CLEFT LIP AND PALATE

Presented by: Maqsooda sttar

Lecturer, snc
RN, RM, Post RN BSN
Dip in paediatric health
nursing
 Objectives
 At the end of session the students will be able to,
 Introduction
 Discuss incidence
 Explain embryological background
 Identified Etiology
 Describe problems associated with cleft lip and palate
 Enumerate management of cleft lip and palate
 INTRODUCTION

Congenital abnormal space or gap in the upper lip, and

palate ,tongue tie and tracheoesophageal fistula
 INCIDENCE
More common in south Asians: Less frequent in Africans:
Prevalence in Europeans and Americans:
1 in 750.
 Cleft Lip and Palate occur twice as often in boys as in girls
Isolated Clefts of Palate are more often in girls
75% of Clefts are Unilateral, rest are Bilateral
Left side is more involved than right side
 CLASSIFICATION
A‐incomplete cleft of the secondary palate.
B‐
Complete cleft of the secondary palate.

C‐Incomplete cleft of the primary and secondary

palate.
D‐Unilateral complete cleft of the 1 and 2
palates.

E‐bilateral complete cleft of the 1 and 2 palates.

 PRENATAL DIAGNOSIS
 Cleft lip can be easily diagnosed by performing
ultrasonography in the second trimester
 Diagnosing a cleft palate with ultrasonography is very
difficult
 Three-dimensional imaging has been introduced to prenatal
ultrasonography diagnostics of cleft anomalies
 ETIOLOGY
 Actually no one knows exactly what causes clefts” Multiple
factors may be involved, like:
 Genetics (inherited characteristic) from one or both parents
environmental factors
 Drugs: corticosteroids (anti-inflammatory), phenytoin
(anticonvulsant)
Infections: like rubella during pregnancy.
 Alcohol consumption, smoking, hypoxia during pregnancy,
some of dietary and vitamins deficiencies (like folic acid and
vitamin A deficiency)
Maternal Age
 Problems Associated With Cleft
Lip and Palate
 Feeding
 Dental problems
 Nasal deformity and esthetic problems
 Ear problems
 speech difficulties
 associated anomalies
 FEEDING DIFFICULTIES
 Cleft lip: makes it more difficult for an infant to suck on a
nipple.
 cleft palate: may cause formula or breast milk to be
accidently taken up into the nasal cavity.
 inability to create negative pressure inside oral cavity
frequent regurgitations.
 upper respiratory tract infections.
 Dental Problems
Local Dental Problems:
 Congenitally Missing teeth, Hypodontia, Hyperdontia,
Oligodontia
 Presence of natal and neonatal teeth
 Anamalies of tooth morphology like microdontia,
macrodontia etc
 Fused teeth
 Enamel Hypoplasia
 Poor periodontal support, early loss of teeth
 Orthodontics Problems:
 Class III tendency
 Anterior and Posterior Cross bite
 Spacing and crowding
Nasal deformity and esthetic problems
 Facial Disfigurements
 Poor nasal shape
 Scar marks of surgeries
 Poor lip function during speech
 Poor dental alignment and smile
 Ear Problems
 Middle ear disease - 22% to 88%
 Conductive hearing loss and chronic suppurative otitis
media may result
 Speech Problems:
 Hearing loss hampers(restrict the movement) proper development of speech
 Velopharyngeal Insufficiency (VPI)
 Abnormal air

Velopharyngeal Insufficiency
MANAGEMENT OF CLEFT
LIP AND PALATE
SCHEDULE OF TREATMENT
Birth:
 Initial Assessment

 Pre-surgical assessment
 3 Month:
 Primary Lip repair
9-18 month:
 Palate Repair
2 Year:
 Speech assessment
 3-5 Year:
 Lip Revision Surgery
 Conti…
8-9 Year:
 Initial interventional Orthodontics
Preparation for alveolar bone grafting
10 Year:
 Alveolar Bone Grafts
12-14 Year:
 Definite Orthodontics
16 Year:
 Nasal Revision Surgery
17-20 Year:
 Orthognathic Surgery
Multidisciplinary Cleft Lip
And Palate Team
 Genetic Scientist
 Pediatrician
 Pedodontist (specializes in children's dental care.)
 Orthodontist(who is qualified to treat irregularities in the teeth and jaws.)
 Oral and Maxillofacial Surgeon
 Prosthodontist(a specialized branch of dentistry dedicated to making dental prosthetics
(artificial teeth) for damaged or missing teeth.)

