cleft lip and palate are the most common type of congenital anomalies. the worldwide prevalence of cleft lip and cleft palate ranges from 0.8 to 2.7 cases per 1000 live births. cleft lip is called cheiloschisis and cleft plate is called palatoschisis. Cleft lip is a gap or indentation in the lip or split continued up to the nostril due to the failure of fusion of the maxillary and medial nasal process. Cleft palate is the condition in which the two plates of the skull that forms hard palate are not completely joined due to the failure of fusion of the lateral palatine processes, nasal septum and medial palatine process. EMBRYOLOGYPrimary palate forms during the 4-7th week of gestation when two maxillary processes and two medial nasal processes fuse. Secondary palate forms in 6-9th weeks of gestation when palatal shelves change from vertical to horizontal position and fuse. Tongue migrates Antero-inferiorly. Cleft lip occurs when an epithelial bridge fails. Clefts of primary palate occur anterior to incisive foramen and clefts of secondary palate occur posterior to the incisive foramen. ETIOLOGY Genetic: Non-syndromic inheritance (risk increases with parents or siblings or both affected); chromosome aberrations, associated with other syndromes like Van der Woude syndrome. Environmental teratogens: Intrauterine exposure to the anticonvulsant phenytoin, alcohol, retinoic acid, maternal smoking, Rubella virus, thalidomide, aminopterin. Maternal/intrauterine condition: Maternal diabetes mellitus and amniotic band syndrome. Advanced paternal age  Unknown  CLASSIFICATION Prof. Balakrishnan (1975) classified cleft lip and palate according to the Indian context and divided them into three groups.  Group 1: Only cleft lip, which may be unilateral (right/ left), bilateral, or midline. Group 2: Only cleft palate, which may be which also can be unilateral (right/left), bilateral, or submucosa. Group 3: Includes cleft lip, alveolus, and cleft palate, which can be unilateral, bilateral, or midline. LAHSAL system for the classification of cleft lip and/or palate (2005) modified by Royal College of Surgeons Britain: LAHSAL system is a diagrammatic classification of cleft lip and palate. According to this classification, the mouth is divided into six parts. LAHSAL code indicates a complete cleft with a capital letter and an incomplete cleft with a small letter. CLINICAL FEATURES Cleft lip: Notched vermilion border and may involve alveolar ridge. Cleft palate: Nasal distortion, exposed nasal cavities.  Misaligned teeth. Passage of milk through nasal passages during feeding. Recurrent ear infection. Speech difficulties. Poor weight gain and failure to thrive. DIAGNOSIS Newborn examination at birth Palpate with a gloved finger or visual examination flashlight  In-utero ultrasonography  PROBLEMS OR COMPLICATIONS OF A CHILD WITH CLEFT LIP AND CLEFT PALATE Immediate Problems: Feeding difficulty: Infant with an unrepaired cleft palate will have ...

2. Presented by
Ms. Pradnya Vijay Sorate,
V.M.P. College of Nursing and
Medical Research Institute
Akluj

3. Introduction
 Cleft lip and palate are the second most
common congenital anomalies after clubfoot.
 The worldwide prevalence of a cleft lip and/or
palate (CL/P) ranges from 0.8 to 2.7 cases per
1000 live births.
 Cleft lip (cheiloschisis) and cleft palate
(palatoschisis) both can occur separately or
together. These are craniofacial abnormalities
caused during embryonic period.

4. DEFINITION
 Cleft lip is a gap or indentation in the lip or split
continued up to the nostril due to the failure of fusion
of the maxillary and medial nasal process.
 Cleft palate is the condition in which the two plates of
the skull that forms hard palate are not completely
joined due to the failure of fusion of the lateral palatine
processes, nasal septum and medial palatine process.

5. EMBRYOLOGY
 Primary palate forms during the 4-7th week of gestation
when two maxillary processes and two medial nasal
processes fuse.
 Secondary palate forms in 6-9th weeks of gestation
when palatal shelves change from vertical to horizontal
position and fuse. Tongue migrates Antero-inferiorly.
 Cleft lip occurs when an epithelial bridge fails.
 Clefts of primary palate occur anterior to incisive
foramen and clefts of secondary palate occur posterior to
the incisive foramen.

