CLEFT LIP AND PALATE

1. CLEFT LIP AND CLEFT
PALATE

2. Anatomy of Mouth

3. Embryology
The face develops between 4 and 8 weeks of
gestation from 5 prominences. They are,
🞒 Frontonasal prominence
🞒 Paired maxillary prominence
🞒 Paired Mandibular prominence, around the
stomodeum

4. 🞒 The maxillary prominences from both sides grow
towards each other and towards the medial nasal
prominence and fuse together to form the midface.
🞒 The defect in the mesenchymal migration and fusion
of these prominences leads to cleft lip and palate.
🞒 Cleft lip occurs when the medial nasal processes fail
to fuse with maxillary process.
🞒 Palatal clefts are due to failure of the fusion of the
palatal shelves and occur later, between 7 -12 weeks
of gestation.
🞒 The cleft can involve the lip-, alveolus (gum), hard
palate and/or soft palate and can be complete or
incomplete, unilateral or bilateral.

5. Definition
🞒 Cleft lip
Cleft lip refers to open space
between lip especially in part of
vermilion line or failure in fusion
of lip. It is also known as
“harelip”.
. .…. WONGS text book of pediatric

6. Definition
🞒 Cleft palate
Cleft palate refers to failure in
development of parts which making the
palatine bone (maxillary process), soft
palate (uvula).
. .…. WONGS text book of pediatric

8. CLEFT LIP & PALATE

9. Incidence
 Cleft lip-1:750 births, predominantly seen in
males.
 Cleft palate-1:2500 births, mostly seen in females
 If the sibling has disorders – 1 in 20 to 1 in 10.
 If parent has disorders – 1:30
 Monozygotic twins are more prone to get than the
non-zygotic twins.
 Cleft lip and palate is higher in Asian and lowest
in Africans, Americans.

10. Etiology
🞒 Genetic factors- It has been estimated that the chances
of a child having a cleft lip and cleft palate is two
percent when one of the parents has a cleft lip or cleft
palate.
🞒 Unfavorable maternal factors-
 Illness especially viral infections during the fifth and
twelfth weeks of gestation, e.g. rubella
 Anemia
 Hypoproteinemia
 Maternal malnutrition
 Maternal smoking – severity is depending upon the
number of cigarettes smoked
 Ingestion of drugs, e. g. thalidomide, corticosteroids.
 Exposure to radiation during pregnancy

11. CLASSIFICATION
Indianclassification
A simple Indian classification is in current use. It is
called the Nagpur classification and was first
described by Prof. C Balakrishnan in Indian
plastic surgeon.
Group I - Cleft lip only
Group IA - Cleft lip alveolus
Group IB - Subsurface cleft lip
Group II
Group III
- Cleft palate only
- Cleft lip and cleft palate.

12. 🞒 According to the site
 Left unilateral
 Right unilateral
 Bilateral

13. 🞒 According to the anatomy
 Cleft of primary palate
 Cleft of primary& secondary
 Cleft of secondary alone
 Bilateral

15. Clinical manifestations
Cleft lip has the following manifestations
 A notched vermilion border
 Dental anomalies – supernumerary teeth,
extra teeth, teeth may be absent
 Variably sized clefts that involve the
alveolar ridge

16. Clinical manifestations
Cleft palate includes,
 Opening in roof of the mouth felt with
examiners finger on palate
 Nasal distortion
 Breathing difficulty
 Exposed nasal cavities
 Recurrent ear and throat infection
 Speech defects and psychological
problems.

17. Clinical manifestations
 Feeding problems
 Inability to coordinate breathing and feeding
leads to inadequate nutrition.
 Difficulty in feeding leads to anemia,
malnutrition and failure to thrive.
 Mouth breathing.

18. Diagnostic Evaluation
 History collection – collect history of parent with cleft
lip and cleft palate, and antenatal check up.
 Prenatal ultrasonography- enables many cleft lips
and some cleft palates to be identified in utero.
 Physical examination – cleft lip and palate is
diagnosed by inspection. Physical examination
reveals the anemia, breathing difficulty, speech
defects and dental anomalies.

19.  X-ray – it shows the deformity of palatine bone.
 MRI-to evaluate extent of abnormality before
treatment
 Dental imprecision’s for expansion prosthesis.
 Genetic evaluation – to determine recurrence
risk.

20. Management
 Management is based on the severity of
the defect.
 Management of cleft lip and cleft palate
requires a team effort involving
 a pediatrician,
 a plastic surgeon,
 orthodontist
 ENT specialist and
speech therapist,
 psychologist and
community health nurse.

