Paediatric Cleft Lip and Palate
Cleft lip and palate are common malformations in children. The lips and palate are formed in the foetus during the second and third month of pregnancy. They are made from parts of the face that gradually grow together and merge. Sometimes, an incomplete union and cleft is formed. Clefts can occur in different parts of the face, but the most common place of the cleft is the lip, the alveolar ridge (jaw) and the palate. Sometimes the cleft is complete and at other times, only a part of the lip or palate is affected. The cleft can also be unilateral (one-sided) or bilateral (two sided), thus appearing in many different forms.
Did You Know?
- 1 out of 500 children is born with a cleft
- Parents who have had cleft malformations have a higher risk of having a child with a cleft as compared to other parents
- Parents that have one child with a cleft malformation are at risk that the next child will also have a cleft. The risk is, nevertheless, still rather low
Every child referred to the Cleft Centre at Al Jalila Children’s has an individual treatment plan, depending on the type of cleft. Children with a cleft in the lip and palate will consult at the outpatient clinic. The Cleft Surgeon will then inform them of the malformation and the treatment. After a clinical examination, parents are provided with adequate information about the malformation, the general care, and treatment plan. As part of the visit, a consultation with the orthodontist is also planned. The first appointment also includes a visit to the speech pathologist who provides information about speech, swallowing and the future follow-ups. A consultation with a feeding specialist can also be arranged as required.
|Type of Cleft||Information||Surgery 1||Surgery 2||Surgery 3||Surgery 4||Surgery 5||Surgery 6|
|Lip (L)||Within one month in an out patient visit||4-6 monthsLip-nose repair|
|Lip- alveolus(L-A)||Within one month in an out patient visit||4-6 monthsLip-nose repair||7-9 years bone transplant|
|Palate (P)||Within one month in an out patient visit||4-6 months soft palate closure||3 years hard palate closure|
|Unilateral Cleft Lip and Palate(UCLP)||Within one month in an out patient visit||4-6 months lip-nose repair and soft palate closure||hard palate closure||7-9 years bone transplant|
|Bilateral Cleft Lip and Palate(BCLP)||Within one month in an out patient visit||3 months lip adhesion one side||6 months soft palate closure and lip adhesion other side||10-12 months Lip-nose repair||2 ½ years hard palate closure||7-8 years bone transplantation||8-9 years bone transplantation|
Ears and Hearing
Hearing is important for the development of speech and language and should be tested early and regularly.
Children with cleft lip and palate have high risk for middle ear infection. Therefore, hearing has to be tested early and treatment should be provided, if hearing is affected.
Function of the Eustachian tube
In children with cleft lip and palate, the cleft palate often causes Eustachian tube dysfunction. The Eustachian tube connects the pharynx and the middle ear, regulating the pressure of the middle ear. An equal and normal pressure is a prerequisite for normal hearing.
Chronic inflammation of the middle ear can develop if the Eustachian tube is not functioning properly.
If the Eustachian tube is not functioning properly, chronic middle ear inflammation may result. Consequently, negative pressure can develop in the middle ear and fluid will be produced and accumulated. On examination, the fluid can be seen behind the eardrum and the negative pressure can be measured. The chronic inflammation will cause impaired hearing, varying in severity. It is common in children with cleft lip and palate but can also be present in children without any malformation. Often the chronic inflammation will resolve spontaneously, but occasionally drugs such as antihistamines and decongestants are used initially. If chronic inflammation persists for a long time, the eardrum has to be punctured, the fluid removed by suctioning and the pressure normalized and the hole in the eardrum will have to be kept open for a longer period of time by plastic tube (grommets) insertion to prevent build up of new fluid. This treatment is performed by an Ear Nose and Throat (ENT) surgeon under general anaesthesia. Children will be seen on regular check up by ENT. However, ear problems may resolve after palate surgery and as the child grows.
The speech pathologist can provide, from an early age, information about feeding, oral motor function and speech.
The speech pathologist will see the newborn child at the hospital and give the first information about feeding and at further follow-up the family will get more information about:
- Development of oral motor function
- Speech and language development and how a cleft lip and palate can affect the speech
- Pre and post counselling on feeding and swallowing
The speech pathologist will see the patients on regular follow-ups until adulthood.
If the cleft involves the palate, a speech pathologist in the cleft team, will see the child around the age of one year, to provide information and assess babbling.
The lips, tongue and the soft palate have important functions in speech. The soft palate closes the passage between the oral and nasal space and is used in pronunciation of most speech sounds. It is necessary to be able to move the lips, tongue and palate fast and with precision in order to have correct and clear articulation.
A remaining cleft in the hard palate (residual cleft) after soft palate repair can make it more difficult to develop normal articulation and can result in incorrect patters of speech. However, the child has a good chance of spontaneously correcting theses anomalies when the residual cleft is closed at later age. A normal pattern for sucking and swallowing by early operation of the soft palate and the lip, improves the development of pronunciation of the speech sounds.
The child will be seen for further follow-ups by the speech pathologist. Some children with cleft lip and palate will need speech therapy to correct articulation and also develop speech and language. Such speech therapy can start at around three years of age, sometimes earlier. Speech and language is also improved by playing and by interacting with people around the child. Speech pathologists will provide information to the parents, teachers and staff in day-care centres.
In patients with cleft lip and palate or only cleft palate, recordings and evaluation of the speech and the function of the palate are performed by a speech pathologist on several occasions and in conjunction with visits to the cleft team.
Orthodontic treatment will start at age of 6 ½ -8 years. The final phase of orthodontic treatment is usually performed when patient is 12-14 years of age.
From early childhood, an orthodontist is engaged is evaluating growth and development of the jaws, teeth and occlusion. Children in need of a bone transplant often require active orthodontic treatment prior to the operation. The next phase of orthodontic treatment is usually implemented when all permanent teeth have erupted (12-14 year). Orthodontic treatment is usually done with fixed orthodontic appliances. If there are teeth missing in the cleft region, this can be treated by prosthesis or the space can be closed using orthodontics. The prosthodontic treatment will not be started until the patient is 18-20 years old. A titanium implant or a conventional crown and bridge can be used.