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Craniofacial Conditions

 

Cleft Palate

What is a cleft palate?

The palate is formed during weeks eight to 12 of pregnancy, when bone and muscle grow in from both sides of the upper jaw to divide the mouth from the nose. If this muscle and bone do not join completely, the baby is born with a cleft palate.

Is cleft palate always the same?

The palate is composed of two parts: a muscular part, known as the soft palate, and a bony part, known as the hard palate. Both the hard and soft palates can be involved to varying degrees which are illustrated in the diagram below.


Do children with a cleft palate always have a cleft lip?

Not necessarily. A child may be born with only a cleft palate, or with a cleft palate and cleft lip together, or with just a cleft lip.

Why was my child born with a cleft palate?

In rare cases, children with a cleft palate have one or more relatives with a cleft, but most commonly there is no known family history of the condition. Some researchers believe that environmental factors play a role in the development of cleft palate. A specialist on your child’s care team will discuss this with you.

What are my chances of having another child with a cleft palate?

The chances vary for each family. The members of your child’s care team, especially the geneticist, will give you more detailed answers to this question.

Research indicates that certain precautions may reduce the chance of developmental anomalies. Prior to conception, mothers should take a multivitamin that includes folic acid. Avoid smoking, alcohol, and taking other medications. (If you must take a medication, discuss it with your physician.)

Are special steps needed to feed my child?

There are several special types of bottles, known as  ‘cleft feeders,’ for infants with a cleft lip or palate.  A nurse will help you choose the kind that works best for you and your child. The nurse you also teach you how to use the cleft feeder and demonstrate the proper feeding technique. You can give your baby the same type of formula as a child without a cleft would receive.

Can I breast-feed my child?

Usually it is difficult for the baby with a cleft palate to be breast-fed; particularly in cases of complete left lip and palate, the infant may be functionally unable to nurse. Members of your child’s care team will evaluate the ability to breast-feed. If your child cannot breast-feed, you may wish to use a breast pump to collect your breast milk and feed it to your baby with a cleft feeder.

Is my child likely to develop hearing problems?

Ear problems are more common in a child with a cleft palate than in children with an intact palate.  This is because the tube that connects the middle ear to the throat does not drain well in a child with a cleft palate. Fluid collects in the middle ear space prevents sounds from reaching the inner ear, resulting in hearing loss. Bacteria grows in the fluid and causes an infection called otitis media. Because good hearing is crucial to a child’s ability to learn to speak, it is important that your child’s hearing is tested regularly.

Can such problems be treated or prevented?

Yes. An infant with a cleft palate, fluid build-up, and hearing loss should have a procedure to remove the fluid and insert a ventilation tube. This operation (called myringostomy), is done under general anesthesia and is usually performed at the same time as the cleft palate repair. The tiny ventilation tubes typically stay in place for nine to 12 months; an otolaryngologist (ear, nose, and throat specialist) should evaluate your child every six months. The tubes usually fall out on their own accord and do not require an operation for removal.  Unfortunately, about half of children with a repaired cleft palate require repeated insertion of tubes.

Will my child have speech problems?

Cleft lip alone does not result in speech problems; however, children born with a cleft palate cannot make certain speech sounds until the palate has been surgically repaired. This is because normal speech requires the muscles in the soft palate and the back of the throat to seal off the nasal passage so air passes only through the mouth. Because the muscles and tissue of the soft palate are not properly formed in children with a cleft palate, this closure doesn’t take place, and speech is impaired.

Can my child’s cleft palate be repaired?

Yes. The opening can be repaired in one operation.

When will my child’s cleft palate be repaired?

When your child is between eight and 10 months of age; repair of a cleft palate is a separate operation from cleft lip closure. A plastic surgeon on your care team will talk with you about the best surgical plan for your child. 

After your child’s palate is closed, the speech pathologist on your child’s care team will give you suggestions for home activities that can help in developing speech and language skills. Some children with a cleft palate have minor delays in acquiring those skills. This may be related to the temporary hearing loss associated with a cleft palate and the build-up of middle ear fluid. Most children quickly develop speech at a normal pace once the palate is repaired. A small percentage of children will need speech therapy to help them make speech sounds in a normal manner. The speech pathologist on the team will determine your child’s need for speech therapy.

How is my child’s cleft palate repaired?

In the operation, the plastic surgeon brings the existing muscles and tissues from the split palate together to close the opening. The figure below shows how the palate appears before and after repair.

The procedure is performed in an operating room under general anesthesia. Your child will stay in the hospital for one or two nights after the operation. Parents are encouraged to stay with the child in the hospital. The nurse will teach you how to care for your child after the operation.

As my child gets older, will another operation on the palate be needed?

About five to 15 percent of children will not be able to seal off the nose during speech, even after the cleft has been repaired. The speech sounds ‘nasal’ (from too much air flow through the nose) and requires another operation to correct the problem. During the procedure, the surgeon may lengthen the palate or attach tissue from the back of the throat to the palate called pharyngeal flap. This operation is usually performed at about four to five years of age following a speech video X-ray study and /or examination of the palate with a small fiber-optic tube (endoscope).

Your child’s speech should be evaluated every six months until the age of three years, and on a yearly basis thereafter.

Will my child have problems with the teeth?

Children whose cleft involves the gum line usually need another operation to allow the permanent teeth to grow properly and orthodontic treatment. Bone, usually taken from the hip, is placed in the gum cleft to provide a solid ridge of bone to properly anchor the teeth. This operation, called alveolar bone graft, is usually performed when the child is about eight to 10 years old. Additional dental or orthodontic intervention may be needed after the bone graft.

Forward growth of the upper jaw (maxilla) often lags behind that of the lower jaw, particularly in children with a complete cleft lip and palate. An operation to advance the upper jaw is necessary after growth is completed. Some children will require a dental implant in early adulthood when growth is complete.

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