1. Cleft lip and palate is a common congenital deformity resulting from incomplete fusion of tissues in the face and palate during early embryonic development between 4-8 weeks. 2. Risk factors for cleft lip and palate include family history, certain ethnicities being more susceptible, male sex, environmental exposures like smoking and medications during pregnancy, and advanced parental age. 3. Surgical repair of cleft lip is usually done by 6 months of age, with cleft palate repair by 12 months. Multiple surgeries may be needed. Nursing care focuses on adequate nutrition, positioning, and reducing family anxiety regarding the condition

1. CLEFT LIP AND
PALATE
BY
RAJAH AMINA
SULEIMAN
(RN, RM, RNE, RBPN, BNSC., MSC)

2. INTRODUCTION
• Craniofacial birth defects are the fourth most common
congenital anomaly in newborns.
• Cleft lip and palate together represent the most common
congenital deformity of the head and the neck.

3. EMBRYOLOGY OF THE FACE
• The external human face develops
between the 4th and 6th week of
embryonic development.
• There are two important tissue
structures involved in
development of the face and its
structures – the pharyngeal
arches and neural crest cells.
• Six pharyngeal arches arise in the
fourth week of development as
out-pocketings of mesoderm on
both sides of the pharynx.

4. EMBRYOLOGY OF THE FACE
• The lips and palate originate from three areas of
the baby’s developing face:
• Central or frontal nasal prominence: normally
grows to become the forehead, nose, middle
portion of the upper lip (philtrum or cupid’s bow)
and the primary palate (part of the upper jaw that
holds the middle four teeth)
• Left and right maxillary prominences: grow and
become the lower face, lower lip and jaw, all but
the middle portion of upper lip and jaw, and the
secondary palate (behind the four upper middle
teeth to back of mouth.

5. EMBRYOLOGY OF
THE PALATE
• Between the 6th and 8th week,
the palate begins to develop.
• Prior to palate formation, the tongue is
high and in the area of the nasal cavity.
The palatal shelves are vertical and
positioned on each side of the tongue.
• Around the seventh or eighth week of
gestation, the tongue begins to gradually
drop down. When this occurs, the palatal
shelves move slowly from a vertical to a
horizontal position and fuse, first with the
premaxilla at the incisive foramen, and
then with each other.

6. EMBRYOLOGY OF
THE LIPS
• The lips forms from initially freely
projecting maxillary, medial nasal, and
lateral nasal prominences at the rostral
and lateral boundaries of the primitive
oral cavity.
• Initial fusion is between lateral and medial
nasal processes and is followed by fusion
between maxillary and medial nasal
processes.

7. ANATOMY OF THE LIP

8. ANATOMY OF THE PALATE

9. DEFINITION OF TERMS
• Cleft: A cleft is any opening or division in some part of the
anatomy that is not normally open or divided.
• Cleft lip – cleft lip is defined as a gap between the philtrum and
the lateral upper lip which occurs when the medial nasal
prominence and maxillary prominence fail to fuse.
• Cleft palate – is defined as a gap in the palate due to partial or
total lack of fusion of palatal shelves as a result of defective
growth of palatal shelves, failure of the shelves to attain a
horizontal position, lack of contact between shelves or rupture
after fusion of shelves.

10. EPIDEMIOLOGY
• Worldwide, oral clefts in any form (i.E., Cleft lip, cleft lip and
palate, or isolated cleft palate) occur in about one in every 700 live
births (world health organization [WHO], 2011).
• International estimates that are limited to cleft lip with or without
cleft palate range from 7.94 to 9.92 per 10,000 live births.

11. ETIOLOGY
• There is no one cause of cleft lip and palate. However, most cases
are thought to result from multifactorial inheritance—an
interaction between the person's genes (genetic predisposition)
and specific environmental factors.
Risk factors that increase the likelihood of cleft lip and palate
include the following:
• Strong family history of cleft lip and palate
• Race—cleft lip and palate are more common in asians and native
americans than in african americans.
• Sex—males are more likely to have cleft lip with or without cleft
palate; females are more likely to have cleft palate without cleft

12. ETIOLOGY
• Exposure to certain environmental substances, such as tobacco
and alcohol, prescription drugs, and illegal drugs
• Diabetes mellitus
• Obesity
• Lack of folic acid supplementation
• Medications taking during pregnancy such as anti-
seizure/anticonvulsant drugs, acne drugs containing accutane,
and methotrexate, a drug commonly used for treating cancer,
arthritis, and psoriasis.
• Advanced parental age
• Maternal viral infections

13. CLASSIFICATION OF CLEFT LIP
• Forme fruste unilateral cleft lip (microform). A subtle cleft on one
side of the upper lip, which may appear as a small indentation.
• Incomplete unilateral cleft lip.
• Complete unilateral cleft lip.
• Incomplete bilateral cleft lip.
• Complete bilateral cleft lip.

