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The term "cleft lip and palate" includes a group of congenital malformations on the face. Here, the upper lip, the upper jaw and hard and / or soft palate have a gap. This pervades either all of these face structures or only parts of them.
In the upper lip, the cleft is reminiscent of the Y-shaped retraction to the nose on the upper lip of a hare. Therefore, the cleft lip and palate is colloquially referred to as harelip. The medical term is cheilognathopalatoschisis.
The treatment of a cleft lip and palate is tedious and complicated. It is usually done at specialized cleavage centers. Oral and maxillofacial surgeons, orthodontists, otolaryngologists and speech therapists work together to create a suitable treatment plan for every patient.
As a rule, the treatment of a cleft lip and palate is approached soon after the diagnosis. The essential steps take place during the first years of childhood of the children. Treatment on adult patients is rare in Germany.
The primary goal is to close the gap or the gaps in all sections (primary treatment). Functional restrictions and subsequent growth disturbances are to be avoided. In addition, attention is paid to a cosmetically satisfactory result. In addition to the actual operations for crevice closure usually requires some preparatory measures and any surgical intervention in the further course of therapy (secondary treatment).
There is no standard of treatment for a cleft lip and palate. The different treatment centers are sometimes very different, especially the timing vary. The basic procedure is usually the same.
In this context, the word “cleft” means incorrect formation. Lip cleft forms between the upper lip and nose. It may happen when some certain parts of fetus’ face did not close or did not grow properly during pregnancy.
In some kids, the pathology is pronounced only with a small trough on a lip. Other kids may have one or even two sides of lips pulled to the nose. In layman’s terms, it’s also called “harelip”, though today this word is less widespread.
What is cleft palate?
Cleft palate can appear when the cavity of pharynx in fetus did not close totally during pregnancy. The back part of the pharynx is also called the soft palate, and the front part – the hard palate.
Cleft palate can be of different severity level. Some babies only have a small hole on the back soft palate, while the other kids may have the pharynx cavity entirely divided in half. Sometimes there can be bone cleft palate covered with mucous membrane. This way, when the newborn baby is examined, it’s crucial to palpate the palate to define whether there’s a bone split.
Cleft palate can occur together with cleft lip, though both diseases can develop separately.
Just like a “harelip”, the term “wolf jaw” is rarely used today, and is even considered to discriminate people.
Why cleft palate and cleft lip develops?
When the fetus is growing in mother’s womb, its skull, face and head are gradually growing together. Cleft palate or cleft lip can happen, if some of these areas did not entirely connect before the birth.
Cleft palate and cleft lip may also be inherited. If the first child has this defect, there’s a high chance that the other kids will have it, too. However, there are some other factors contributing to the pathology, and it’s impossible to make a precise diagnosis concerning the frequency of this disease. For instance, in Germany, every 500th child has palate cleft or lip cleft, but the reasons for that are mostly unknown. However, there are some factors that promote development of this pathology:
- If a mother drinks alcohol or smokes during pregnancy, the risk of abnormalities increases, though the exact reasons for that are unknown.
- Some drugs may also contribute to pathologies. If you have chronic diseases and you need to take medications, consult with your doctor when planning to have children.
- The older parents are, the more often cleft palate or cleft lip occurs in children.
Use of folic acid during the first three months of pregnancy and healthy eating helps to prevent development of this disease.
How long will my child look like that? How these pathologies are typically cured?
As soon as your child turns 2-3 months, you can have the cleft lip operated. Children at this age recover very quickly, so they can be left in a hospital for three-five days. Nutrition and breastfeeding won’t cause any problems: doctors in the hospital will explain how it can be done after the operation.
Cleft palate is usually corrected when a child turns one year, because this is when intense jaw growth stops. The operation is performed under general anesthesia, and just like in case with cleft lip operation, it takes about one and a half hour.
Which problems can cause cleft lip or cleft palate?
Some parents are seriously concerned about child’s appearance, though surgery allows making the gap almost invisible. Kids may also be worried about their look, and that can cause social and emotional problems. However, the vast majority of children manage to deal with the outcomes of operation normally.
Lip and palate cleft may also complicate eating. In order to get enough water, a kid forms vacuum inside the mouth and keep the tongue in some certain place. During the first days of baby’s life, a special palatal plate is installed in kid’s mouth which makes breastfeeding possible and helps the baby to suck normally.
If a kid has cleft lip only, breastfeeding is still possible. Parents should consult with a lactation specialist who has experience of working with such children.
If a child has cleft palate, probably, breastfeeding may not be possible. However, you can feed the baby with decanted breast milk. You may need a special bottle for a baby to drink from. It’s also crucial to have a palatal plate for breastfeeding.