21. Children with Cleft Lip and Palate
🞒 Cleft lip repair: 3 to 6 months
🞒 Cleft palate repair: 9 to 12 months
🞒 Ear tubes at palate repair: 9 to 12 months
🞒 Lip/nare revision: 4 years
🞒 Phase I orthodontics: 7 years

22. 🞒 Alveolar bone graft: 6 to 10 years
🞒 Phase II orthodontics: 15 to 17 years
🞒 Orthognathic surgery: 15 years for
females; 18 years for males
🞒 Definitive rhinoplasty: Teenage years

23. 🞒 Historically, the surgery for cleft lip and
cleft palate is planned by
“Kliners ruleof ten”
For cleft lip – 10 weeks of age,
10 pound weight and
10 grams of hemoglobin.

24. For cleft palate – 10 months of age,
10 kg weight and
10 gm of hemoglobin
was the norm.

25. Surgical repair technique for
cleft lip
🞒 Cheiloplasty
🞒 Ralph Millard's Rotation advancement
technique

27. Logan bow

28. Cleft palate repair technique
 Palatoplasty
 Von langenback
procedure
 Veau wardil kilners
 Three flap technique &
Millards
 Double revising ‘Z’ plasty

30. Nursing management
Preoperative care:
 Keep the infant NPO for 6 hours before
surgery.
 Administer premedication as per doctors
order
 Physical, physiological, psychological
and legal preparation should be done.

31. Post operative care
 Keep the airway clear from accumulation of mucus
in the nose and mouth.
 Mild sedation may be prescribed to prevent infant
from crying.
 Careful positioning (never on the abdomen)
 Restraining the arms if necessary.

32. • The mother and father should be
encouraged to remain with their child as
much as possible.
• The infant is fed with a medicine dropper.
• Clear fluids offers initially, breast milk or
formula can be given when tolerated.

33. Post operative care
• The mouth should be rinsed with water before and
after feeding.
• Do not brush the teeth 1-2 weeks after the surgery.
• The suture line must be cleaned gently with cotton or
gauze-tipped swab dipped in hydrogen peroxide or
saline solution and dried carefully several times a
day to ensure proper healing.

34. • The parents are taught the ways by which injury
to the palate can be prevented after discharge
and prevention of upper respiratory tract
infection.
•
• Speech therapy should be given.
• Encourage the child to socialize with family
members and others.

35. Preoperative Nursing
diagnosis

36. Imbalance nutrition; less than body requirements related to
inability to suck.
🞒 Describethedegreeofcleft andimpairmentofsucking
🞒 Themothershouldbeencouragedtobreastfeedtheirbabiesand
whenevertherearefeedingproblemsexpressedbreastmilkmay
begive.
🞒 Usespecial feedingtechniqueif needed
🞒 Incaseoffailureofbreastfeeding,artificialfeedinghastobe
substituted
🞒 Whenextremedifficulty is encounteredwithfeeding,gavagemay
becomenecessary.
🞒 Burpfrequentlyandholdtheinfantinamoreuprightposition.
🞒 KeepanaccuraterecordofChildsgrowthbyusingagrowth
chart.

37. Feeding technique:
Description
compresses easily, readily
available
large surface for compression
allows easy flow of milk
Equipment
🞒 Soft, thin walled nipple -
🞒 NUK orthodontic nipple -
🞒 Cross-cut nipple -
with compression
🞒 Ross cleft palate nurser - for infants with weak suck;
has soft tube like nipple.
🞒 Mead Johnson cleft palate nurser -soft, long cross-cut
nipple, soft bottle for
squeezing
Can monitor the milk flow

38. 🞒 Haberman feeder- large, squeezable nipple with a
slit cut, has one way valve to
reduce amount of air ingested.
🞒 Pigeon cleft palate nurser-
larger, more bulbous Y-cut nipple;
firm on top with soft bottom;
has air valve to prevent collapse and
airflow;
has flow setting in bottle collar.
🞒 Asepto syringe, rubber tip-
readily available;
places with milk beyond cleft

39. A and B : Above, left and center: Soft squeezable bottle with
cross cut orthodontic nipple (top right).
C. Ross Syringe Nipple.
D. Cross cut in top of nipple.

40. Mead Johnson Cleft
Palate Nurser Unit
comes with a soft
plastic bottle that
works well and a
long, cross-cut
nipple.
This nipple and
nipple ring should be
discarded and the
"syringe nipple"
substituted for post
surgical feeding.