6. ETIOLOGY
 Genetic: Non-syndromic inheritance (risk increases with
parents or siblings or both affected); chromosome
aberrations, associated with other syndromes like Van der
Woude syndrome.
 Environmental teratogens: Intrauterine exposure to the
anticonvulsant phenytoin, alcohol, retinoic acid, maternal
smoking, Rubella virus, thalidomide, aminopterin.
 Maternal/intrauterine condition: Maternal diabetes
mellitus and amniotic band syndrome.
 Advanced paternal age
 Unknown

7. CLASSIFICATION
 Prof. Balakrishnan (1975) classified cleft lip and
palate according to the Indian context and divided
them into three groups.
 Group 1: Only cleft lip, which may be unilateral
(right/ left), bilateral, or midline.
 Group 2: Only cleft palate, which may be which
also can be unilateral (right/left), bilateral, or
submucosa.
 Group 3: Includes cleft lip, alveolus, and cleft
palate, which can be unilateral, bilateral, or midline.

8. Cont……..
 LAHSAL system for the classification of cleft lip
and/or palate (2005) modified by Royal College of
Surgeons Britain: LAHSAL system is a
diagrammatic classification of cleft lip and palate.
According to this classification, the mouth is divided
into six parts. LAHSAL code indicates a complete
cleft with a capital letter and an incomplete cleft
with a small letter.

10. CLINICAL FEATURES
 Cleft lip: Notched vermilion border and may involve
alveolar ridge.
 Cleft palate: Nasal distortion, exposed nasal cavities.
 Misaligned teeth.
 Passage of milk through nasal passages during feeding.
 Recurrent ear infection.
 Speech difficulties.
 Poor weight gain and failure to thrive.

11. DIAGNOSIS
Newborn examination at birth
Palpate with a gloved finger or visual
examination flashlight
 In-utero ultrasonography

12. PROBLEMS OR COMPLICATIONS OFA
CHILD WITH CLEFT LIPAND CLEFT PALATE
 Immediate Problems:
 Feeding difficulty:
Infant with an unrepaired cleft palate will have difficulties
creating enough suction to get sufficient milk from the breast
or teat as well as compressing the nipple adequately. This
makes the infant tired easily.
 Breathing:
Breathing becomes difficult due to a malformed palate and
jaw. There is an increased chance of aspiration as well due to
air entry during feeding through the gap.

13. Long Term Problems
 Recurrent ear infection and hearing loss:
Frequent ear infections can occur due to dysfunction of the
tube that connects the middle ear and the throat. This can lead
to hearing loss.
 Speech difficulty:
Due to palatal deformity, air escapes into the nose and may
prevent the development of consonants as well as cause an
excessively nasal-sounding voice. Some children also develop
a range of unusual sounds which makes them difficult to
understand and feel frustrated.

14. Cont…….
 Malocclusion of teeth:
A cleft lip and palate infant will have missing teeth,
particularly in the line of the cleft. They may also have
extra teeth or malformed teeth. Because of this, their
teeth can be crowded, tilted or rotated.
 Maxillary cleft:
If the cleft affects the maxilla then the bony part of
the alveolus will need to be joined together with a
bone graft. Otherwise difficulties with chewing and
affects the appearance on the face.

15. MANAGEMENT
 Team approach with pediatrician, craniofacial
surgeon, orthodontist, speech therapist,
otolaryngologist, audiologist, pediatric nurse, and
genetic counselor.
 In the case of Katori spoon feeding, a long straight
handled spoon is used. The technique used for
feeding is ESSR.
 E = Enlarged nipple,
 S = Stimulate sucking reflex,
 S = Swallow fluid appropriately,
 R = Rest.

16. Cont….
 Modified feeding: Breastfeeding can be given with extra
time and patience.
 Hold the baby in an upright position and burp frequently in
between feeding to prevent air trapping and chocking.
 For bottle feeding large hole specially designed for cleft lip
and palate child should be used. Haberman feeder is a
specially designed bottle with a valve to control the air entry
and prevent backflow. NUK nipple, which can be adjusted
with the size of the hole by making a crisscross cut in the
midline can be used with a regular bottle.

