Cleft lip and cleft palate are birth defects where the tissues of the lip and roof of the mouth do not fully fuse during development in the womb. They occur in approximately 1 in 700 births. Cleft lip involves a split in the upper lip while cleft palate involves an opening in the roof of the mouth. Treatment involves surgery to repair the cleft, with cleft lip surgery typically occurring in the first few months of life and cleft palate surgery between 6-12 months. Long term care is multidisciplinary and aims to address issues with feeding, speech, hearing and socialization that can arise.

1. Presented by –
Ms. JYOTI DWIVEDI
M.SC FINAL YEAR STUDENT

2. 
 Cleft lip and cleft palate refer to facial malformations that evolve
during embryonic development resulting in nonunion of the bones
and tissues of the lip and palate.
• Cleft lip and cleft palate may occur independently or together.
• There may be a combination of defects and degrees of
involvement.
• Facial defects are noticeable at birth.
Cleft lip (cheiloschisis) and cleft palate (palatoschisis), which can also
occur together as cleft lip and palate, are variations of a type of clefting
congenital deformity caused by abnormal facial development
during gestation. A cleft is a fissure or opening—a gap. It is the non-
fusion of the body's natural structures that form before birth.
Approximately 1 in 700 children born have a cleft lip or a cleft palate or
both. In decades past, the condition was sometimes referred to
as harelip, based on the similarity to the cleft in the lip of a hare, but
that term is now generally considered to be offensive.
Introduction

3. 
 Approximately 1 in 700 children born have a cleft lip
or a cleft palate or both. In decades past, the
condition was sometimes referred to as harelip,
based on the similarity to the cleft in the lip of a hare,
but that term is now generally considered to be
offensive.
Cont..

4. 
 Cleft lip is a birth defect that occurs when the tissues
of the upper jaw and nose do not join as expected
during fetal development, resulting in a split (cleft)
in the lip.
 Cleft palate is a condition in which the two plates of
the skull that form the hard palate (roof of the
mouth) are not completely joined. The soft palate is
in these cases cleft as well.
Definition

5.  Cleft lip is classified according to its location and
severity:
 Unilateral - (on one side of the lip). The unilateral cleft
may cause the nostril on that side to be tilted and lower
than the other nostril.
 Bilateral - (on two sides of the lip). The bilateral cleft may
cause the nose to be broader and shorter than normal.
 Complete - extends to the nose.
 Incomplete -does not extend to the nose.
 A cleft palate is first categorized according to whether it
affects the hard palate, the soft palate, or both.
 The hard palate is the front part of the roof of the mouth.
 The soft palate is the back part of the roof of the mouth.
 In cleft palate , the roof of the mouth (Palate) has an
opening (cleft)that may go through to the nasal cavity .
Types of cleft lip AND
CLEFT PALATE

6. 
 Combination terms
 Complete classification of a cleft palate combines all of the
appropriate terms. For example:
 A cleft of the hard palate with an incomplete unilateral
cleft lip is a cleft in the front of the mouth and a cleft in
one side of the upper lip that doesn't extend to the nose.
 A cleft of both the hard and soft palate with bilateral
complete cleft lip describes a cleft that extends from the
soft palate to the hard palate, and includes the alveolar
ridge. Both sides of the lip have clefts extending to the
nose.
Cont..

7. 

8. 

9.  There are many causes of cleft lip and palate.
Problems with genes passed down from one or both
parents, drugs, viruses, or other toxins can all cause
these birth defects. Cleft lip and palate may occur
along with other syndromes or birth defects.
 A cleft lip and palate can:
 Affect the appearance of the face
 Lead to problems with feeding and speech
 Lead to ear infections
Causes

10.  Combination of genetic and environmental factors; cleft
palate is found mostly in girls and cleft lip alone or
together with cleft palate is found mostly in boys
 family history of cleft lip or palate and other birth defects.
 Anti-convulsant drugs.
 Maternal tobacco use.
 Genetic predisposition.
 Maternal alcohol consumption
 Folic acid deficiency.
 Maternal smoking.
Risk factors

11. 

12. 
 • Incompletely formed lip
• Opening in roof of the mouth can be palpated
• Unilateral or bilateral cleft lip
• With cleft palate, milk or formula escapes through
the nose
• Abdominal distention due to swallowing air
• Slow weight gain
CLINICAL
MANIFESTATION

13. 
 Traditionally, the diagnosis is made at the time of birth by
physical examination. Recent advances in prenatal
diagnosis have allowed obstetricians to diagnose facial
clefts in utero.
 Visual assessment of defects at birth and by palpation.
 ultrasound to identify cleft lip or cleft palate in utero.
 MRI to detect the extent of the abnormality; evaluation of
the infant’s ability to suck, swallow and breathe.
 A genetic evaluation to determine reoccurrence.
Diagnostic evaluation

14. 
 CLEFT LIP -
 Within the first 2–3 months after birth, surgery is performed to
close the cleft lip. While surgery to repair a cleft lip can be
performed soon after birth, often the preferred age is at
approximately 10 weeks of age, following the "rule of 10s"
coined by surgeons Wilhelmmesen and Musgrave in 1969 (the
child is at least 10 weeks of age; weighs at least 10 pounds, and
has at least 10g hemoglobin). If the cleft is bilateral and
extensive, two surgeries may be required to close the cleft, one
side first, and the second side a few weeks later. The most
common procedure to repair a cleft lip is the Millard
procedure pioneered by Ralph Millard. Millard performed the
first procedure at a Mobile Army Surgical Hospital (MASH)
unit in Korea.
Management

15. 
 Often an incomplete cleft lip requires the same surgery as
complete cleft. This is done for two reasons. Firstly the
group of muscles required to purse the lips run through
the upper lip. In order to restore the complete group a full
incision must be made. Secondly, to create a less obvious
scar the surgeon tries to line up the scar with the natural
lines in the upper lip (such as the edges of the philtrum)
and tuck away stitches as far up the nose as possible.
Incomplete cleft gives the surgeon more tissue to work
with, creating a more supple and natural-looking upper
lip.