41. Methods:
• Useanippleorfeedingsystemthat providesa
controllable flowrate andis energyefficientfor
theinfant
• Holdinfant inupright positiontoassist in
reducingtheamount ofnasalregurgitation.
• Useapillowfor additional supportfor infant to
assist withlonger feedingtime
• Keepchintuckedbecauseneckextension
inhabitsswallowing.

43. 🞒 If regurgitationoccurs,stopfeedingandallowinfant to
cough/ sneezetoclear theair way.
🞒 Placenipple ontopoftongue.Nipple insertionmaypush
tonguetothebackofmouth.
🞒 Burptheinfant frequently becauseofincreasedair ingestion
🞒 Monitor fordistressandfatigueduringfeeding
🞒 Limitfeedingtimetoapproximately30minutestoavoid
fatigue
🞒 Followfeedingwithsterilewatertocleananyrappedfoodin
thecleft
🞒 Cleanmouthandnose.

44. 2. Interrupted family processes related to emotional
reaction to an infant with a visible defect.
•Encourage parents to discuss their fears, concerns
and negative emotions
•Encourage touching and holding to prevent
delayed attachments.
•Expressacceptanceofbabybymodelingandclosephysical
contact.
•Make appropriate referral to a cleft lip and palate team
of nurses,physiciansandother specialists.

45. 3. Parental fear and anxiety related to special
care needs and surgery.
•Use a calm, reassuring, accepting approach
with infant andfamily
.
•Explain all procedures and their rationale
including sensations likely experienced by their
child.
•Listen actively to parents and their concerns,
encourage verbalization of feelings and
perceptions
•Encourage parents to stay with their child in
the immediatepreandpostoperativeperiods.

46. 4. Parental knowledge deficit about
feeding techniques and surgery.
•Explainpreandpostoperativeprocedures
•T
eachabout surgical proceduresandits
advantagestotheparents
•Clarifytheparentdoubtsoranyquestions.
•Explainabout long-termfollowupcare.

47. 5. High risk for respiratory distress or dyspnea
related to cleft lip and cleft palate.
•Assesstherespiratorymovement
•Auscultatethelungs
•Preventrespiratoryobstruction, especiallyon
inspiration andwhentheinfant is quiet–place
theinfant inpronesothattongueandjawfall
forward,tilt headbackasbesttoleratedbythe
infant &slightly elevateuppertrunk.
•Provideadequatesuctioninginordertoremove
secretions
•Administeroxygenasperdoctor’sorder.

48. Post-operative Nursing
diagnosis

49. 1. Dyspnea related to anesthetic effect
•Assesstherespiratoryrate
•Providecomfortableposition
•Administeroxygen
•Dosuctionfrequently
•Positionthechildontheabdomenorsideinorderto
encouragedrainagefromthemouth
•If increaserespiratoryrate,coughing,chokingor
cyanosisshouldbereportedimmediately

50. 2. Fluid and electrolyte imbalance related to fluid
restriction
•MaintainIVfluidsasperdoctorsorder.
•Feedthechildafter 3hoursofthesurgeryby
usingbottleorsyringe
•Softfoodsareusuallycontinuedforabout 1
monthafter surgeryat whichtimearegulardiet
is started.
•Checkweight periodically
•Feedthechildinthemannerusedpre
operatively(neverusestraw,nippleorplain
syringe)

51. 3. Acute pain related to surgical incision and
elbow restraints
•Providecomfortmeasures,especiallyholding,rocking
andparentalvoices
•Provideanalgesicsandsedativesasordered
•Reportit painnotmanagedbyusualmeans.

52. 4. High risk for complications related to surgery
•Assessthebreathingpattern
•Noterespiratoryrate
•Providemoisturetomucusmembranethatmay
becomedrybecauseofmouthbreathing.

53. 5. Risk for infection related to surgical repair and
aspiration.
•Irrigatethemouthwithnormal salinesolutionorwater
•Directagentlestreamoverthesuturelineusinganear
bulbsyringe
•Whileirrigatingheldthechildinsittingpositionwith
hisheadforward
•Keepthemouthmoisttopromotehealingandprovide
comfort
•Rinsethemouthafter eachfeeding
•Administerantibioticsasprescribed.

54. Layla’s turn

59. References:
1.Dorothy R. marlow .text book of pediatric nursing ,south
asian edition . Elsevier publication .
2.Wong’s. Essentials of pediatric nursing 8th edition
elsevier publication.