Classification of Cleft lip and cleft palate- This course is designed to understand the care of pregnant women and newborn: antenatal, intra-natal and postnatal; breast feeding, family planning, newborn care and ethical issues, The aim of the course is to acquire knowledge and develop competencies regarding midwifery, complicated labour and newborn care including family planning.
Classification of Cleft lip and cleft palate
Key concept of cleft lip and cleft palate
- Cleft lip & cleft palate congenital anomalies resulting in structural facial malformation.
- These defects are usually present in early fetal development complete formation of lip often occurs by 5 to 12 weeks, whereas the formation of palate may occur only by 12 to 14 weeks of gestational age.
- Cleft lip & cleft palate may occur as single or in combination.
- It may be unilateral or bilateral, complete or incomplete.
- Cleft lip & cleft palate are common-1 in 700 births.
- Cleft palates occur when tissue migration is disorganized or obstructed.by the tongue.
Cleft lip
It results from failure of the maxillary process to fuse with nasal elevations on frontal prominence. The extent of cleft lip is varying from a notch in the vermilion border to a large cleft reaching the floor of the nose. It is apparent at birth as incomplete formation of lip. It may be associated with cleft palate and supernumerary, deformed or absent teeth. Cleft lip may be found unilateral or bilateral.
Or
A fissure in the upper lip that is due to failure of the left and right sides of the fetal lip tissue to fuse, an event that should take place by 35 days of fetal age. Cleft lip can be on one side only or on both sides.
Cleft palate
It results from failure of masses of lateral palatine processes to meet and fuse together. It may be unilateral or bilateral or may occur in isolation or with cleft lip. Cleft palate in isolation may found in the midline involving only uvula or reaches the incisive foramen through soft palate. In association with cleft lip, it involves soft palate and exposes the nasal cavity on one or both side depending upon the defect.
Cleft palate is found as an opening or elongated opening or fissure in the roof of the mouth, which should be detected during routine neonatal examination.
Figure: Cleft Plate
Causes of cleft lip and cleft palate
A. The causes of cleft lip and cleft palate may be genetic or due to unfavorable maternal factors.
B. Maternal factors maybe
- Viral infections during 5th to 12th weeks of gestation or
- Ingestion of drugs,
- Exposure to X-ray
- Anemia and
- Hypoproteinemia.
Complications associated with cleft lip and cleft palate
Beyond the cosmetic abnormality, there are other possible complications that may be associated with cleft lip and cleft palate, including the following:
1. Feeding difficulties:
Feeding difficulties occur more with cleft palate abnormalities. The infant may be unable to suck properly because the roof of the mouth is not formed completely.
2. Ear infections and hearing loss:
Ear infections are often due to a dysfunction of the tube that connects the middle ear and the throat. Recurrent infections can then lead to hearing loss.
3. Speech and language delay:
Due to the opening of the roof of the mouth and the lip, muscle function may be decreased, which can lead to a delay in speech or abnormal speech. Referral to a speech therapist should be discussed with your child’s doctor.
4. Dental problems:
As a result of the abnormalities, teeth may not erupt normally and orthodontic treatment is usually required.
Surgical management of cleft lip & cleft palate
In cleft-lip:
Surgical repair of the defect of the lip is done, preferably at 2 to 3 months of age when the infant is having good health (At 10 weeks age, 10lb weight and 10 g Hb%). The operation is termed as cheiloplasty.
In cleft palate:
Palatoplasty, the surgical reconstruction of the palate is done with repair of the cleft, at about age of 1 to 2 years of age. It should be done before the child develops defective speech.
Nursing assessment related to cleft lip & cleft palate
1. If the patient has a cleft lip, assess for cleft lip, assess for cleft palate by direct visualization and palpation with finger.
2. Obtain family history of cleft lip or palate.
3. Evaluate feeding abilities:
4. Effectiveness of suck and swallow.
5. Amount taken.
Risk factors for lip and cleft palate during pregnancy
1. Exposure to tobacco and alcohol
2. Obesity
3. Pre-existing diabetes
Clinical features of cleft lip and cleft palate
Physical appearance of cleft lip or palate:
1. Incompletely formed lip-varies from slight notch in vermillion to complete separation of lip.
2. Opening in roof of mouth felt with examiner’s finger on palate.
3. Eating difficulty:
4. Suction cannot be created for effective sucking.
5. Food returns through the nose.
6. Nasal speech.
Problems associated with cleft lip and palate
A. Intermediate problems:
1. Feeding problem due to ineffective sucking resulting in undernutrition.
2. Aspiration of feeds resulting respiratory infections.
3. Parental anxiety due to defective appearance of the infant.
B. Long-term Problems:
1. Recurrent infections especially otitis media.
2. Disturbed parent-child relationship and maladjustment with non-acceptance of the infant.
3. Impairment of speech.
4. Malocclusion and mal-placement of teeth.
5. Hearing problems due to oral malformation especially in cleft palate.
6. Impaired body image due to altered shape of face and oral cavity.
7. Observe for other syndrome features.
Nursing diagnosis related to cleft lip & cleft palate
1. Ineffective infant feeding pattern related to defect.
2. Risk for infection related to open wound created by malformation, ear infections.
3. Risk for impaired parent/infant attachment related to malformation and special care needs.
4. Risk for aspiration related to tongue and palate deformities in Pierre Robin Syndrome.
5. Deficient knowledge related to home management of infant with cleft malformation.
6. Fear related to surgery.
7. Deficient knowledge related to postoperative care.
Nursing intervention of cleft lip and cleft palate
1. Maintaining adequate nutrition:
- Encourage and demonstration to be given to the mother and family members regarding feeding of the baby as soon as possible to provide adequate nutrition for growth and development.
