and-palate 18
 Cleft lip and Palate

Complete Unilateral cleft lip Tand palate

, C P PT
P hD I, C
RN , C IM
a r, hD ,
a ss , P
h N , R N
y ya la sa
a a
Om aila H
S uh

05/07/2023
https://embryology.med.unsw.edu.au/embryology/index.php/File:Cleft_lip_004.jpg 19
 Cleft lip and Palate

Complete bilateral cleft lip and palate

C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

05/07/2023 20
 Cleft lip and Palate

C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

05/07/2023 21
 Diagnostic Evaluation

• CL with or without CP is apparent at birth.

C PT T
hD , , CP
• CL is detected by inspection , P IM I
, RN , C
sa r P hD
N a
• CP is identified when the hexaminers N,
palpates the hard and soft palate with
a lasa , R
ay y
gloved finger O m H a
a ila
S uh
• Prenatal diagnosis with fetal ultrasound is not reliable until the soft tissues
of the fetal face can be visualized at 13 to 14 weeks.

05/07/2023 22
 Therapeutic Management

• It needs the cooperative efforts of a multidisciplinary health care

team: C PT T
hD , , CP
- Pediatrics , P IM I
, RN , C
sa r P hD
- Plastic surgery
Na s N,
a h a , R
- Orthodontics ayy alas
O m la H
- Otolaryngology and a i
audiology
S uh
- Speech/language pathology
- Nursing
- Social work
http://www.facesofhopeantigua.org/what-are-clefts.html
05/07/2023 23
 Therapeutic Management

The aims of therapeutic management are:

C PT T
hD , , CP
• Managing the deformity through surgical , P closure
IM I for both of CL& CP
, RN , C
s a r P hD
N a s N,
a h a , R
(The initial repair of CL&
a y y CP are
la s required within the first year of life)
m
O aila H a
S u h
• Preventing complications

05/07/2023 24
 Therapeutic Management

The aims of therapeutic management are:

C PT T
hD , , CP
• Facilitating normal growth and development , P M I
I the child
, RN , Cof
s a r P hD
Na s N,
a h a , R
• Surgery is now possible
a yyin younger
a la s neonates because of advance in
Om aila H
S u h
pediatric anesthesiology and neonatology

05/07/2023 25
 Surgical Correction: Cleft Lip

• Cheiloplasty
C PT T
hD , , CP
• Repair of CL is done between 2-3 N, P IM I
r , R D , C
ssa , P h
months Na R N
a h a ,
ayy alas
Omofaoral,
• Infant must be free ila H
S uh
respiratory or systemic infection first

• Different techniques are used

05/07/2023 http://craniofacialteamtexas.com/cleft-lip-and-cleft-palate/
26
 Surgical Correction: Cleft Lip

C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

http://craniofacialteamtexas.com/cleft-lip-and-cleft-palate /
05/07/2023 27
http://www.drtravistollefson.com/news/cleft_china.htm
 Surgical Correction: Cleft Lip Z- Plasty

• Utilizes a staggered PT T
D , C CP
, P h M I,
suture line (Z- Plasty) RN , C I
sa r , hD
a s N, P
h N , R
to minimize notching a
yy alas a
a
Om aila H
S uh
of lip from retraction
of the scar

05/07/2023 http://craniofacialteamtexas.com/cleft-lip-and-cleft-palate/
28
 Surgical Correction: Cleft Lip

C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

05/07/2023
http://cosmoplas.in/services/cleft-lip-and-palate-surgery/ 29
https://www.smbalaji.com/wp-content/uploads/2019/02/Unilateral-Cleft-Lip-and-Palate-Repair-India-700x400.jpg
 Surgical Correction: Cleft Palate
• Palatoplasty
C PT T
hD , , CP
, P M I
I advantage of normal
• Repair is completed between 6-12 months
, RN to
, Ctake
sa r P hD
Na s N,
a h a , R
palatal growth
a yy alas
Om aila H
S u h
• Repaired at this time to prevent speech and language problems

05/07/2023 30
 Surgical Correction: Cleft Palate
• Common techniques are used
CPT T
hD , , CP
• Around 20%-30% of children with repaired , P I exhibit features of:
CP Iwill
M
, RN , Cadditional surgery)
• Velopharyngeal dysfunction:sa(that r needs P hD
Na s N,
a h a , R
ay y la s
Om aila H
• Audible nasal air emission a
S uh
• Hypernasality

