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Craniofacial Conditions

 

Cleft Palate

What is a cleft palate?

A cleft palate is an opening in the roof of the mouth. 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?

There are several types of cleft palate, which are illustrated in the diagram below. 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.

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 of the time 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 can talk to you about these factors.

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 can help you choose the kind that works best for you and your child. The nurse can 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 breastfeed my child?

Usually it is difficult for the baby with a cleft palate to be breast-fed; in some cases, the infant may be functionally unable to nurse. Members of your child’s care team will evaluate his or her 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 a normal palate.  This is because the tube that connects the middle ear to the throat may not drain as well in a child with a cleft palate. Fluid that collects in the middle ear space can prevent sounds from reaching the inner ear, resulting in hearing loss. The fluid attracts bacteria that cause 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 an operation to remove the fluid and insert a ventilation tube. The operation (called myringostomy), which is done under general anesthesia, 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 them 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?

A cleft lip alone does not result in speech problems.  Children born with a cleft palate, however, often cannot make certain speech sounds until the palate has been surgically repaired. This is because normal speech requires the muscles in the soft palate at 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 becomes impaired.

After your child’s palate has been repaired, the speech pathologist on your child’s care team will give you suggestions for home activities that can help develop 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 acquire these skills 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.

About five to 15 percent of children will not be able to seal off the nose during speech after the cleft has been repaired. This results in speech that sounds ‘nasal’ (from too much air flow through the nose) and requires another operation to correct the problem. During the procedure, called pharyngeal flap, the surgeon may lengthen the palate or attach tissue from the back of the throat to the palate. 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 scope.

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

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.

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?

Children whose cleft involves the gum line often need another operation to allow the permanent teeth to grow properly. An alveolar bone graft, with bone usually taken from the hip, is performed to provide a solid ridge of bone in the gum to properly anchor the teeth. This operation 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. Some children will require a dental implant in early adulthood when growth is complete.

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