- Administered gavages feeding if nipple feedings to be delayed to prevent spread of a cleft lip and palate. Breast feeding is possible in the baby with cleft tip and palate. Cleft palliate baby may require palatal obturator which can make feeding easier.
- If the baby is unable to suck the breast, then expressed breast milk or artificial feeding to be given with long hole handled spoon. Dropper or soft large hole nipple or soft feeder or syringe can also be used.
- Hygienic measures to be followed strictly to prevent diarrhea and other GI disturbances.
Small quantity of foods to be given slowly at the side of the mouth. - While feeding, the infant should be held in upright position or sitting position.
2. Preventing infection:
- Protection child from infection so that surgery will not delayed.
- Use and teach good hand washing practice
- Avoid patient contact with anyone who has an infection
- Change the infant position frequently.
- Clean the cleft after each feeding with water and cotton tipped applicator’
- Observe for fever, irritability, redness, or drainage around cleft, and report promptly.
- Monitor vital signs; report temperature greater than 101°F
3. Promoting acceptance and adjustment:
- Show acceptance of the infant; maintain composure, and do not show negative emotion when handling the infant.
- Support parents when showing a neonate for the first time. Demonstrate acceptance of the infant, and the parent’s feelings. Explanation to be given to the parents about details of surgical correction of the birth defect.
- Encourage parental involvement in infants care: frequent holding, cuddling and playing.
4. Preventing aspiration and airway obstruction:
- When feeding the infant; use orthopnic position: vertical and slightly forward; this allows infant to push jaw forwards to suck and allows the feeder a clean view of the infant.
- Use gentle finger pressure at mandibular attachment to bring the jaw forward.
Feed slowly. - Prevent respiratory obstruction by the tongue, especially on inspiration and when the infant is quiet –
➤ Place the infant in prone position so tongue and jaw fall forward.
➤ Tilt head back as tolerated by the infant, slightly elevate upper trunk.
➤ Suction nasopharynx as needed.
➤ If the tongue is sutured to pull it forward, observe for slipping cut tongue and infection.
➤ Observe closely for respiratory compromise.
5. Preparing for home management:
- Explain the parents about routine care of the baby.
- Demonstrate the technique of feeding and prepare family for home feeding by providing several days to practice feeding and to become familiar with the infants feeding pattern. Using feeding techniques preferred by surgeon/physician after surgery until the incision heals. In general:
➤ Breast feeding may be possible if child has a small cleft lip or palate.
➤ A longer nipple may allow the milk to be swallowed without entering the nose.
➤ A syringe with a rubber tip may also be used especially after surgery.
➤ Try to keep the child in an upright position during feeding.
➤ After surgery, elbow restraints but do not apply the restraints too tight.
➤ Position the child for sleep using blankets to prevent rolling into the abdomen.
➤Do not brush the child’s teeth for 1 to 2 weeks after surgery. Feeding a small amount of water after meals will help keep the teeth clean.
➤ Encourage the parents to prepare siblings for the arrival of this infant.
Team approach for managing and correcting cleft abnormalities
There may be many people involved in management of a cleft abnormality for your child, because the skills of many different areas are needed to help with the problems that can occur with cleft abnormalities. The following are some of the members of the team:
1. Plastic/craniofacial surgeon–a surgeon with specialized training in the diagnosis and treatment of skeletal abnormalities of the skull, facial bones, and soft tissue; will work closely with the orthodontists and other specialists to coordinate a surgical plan.
2. Pediatrician–a doctor who will follow the child as he or she grows and help coordinate the multiple specialists involved.
3. Orthodontist–a dentist who evaluates the position and alignment of your child’s teeth and coordinates a treatment plan with the surgeon and other specialists.
4. Pediatric dentist–a dentist who evaluates and cares for your child’s teeth.
5. Speech and language specialist–a professional who will perform a comprehensive speech evaluation to assess communicative abilities and who will closely monitor your child throughout all developmental stages.
6. Otolaryngologist (ear-nose-throat specialist)–a doctor who will assist in the evaluation and management of ear infections and hearing loss that may be side effects of your child’s cleft abnormality.
7. Audiologist (hearing specialist)–a professional who will assist in the evaluation and management of hearing difficulties your child may have.
8. Genetic counselor–a professional who reviews the medical and family history, as well as examines your child to help in diagnosis. A genetic counselor also counsels your family regarding risk for recurrence in future pregnancies.
9. Nurse team coordinator-a registered nurse who combines experience in pediatric nursing with specialization in the care of your child and acts as liaison between your family and the cleft team.
10. Social worker–a professional who provides guidance and counseling for your child and your family in dealing with the social and emotional aspects of a cleft abnormality and assists your family with community resources and referrals (i.e., support groups).
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