05/07/2023 31
 Surgical Correction: Cleft Palate

C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

05/07/2023
https://www.researchgate.net/figure/Patients-with-clefts-A-incomplete-unilateral-cleft-of-the-lip-B-unilateral-cleft-of_fig1_8494934 https://www.thieme-connect.de/products/ebooks/pdf/10.1055/b-0034-97703.pdf 32
 Long Term Problems

• Speech impairments PT T
D , C CP
, P h M I,
RN , C I
• Rotated, missing or malformedsteeth a r, PhD
Na s N,
a h a , R
ayy alas
Omskeletal
• Differences in facial
a ila H development
S uh
• Psychological problems to the children and their parents (social

adjustment)
05/07/2023 33
 Long Term Problems

• Hearing loss leads to speech and language C PT delays

T
hD , , CP
, P IM I
, R N , C
a r D
h drainage of the middle ear
• Hearing impairment dueNato ss improper
N , P
a h a , R
ay y la s
Om aila H a
• Insertion of pressure-equalizing (PE) tube (to facilitate fluid drainage)
S uh

05/07/2023 34
 Long Term Problems

• Additional surgeries to the nose, lip, and palate

PTthroughout childhood
D , C CPT
, P h M I,
RN , C I
• Alveolar bone graft to repair the s a r,
cleft D
defect
h
a s N, P
h N , R
y y a la sa
a a
Om a(when
• Orthognathic surgery
ila H child has reached skeletal maturity)
S uh
• Orthodontic treatment

05/07/2023 35
 Nursing Considerations

CPT T
• The immediate nursing problems is feeding problems
D , CP
, P h MI,
RN , C I
a r
• Support to the parents that include:
s , hD
a s N, P
h N , R
• Emotional support a
yy alas a
a
Om aila H
S uh
• Encourage expression of grief and fears
• Discuss the disease and the surgery
• How to handle their infant
05/07/2023 36
 Nursing Considerations

• Feeding: (big challenge)

C PT T
hD , , CP
• Growth failure due to feeding difficulties, P IM I
, RN , C
s a r P hD
Na s N,
a h a , R
yy alaformula,
• Children need higher-caloric
a s nutrition counseling and evaluation
Om aila H
S uh
• Check weight weekly

05/07/2023 37
 Nursing Considerations

• Feeding: (big challenge)

CPT feed
• Cleft Palate Foundation recommends mothers to ,breast
D PTtheir infants by:
C
, P h MI,
RN , C I
• Skin-skin contact s a r, hD
a s N, P
h N , R
ya
yand givela sa
a a
Om aila H it to the child (adapted bottle)
• Pumping the breast milk
S uh
• After bottle-feeding put the infant on mother’s breast (nonnutritive sucking)

05/07/2023 38
 Nursing Considerations

• Feeding: (big challenge)

C PT T
• Position during feeding (CL): hD , , CP
, P IM I
- Upright with the head supportedar, RN , C
ss P hD
by the caregiver’s hand or h N a
cradle R N,
a a ,
in the arm a yy alas
Om aila H
S u h
• Breast and bottle feeding without
difficulty

05/07/2023 https://www.clapa.com/treatment/feeding/ 39
 Nursing Considerations

• Feeding: (big challenge)

C PT T
hD , , CP
, P IM I
, RN , C
• Position during feeding for CP: s a r P hD
N a s N,
a h a , R
• Upright with the ayy supported
head a la s by
m
O aila H
h
the caregiver’sSuhand or cradle in the arm

05/07/2023 40
 Nursing Considerations

• Feeding: (big challenge)

• Modified bottles or specialized feeding systems , CPT PT
P hD I , C
R ,
• The soft palate must elevate and separateNthe I
oral and
C M nasal activities to achieve
r, D ,
negative intraoral pressure sa
a s h, P
h N , R N
y y a la sa
• Types of Bottles:Om a H a
a ila
Su( hHaberman bottle)
• Special Needs Feeder
• Pigeon
• Mead-Johnson Cleft Palate Nurser

05/07/2023 41
 Nursing Considerations
Types of Bottles
C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
ayy alas
Om aila H
S uh

