Chapter 14 Cleft Lip and Cleft Palate
PATHOPHYSIOLOGY
Cleft lip and cleft palate are the outcomes of the failure of the soft tissue and/or bony structure to fuse during embryonic development. Cleft lip is a separation of the two sides of the lip. It may affect both sides of the lip as well as the bone and soft tissue of the alveolus. Cleft palate is a midline opening of the palate that results from the failure of the two sides to fuse during embryonic development. The exact cause is unknown, but in most cases it is thought to be multifactorial (a combination of environmental and genetic factors). Clefting is usually an isolated event but may occur as part of a syndrome. A good physical examination is very important to identify any other malformations.
COMPLICATIONS
1. Speech and language: speech difficulties may include hypernasality, hyponasality, and compensatory articulation.
2. Dental: malocclusion may occur, with abnormal tooth eruption pattern and abnormal development of the way the mandible and the maxilla meet; excessive dental decay is not unusual.
3. Auditory: chronic otitis media, secondary to eustachian tube dysfunction, may result in hearing loss and speech delay.
4. Psychosocial: altered self-esteem and body image may occur.
LABORATORY AND DIAGNOSTIC TESTS
1. Multidisciplinary team evaluation to counsel parents on clefting and to prepare them for the treatment plan including the surgical plan.
2. Evaluation by a geneticist including laboratory and diagnostic tests if other anomalies exist.
3. Audiologic evaluation to determine if hearing loss is present and if the use of pressure-equalizing tubes is warranted.
SURGICAL MANAGEMENT: CLEFT LIP AND CLEFT PALATE REPAIR
Cleft lip is repaired at 8 to 12 weeks of age if the baby has demonstrated good weight gain. The usual suggestion is that the baby weigh 10 pounds at the time of cleft lip repair. Cleft lip repair is usually done by a plastic surgeon specially trained in the repair of clefts. The plastic surgeon may choose among several methods for repair of the cleft lip, depending on his or her training and experience. Some surgeons choose the Millard repair, which results in a zigzag scar on the lip. Others choose to place the suture lines where the lines of the columella would have been if the clefting had not occurred. Still others choose among other types of repairs. The goal of all cleft lip surgery is the same, however—to achieve lip competence and to create the most natural-appearing lip.
Cleft palate repair is usually performed when the child is 9 to 12 months of age, weighing 18 to 20 pounds. Palatoplasty involves reconstruction of the palatal musculature with the goal of creating an intact palate in order to develop normal speech.
NURSING ASSESSMENT
1. Assess feeding to determine if the baby is receiving adequate caloric intake for growth. Work with the family to develop the best feeding method for that baby. The following are broad guidelines for determining infant calorie requirements:
2. Assess parents’ interactions with infant for signs of healthy attachment.
3. Screen for maternal depression.