 Plastic Surgeon
 Psychiatrist
 Speech Therapist
 Feeding
• Cleft lip= makes it more difficult for an infant to suck on a
nipple
use special nipples to allow the baby to latch properly
(either pump or use formula)
Cleft Palate= may cause formula or breast milk to be
accidentally taken up into the nasal cavity
don’t feed baby without palatal obturator (prosthetic palate)
feed in an upright position to keep milk from coming out of
the nose
Pigeon Feeder Dr. Brown’s Natural Flow to relieve gas
Mead Johnson/Enfamil Cleft Feeder Special Needs Feeder / Haberman Feeder
 NURSING MANAGEMENT

• A complete and thorough process of care should be

undergone by the newborn with cleft lip and cleft palate.
 Nursing Assessment
• One primary concern in the nursing care of the newborn with a
cleft lip and cleft palate is the emotional care of the newborn’s
family.
• Interview. In interviewing the family and collecting data, the
nurse must include exploration of the family’s acceptance of
the newborn; conduct a thorough interview with the caregiver
that includes a question about the methods they found to be
most effective in feeding the infant.
• Physical exam. Physical examination of the infant includes
temperature, apical pulse, and respirations; listen to breath
sounds, observe skin turgor and color, infant’s neurologic
status, noting alertness and responsiveness.
 Nursing Diagnoses
• Based on the assessment data, the major nursing diagnoses
are:
• Anxiety of family caregivers related to child’s condition and
surgical outcome.
• Deficient knowledge of family caregivers related to care of
child before surgery and the surgical procedure.
• Risk for aspiration related to a reduced level of
consciousness after surgery.
• Ineffective breathing pattern related to anatomical changes.
• Risk for deficient fluid volume related to NPO status after
surgery.
• Acute pain related to surgical procedure.
 Nursing Care Planning and Goals
• Goal setting and planning must be modified to adapt to the
surgical plans; the major goals include:
• Maintaining adequate nutrition.
• Increasing family coping.
• Reducing the parents’ anxiety and guilt regarding the
newborn’s physical defects, and preparing parents for the
future repair of the cleft lip and palate.
 Nursing Interventions
• Nursing interventions for the patient with cleft lip and palat
are:
• Maintain adequate nutrition. Breastfeeding may be
successful because the breast tissue may mold to close the
gap; if the newborn cannot be breastfeed, the mother’s
breast milk may be expressed and used instead of formula; a
soft nipple with a cross-cut made to promote easy flow of
milk may work well.
• Positioning. If the cleft lip is unilateral, the nipple should
be aimed at the unaffected side; the infant should be kept in
an upright position during feeding.
 Conti…

• Tools for feeding. Lamb’s nipples (extra long nipples) and

special cleft palate nipples molded to fit into the open palate
area to close the gap may be used; one of the simplest and
most effective methods may be the use of an eyedropper or
an Asepto syringe with a short piece of rubber tubing on the
tip (Breck feeder).

• Promote family coping. Encourage the family to verbalize

their feelings regarding the defect and their disappointment;
serve as a model for the family caregiver’s attitudes toward
the child.
 Conti…
• Reduce family anxiety. Give the family information about
cleft repairs; encourage them to ask questions and reassure
them that any question is valid.
• Provide family teaching. Explain the usual routine of
preoperative, intraoperative, and post operative care; written
information is helpful, but be certain the parents understand
the information.
• alate care:
 Evaluation

• Major goals for the care of the infant with cleft lip and cleft
palate include:
• Maintained adequate nutrition.
• Increased family coping.
• Reduced parents’ anxiety and guilt regarding the newborn’s
physical defects.
 Documentation
• Documentation for a patient with cleft lip and palate include the following:
• Assessment findings, including current and the past coping behaviors, emotional response
to situation and stressors, support systems available.
• Level of anxiety and precipitating/aggravating factors.
• Description of feelings.
• Awareness and ability to recognize and express feelings.
• Client’s description of response to pain, specifics of pain inventory, acceptable level of
pain.
• Plan of care.
• Teaching plan.
• Responses of family members/client to interventions, teaching, and actions performed.
• Attainment or progress toward desired outcomes.
• Modification to plan of care.
• Long term plan and who is responsible for actions.
• Specific referrals made.
 PRESURGICAL ORTHOPEADICS
• Reduces the size of cleft; Aids in Surgery
2. Partial obturation aids in feeding
3. Parental Reassurance at a crucial time
Maxillary Strapping
Nasoalveolar Moulding Appliances (NAM)
 Pre-operative Nursing Care Of
Cleft Lip
• Feeding to child in an upright position.
• Feeding with soft large –holed nipple or rubber tipped
syringe or cleft lip of palate nurser.
• Burp frequently because of swallowed air.
• Teach parents to give water after each feeding to cleanse
the infant’s mouth.
• Prevent infection from irritating the lip:
• Restrain infant’s arms, if needed.
• Provide a pacifier to increase suckling pleasure.
 Post-operative Nursing Care
• Maintain patent airway
• Problem because of edema of the nose, tongue and lips
combined with infant’s habit of breathing through the
mouth.
• Proper equipment such as laryngoscope, endotracheal tube
and suction at or near the bedside.
• Cleanse the suture line to prevent crust formation and
eventual scarring.
 Conti…
• Prevent crying because of pressure on suture line
(encourage the parent to stay with the infant.
• Place the infant in a supine position with arm or elbow
restraints:
• Change position to side or sitting up to prevent hypostatic
pneumonia.
• Remove restraints only when supervised.
• Feed ( same as before surgery)
• Support the parents by accepting and treating the infant as
normal.
 After The Surgery for Cleft Lip
• The child may be irritable following surgery. Give
prescribed medications to the child. Child may also have to
wear padded restraints on his/her elbow to prevent her from
rubbing at the stitches or surgery site.
• Child’s upper lip and nose will have stitches where the cleft
lip was required. It is normal to have swelling, bruising and
blood around these stitches.
 Pre-operative Nursing Care Of
Cleft Palate.