05/07/2023 https://pediatrics.aappublications.org/content/early/2017/04/20/peds.2017-0628.figures-only?versioned=true 42
 Nursing Considerations
Types of Bottles

C PT T
hD , , CP
, P IM I
, RN , C
sa r P hD
Na s N,
a h a , R
http://www.poshmums.com/breastfeeding/haberman-customer-testimonials.htm

ayy alas
Om aila H
S uh

05/07/2023
http://cleftconnection.com/how-hard-could-eating-be/ http://www.facesofhopeantigua.org/what-are-clefts.html 43
 Nursing Considerations

• Feeding: (big challenge)

• Noisy feeders: C PT T
hD , , CP
• Inability to separate the nose and mouthN, P IM I
Swallow excessive amount of air
r , R D , C
s sa , Ph
N aor 2-3 Rtimes
N
a h
• Burping (every ounce of liquid
a , during feeding)
a yy alas
Om aila H
S u h
• Observe the child during feeding and stop feeding if he/she:
• Elevated eyebrows
• Wrinkled forehead
• Watery eyes

05/07/2023 44
 Nursing Considerations

• Preoperative Care:
CPT feeding
• Encourage the using of cup-feeding and syringe-
D , CPT
, P h MI,
RN , C I
s a r, hD
s
a Lip): N, P
• Postoperative Care a(Clefth N , R
y y la sa
a a
Om aisite
• Protect the operative a H
l ( the most important nursing intervention)
S uh
• Breast or bottle or syringe feeding !!!!!!!!!!!!!!!!!!

• Avoid prone position (why?????)

05/07/2023 45
 Nursing Considerations

• Postoperative Care (Cleft Lip):

C PT T
hD , , CP
, P IM I
RN , C
• Elbow restraints ?????? ssar, PhD
N a R N,
a h a ,
• Avoid suctioning a yyputting
or a la s tongue depressors, thermometers,
m
O aila H
S u h
spoons or straws
• Pain management
05/07/2023 46
 Nursing Considerations

• Postoperative Care (Cleft Lip):

C PT T
• Teach the parents how to:
hD , , CP
, P IM I
, RN , C
• Apply antibiotic ointment/3 sa r
days D
followed
P h by petroleum jelly/ several
Na s N,
a h a , R
weeks ayy alas
Om aila H
Suh by water or H2O2
• Clean the sutures
• Position during and after feeding

05/07/2023 47
 Nursing Considerations

• Postoperative Care (Cleft Palate):

C PT T
• Varies according to the surging’s preference
hD , , CP
, P IM I
, RN , C
• Observe closely for any signs
sa r of: P hD
Na s N,
a h a , R
yy alas
• Airway obstruction
a
Om aila H
S uh
• Hemorrhage
• Laryngeal spasm

05/07/2023 48
 Nursing Considerations

• Postoperative Care (Cleft Palate):

C PT T
• Observe O2 saturation
hD , , CP
, P IM I
, RN , C
• Use face mask s a r P hD
Na s N,
a h a , R
yyprevent
• Apply tongue stitchato a la s tongue from obstructing the airway
Om aila H
uh (optional airway compromise)
• Observe the vitalSsigns
• Evaluate any difficulties in breathing and/or swallowing

05/07/2023 49
 Nursing Considerations

• Postoperative Care (Cleft Palate):

C PT T
• Assess postoperative pain
hD , , CP
, P IM I
• Give Opiates/ acetaminophen , RN , C
sa r P hD
N a s N ,
• Give clear fluids for 24 hours
a hfollowed
a , Rby liquid diet for 2 weeks (use open cup)
a yy alas
• Soft diet Om aila H
S uh
• Avoid rigid utensils (spoons or straws), or hard-tipped cups

• Elbow restraints ??????

05/07/2023 50
 Discharge and Home Care

C PT T
hD , , CP
• Learn the feeding methods , P IM I
, RN , C
s a r P hD
N a s N,
a h a , R
• Clean suture line yy feedings
after
a a la s
m
O aila H
S uh
• Discuss the infant sleep position

05/07/2023 51
 Please Try to watch this one

• Operation Smile C PT T
hD, , CP
,P I
• https://www.youtube.com/watch?v=4nUkE1moT-g
IM
, RN , C
s r
a , Ph D
Na s N
a h a , R
ay y la s
Om aila H a
S uh

05/07/2023 52