When a child grows up, it may become difficult to pronounce some words. Therefore, doctors recommend finding a speech therapeutist to perform several speech therapy sessions and make kid’s speech clear and understandable. Since the operation is performed during kid’s first year of life, e.g. before speech starts forming, there are much less problems than it used to be.
A kid with such pathologies is more prone to ear infections than the other children. It happens due to the fact that the ear is connected with the throat through a thin tube. Therefore, your kid may need to have the hearing checked regularly to make sure that fluid does not collect in the middle ear. Otherwise, treatment may require injection of a tympanostomy tube (shunt).
Besides, a child may need special dental assistance. Probably, special dental brackets or clamps may be required to make teeth grow straight, and special care is also required to prevent tooth decay.
How cleft lip and cleft palate are diagnosed?
At the second ultrasound examination that is performed at the 20th week of pregnancy, a doctor can define the abnormality, if the fetus is located in a convenient position. Women who have family history of cleft lip or cleft palate should inform the doctor about it so that he or she paid particular attention to this pathology. The diagnosis doesn’t matter before birth, but parents can learn about treatment options beforehand.
Facial cleft with lip damage can be defined with an unarmed eye right after the birth. However, palatal cleft covered with mucous membrane is much more difficult to distinguish. In all cases, detailed examination of face, mouth cavity and throat is obligatory for all newborn babies. If a palatal or lip cleft is revealed, a pediatrician will inform a specialist of maxillo-facial surgery about it. During a more detailed examination, this specialist will estimate the abnormality and discuss the following steps with child’s parents.
Some kids with this disease often suffer from other abnormalities of development, for instance, of kidneys and heart. To prevent such abnormalities and defects, additional examinations are required, such as kidney sonography or electrocardiogram (ECG).
How lip, palate or jaw cleft is treated?
The type of treatment depends on the form and severity of lip and palate cleft. Treatment is always aimed at one and the same thing: to restore normal appearance; at the same time, it’s necessary to ensure normal abilities of speech, hearing, eating, drinking and breathing, because it will guarantee normal growth and development of a child. This is why treatment should be performed in a specialized center that focuses on such type of pathologies. Such centers provide multi-disciplinary approach and help of different specialists: pediatricians, maxillo-facial surgeons, orthodonts, ear nose throat doctors, speech therapists and psychologists.
The cleft formation affects both soft and hard palate, many specialized centers start treatment of newborn babies from the first days of their life. First, a doctor makes an impression of the upper jaw and makes a palatal plate that is used for breastfeeding. It detaches nose cavity from mouth cavity so that a child could drink normally. Besides, this plastic plate should regularly be adjusted to promote normal location and functioning of the tongue and correct formation of the jaws and the palate. It makes the upcoming surgery easier.
Cleft lip can be surgically closed at the age of three-six months. A baby should weigh more than 5 kilos when the operation is performed. The opinions regarding an optimal age period for palatal surgery differ. From one point of view, palatal cleft should be closed as soon as possible to exclude problems with speech development. From another, later surgery is preferred due to the reason that scars may affect normal development of the jaw. This is why the vast majority of children go through surgery when they are about one year old – the time when a baby starts learning to speak.
However, to achieve optimal results of treatment, additional operations can be required all the way to the adult age. Such procedures may include lip or nasal septum protrusion, and operations for improvement of speech. Sometimes jaw is closed with the help of a surgery when it has totally ossified. A child gets nine years old by this time.
If a kid has problems with hearing and/or suffers from often middle ear inflammation (otitis), a doctor can install a tympanostomy tube for a start – it will ensure drainage of the middle ear.
Prognosis for lip, palate or jaw cleft
Thanks to modern surgical methods and additional conservative therapies, such as speech therapy and jaw orthopaedics, treatment of lip and palatal cleft has become pretty successful. It concerns both aesthetic and functional problems connected with the abnormality. At the very least, doctors manage to correct abnormalities of hearing, speech and eating so that a child would live a normal life and develop.
To define and treat possible abnormalities and problems, regular examinations are required at the early stage. All kids with lip cleft should go through routine examinations once a year prior to the moment they grow up and stop developing.
Can you avoid lip, palate or jaw cleft?
In fact, birth of a kid with cleft lip is mostly a chance circumstance. However, the risk of abnormality can be drawn to minimum. The most efficient preventative measure is healthy eating, and a pregnant woman should obtain from alcohol and smoking. When the pregnancy starts, or before conceiving, women should take folic acid. Experts recommend taking 400 mcg of folic acid daily during the first trimester of pregnancy.