• Same as for infants with cleft lip except:

• Feed upright to prevent aspiration.
• Feed by gavage, if necessary.
• Encourage early use of spoon and cup.
• Teach parents the need for proper dental hygiene and the
importance of regular dental supervision.
 Post-operative Nursing Care
• Same as for infants with cleft lip except:
• When trying to maintain a patient’s airway, try to avoid using suction
that traumatizes the operative site.
• Place the child in a prone Trendelenburg position to prevent aspiration
and promote postural drainage.
• Avoid trauma to suture line by telling child not to rub tongue on roof of
mouth , avoid the use of straw, spoon or toothbrush.
• Provide liquid diet, no milk because of curd formation on suture line.
• Recognize the need for emotional support of parents since recovery is
longer and prognosis is uncertain.
After surgery for Cleft Palate.
• This surgery is usually more involved and can cause more discomfort
for the child that the cleft lip surgery. Physician may order pain
medications to relieve pain. As a result of the pain and the location of
surgery, child may not eat or drink as usual. An I/V catheter will be used
to give the child fluids until he/she can drink adequately.
• The child will have stitches on the palate where the cleft was repaired.
The stitches will dissolve after several days. In some cases packing will
be placed on the palate. So, do not take packing out unless ordered by
the physician.
• There may be some bloody drainage from the nose and mouth and will
lessen after first day.
• There may be some swelling at the surgery site, which will diminish
substantially in a week.
• For two or three days child will feel mild pain that can be relieved by
non-aspirin pain medications.
 Conti…
• Many infants show signs of nasal congestion after surgery. These signs
may include nasal snoring, mouth breathing and decreased appetite.
Physicians may prescribe medications to relieve the nasal congestion.
• Child will be on antibiotics to prevent infection.
• A small amount of water should be given after every feed to clean the
incision.
• Child should be given breast feeding, bottle feeding or cup feedings
after surgery. Straw or pacifiers should not be used as both could
damage surgical repair.
• Child can walk or play calmly after surgery. He/she should not run or
engage in rough play or play with mouth toys one to two weeks after
surgery.
• Follow up with surgeon and cleft team is important.
 Practice Quiz: Cleft Lip and Cleft Palate
• 1. When assessing a child with a cleft palate, the nurse is aware that the child
is at risk for more frequent episodes of otitis media due to which of the
following?
• A. Lowered resistance from malnutrition.
B. Ineffective functioning of the Eustachian tubes.
C. Plugging of the Eustachian tubes with food particles.
D. Associated congenital defects of the middle ear.
• 1. Answer: B. Ineffective functioning of the Eustachian tubes.
• B: Because of the structural defect, children with cleft palate may have
ineffective functioning of their Eustachian tubes creating frequent bouts of otitis
media.
• A: Most children with cleft palate remain well-nourished and maintain adequate
nutrition through the use of proper feeding techniques.
• C: Food particles do not pass through the cleft and into the Eustachian tubes.
• D: There is no association between cleft palate and congenital ear deformities.
 REFERENCE
 Hockenberry, m and wilson, d. (2015) wong's nursing care
of infants and children. 10th edition.
 Basis of pediatrics
 Manual of neonatal care,7th ed, john p. Cloherty. Md,eric
Eichenwald, md,anne r. Hansen, md, mph,ann r stark, md
 Basic of peadiatric 7th edition (pervez akber khan)
THANK YOU