18. Nonsurgical management:
Dental obturator for high-risk patients or
those who refuse surgery or lanthum
appliances to expand and realign the parts
of the palate.

21. Surgical management:
 Cleft lip repair or cheiloplasty:
 lip adhesion is done at 2 weeks of age, which converts the
complete cleft into the incomplete cleft. Cleft lip repair
may be done at 10 weeks of age.
 following the rule of 10 (the child should be at least 10
weeks old, weighs at least 10 lb, and has at least 10 g
hemoglobin). Procedures commonly done are Millard
repair, Randall-Graham, or Rose-Thompson procedure.

22. Cont………
 Cleft palate repair or palatoplasty:
It is repaired at approximately between 9 and 12
months of age. Procedures used for repair are V-Y
pushback, two flap palatoplasty, four flap palatoplasty,
Schweckendick's Primary veloplasty, and Furlow
palatoplasty. Complications of palatal repair may be
oronasal fistula and velopharyngeal insufficiency.

23. Cont…..
 Speech and hearing treatments:
A tympanostomy tube is often inserted into the
eardrum to aerate the middle ear, which is often
beneficial for the hearing ability of the child. Speech
problems are usually treated by a speech-language
pathologist. In some cases, pharyngeal flap surgery or
augmentation pharyngoplasty is performed
 Genetic and parental counseling:
To prevent recurrence in the next sibling.

24. NURSING MANAGEMENT :
Preoperative Care Assessment:
 Promoting adequate feeding and prevention of
aspiration –
 Assess the degree of cleft and impairment of
sucking.
 Assist the mother if breast feeding the child with
positioning and stabilizing the nipple back in the
oral cavity.
 Advise feeding in upright position to minimize the
chance of aspiration.
 Use large hole nipple specially designed for cleft
palate if bottle feeding.

25. Cont………..
Use long handled spoon for katori spoon
feeding to place the milk/formula on back of
the tongue.
Advise burping frequently in between Toke out
excessive air swallowed during feeding
 Discontinue the feeding as soon as a baby
provide small and frequent feeds.
Monitor weight gain regularly.

26. Family support and education
 Encourage them to express their feelings, concerns, and
negative emotions.
 Use a calm, reassuring, and accepting approach to the child
and family.
 Allow participation in child care.
 Explain the outcome of the surgical repair.
 Refer them to the other children with the defect who has
recovered after surgery.
 Teach the modified feeding technique and post-surgery care
at home.

27. POSTOPERATIVE CARE
Feeding –
Administer IV fluids if prescribed.
Use modified feeding techniques to
minimize aspiration and trauma to the
surgical site.
 Burp the infant frequently.
 Assume diet from clear liquids to soft diet
as prescribed

28. Preventing trauma: -
 Position the child on the back or side to prevent
trauma to the operated site.
 Restrain the elbow to prevent access to the trauma site.
 Provide jacket restraints to prevent rolling onto the
abdomen.
 Keep straw, spoon, or pacifier away from the child
 Do not take oral temperature.
 Prevent vigorous crying to avoid strain on the suture
line.
 Do not brush the child's teeth for 2-3 days after
surgery.
 Cleanse the suture line gently after feeding.

29. Preventing infection
 Clean the suture line with sterile water using a cotton swab or saline
after feeding.
 Use a rolling motion vertically down the suture line.
 Apply anti-infection ointment as prescribed.
 Observe for redness, swelling, bleeding, drainage, or fever.
 In palatal repair rinse the mouth with water after feeding
Minimizing pain:
 Assess the level of pain by observing the behavior of the child.
 Provide comfort measures like cuddling, rocking, or, holding the
infant.
 Administer analgesics as prescribed.
 Remove the restraint periodically
 Involve parents to provide comfort and a sense of security.

30. Health education for health
maintenance:
 Refer the child to a speech therapist and otolaryngologists.
 Inform the signs of ear infection and advise to seek help in
such cases.
 Encourage to do frequent hearing tests.
 Provide information about support groups.
 Instruct to visit a dentist for the misalignment of teeth.
 Advice to maintain oral hygiene.
 Advise monitoring growth, speech and language
development.
 Encourage genetic counselling for future pregnancy.

31. Assignment
 Write the nursing care plan on cleft lip and cleft palate.