16. CLASSIFICATION OF CLEFT PALATE

17. SYNDROMES ASSOCIATED WITH CLEFT LIP
AND PALATE
• Common syndromes involving cleft palate are apert
syndrome, stickler syndrome and treacher-collins
syndrome. Van der woude and waardenburg syndromes
are examples of syndromes with cleft lip with or without
cleft palate.

18. PROBLEMS ASSOCIATED CLEFT LIP AND
PALATE
• Psychosocial
• Feeding
• Airway infection
• Middle ear infection
• Speech problem
• Dental anomalies

19. SURGICAL MANAGEMENT
• The first procedure that cleft patients receive is surgical
closure of the lip.
• Following the “rule of 10s,” a patient admitted for lip
closure should be 10 weeks of age, weigh at least 10
pounds (4.5 kg), have a hemoglobin ≥10mg/dl, and have
WBC count >10,000cu/mm in order to withstand surgery
and anesthesia.

20. SURGICAL MANAGEMENT
• Pre-surgical orthopedics may be used to move cleft segments closer together
and into better alignment prior to surgical repair. These include
• Lip taping;
• Lip adhesion;
• Nasoalveolar molding (NAM) appliances; and
• Devices attached by pins and screws that force alignment of maxillary
segments.

22. SURGICAL MANAGEMENT
Surgeries can include one or more of the following:
• Repair of cleft lip (usually performed within the first 6 months of life)
• Repair of cleft palate (usually by 12 months of age in a child with typical
development)
• Repair of submucous cleft palate
• Tonsillectomy and/or adenoidectomy (may be needed prior to pharyngeal flap
or other pharyngoplasty)
• Secondary surgeries to repair palatal fistulae (if symptomatic)
• Alveolar bone grafting (determined by stage of dental development and in
collaboration with orthodontist)

23. NURSING MANAGEMENT
• Nursing management
• Maintain adequate nutrition.
• Positioning. If the cleft lip is unilateral, the nipple should be aimed
at the unaffected side; the infant should be kept in an upright
position during feeding.
• Tools for feeding. Lamb’s nipples (extra long nipples) and special
cleft palate nipples molded to fit into the open palate area to close
the gap may be used; promote family coping.
• Reduce family anxiety.
• Provide family teaching.

24. NURSING DIAGNOSIS
• Ineffective airway clearance related to
tracheobronchial aspiration of feedings evidenced by dyspnea
• Imbalanced nutrition: less than body requirements related to
difficulty in sucking evidenced by underweight
• Compromised family coping related to visible physical defect.
• Anxiety of family caregivers related to child’s condition and
surgical outcome evidenced by expression of guilt, blame, and
helplessness.
• Deficient knowledge of family caregivers related to care of child
before surgery and the surgical procedure evidenced by request
for information about cause of defects, feeding techniques

25. NURSING DIAGNOSIS
• Post-op
• Ineffective breathing pattern related to anatomical changes.
• Acute pain related to surgical procedure.
• Risk for deficient fluid volume related to npo status after surgery.
• Risk for aspiration related to a reduced level of consciousness
after surgery.

26. SURGICAL SUCCESSES

27. SURGICAL SUCCESSES

28. NOVEMBER 2017, PAPER I, question 3
Master ifeanyi, a 10-week old boy is admitted into the children’s ward with cleft
lip and palate. He is scheduled for cleft lip repair
• Describe the pre and post-operative care of master ifeanyi (7
marks)
• State six (6) predisposing factors to cleft lip and palate (3
marks)
• NOVEMBER, 2018, PAPER II, question 4
Write concisely on the following
• Embryology of the face
• The problems of a child with cleft palate (4 marks)

29. NOVEMBER 2020 PAPER II, question 3
Baby nneka is booked for cleft palate repair in your hospital.
• Highlight the necessary investigations needed before and after the surgery
(4 marks)
• Discuss the importance of mędical photograph in the management of congenital
abnormalities
(5 marks)
• Develop a nursing care plan to solve three (3) nursing diagnoses of baby nkechi
(9 marks)
• Enumerate four (4) surgical complications of cleft lip repairs (2
marks)