16. 

17. 
Millard procedure

18. 
 A blue line indicate incision.
 Movement of the flaps; flap A is moved between B
and C. C is rotated slightly while B is pushed down.

 Post-operation, the lip is swollen from surgery and
will get a more natural look within a couple of
weeks.
Cont..

19. 
 Often a cleft palate is temporarily covered by a palatal
obturator (a prosthetic device made to fit the roof of the
mouth covering the gap).
 Cleft palate can also be corrected by surgery, usually
performed between 6 and 12 months. Approximately 20–
25% only require one palatal surgery to achieve a
competent velopharyngeal valve capable of producing
normal, non-hypernasal speech. However, combinations
of surgical methods and repeated surgeries are often
necessary as the child grows. One of the new innovations
of cleft lip and cleft palate repair is the Latham appliance.
The Latham is surgically inserted by use of pins during
the child's 4th or 5th month. After it is in place, the doctor,
or parents, turn a screw daily to bring the cleft together to
assist with future lip and/or palate repair.
CLEFT PALATE

20. 

21.  If the cleft extends into the maxillary alveolar ridge, the
gap is usually corrected by filling the gap with bone
tissue. The bone tissue can be acquired from the patients
own chin, rib or hip.
 Lantham appliance
 when the infant is without any infections
(respiratory, oral, or systemic), surgical treatments begin
early and continue into adolescence; scheduling depends
on the severity of the cleft.Chiloplasty used for correction
of a cleft lip the involvement of a multidisciplinary team
is needed: pediatrician, plastic surgeon, orthodontist,
audiologist, speech therapist, prosthodontist, and
psychiatrist.
 Speech and hearing
 A tympanostomy tube is often inserted into
the eardrum to aerate the middle ear. This is often
beneficial for the hearing ability of the child.
Cont..

22. 
 Children with cleft palate typically have a variety of
speech problems. Some speech problems result
directly from anatomical differences such as
velopharyngeal inadequacy. Velopharyngeal
inadequacy refers to the inability of the soft palate to
close the opening from the throat to the nasal cavity,
which is necessary for many speech sounds, such as
/p/, /b/, /t/, /d/, /s/, /z/, etc. This type of errors
typically resolve after palate repair.
Cont..

23. 
 Speech-language pathology can be very beneficial to help
resolve speech problems associated with cleft palate. In
addition, research has indicated that children who receive
early language intervention are less likely to develop
compensatory error patterns later.
 Hearing loss
 Hearing impairment is particularly prevalent in children with
cleft palate. The tensor muscle fibres that open the eustachian
tubes lack an anchor to function effectively. In this situation,
when the air in the middle ear is absorbed by the mucous
membrane, the negative pressure is not compensated, which
results in the secretion of fluid into the middle ear space from
the mucous membrane. Children with this problem typically
have a conductive hearing loss primarily caused by this
middle ear effusion.

24. 
 Hearing loss
 Hearing impairment is particularly prevalent in children
with cleft palate. The tensor muscle fibres that open
the eustachian tubes lack an anchor to function effectively.
In this situation, when the air in the middle ear is
absorbed by the mucous membrane, the negative pressure
is not compensated, which results in the secretion of fluid
into the middle ear space from the mucous
membrane. Children with this problem typically have a
conductive hearing loss primarily caused by this middle
ear effusion.

25. 
 Six-month-old girl before going into surgery to have
her unilateral complete cleft lip repaired.
 The same girl, 1 month after the surgery.
 The same girl, age 8, the scar almost gone.
Cont..

26.  Assessment –
 Assess respiratory status.
 Monitor vital signs.
 Check weight periodically to evaluate adequate
nutritional intake.
 Clean suture line to prevent infection.
 Use a gentle restraint to prevent the infant from placing
hands on its mouth.
 Position infant so that rubbing of lip is prevented.
 Use wrist restraints after cleft-lip repair and elbow
restraints following cleft-palate repair to prevent the
child from putting anything into the mouth.
NURSING CARE
PLAN

27. 
intervention rationale
 Assess respiratory status and monitor vital
signs atleast every 2 hours.
 Position on side after feedings.
 Feed slowly and use adaptive equipment as
needed.
 Burp frequently.
 Position upright for feedings.
 Keep suction equipment and bulb syringe
at bedside.
Allows for early identification of problems.
Prevent aspiration of feedings.
Facilitates intake while minimizing risk of
inspiration.
Helps to prevent regurgitation and aspiration.
Minimizes passage of feedings through cleft.
Suctioning may be necessary to remove milk or
mucus.
Pre-operative :
NURSING DIAGNOSIS -High risk for aspiration(breast milk ,
formula ,or mucus) related to anatomic defect.
GOAL- Infant has no episodes of gagging or aspiration.
Expected outcome –Infants exhibits no signs of respiratory distress.

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29. 

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31. 

32. 
 COMPLICATIONS
 Feeding problems.
 Ear disease.
 Speech problem
 Problem in socialization.
 Prognosis
 A child born with a cleft lip with or without cleft palate
will require a multidisciplinary approach to management
throughout his or her development. In the absence of an
associated syndromic condition; however, children with
cleft lip and/or palate can have excellent esthetic and
functional outcomes.
Cont..

33. 
 HEALTH EDUCATION
 Parents can be directed to various internet resources
for further information and advice
 Parents should be advised on appropriate feeding
methods.
 Feeding the infant in an upright position avoids
nasal regurgitation.
 Bottle feeding can be optimized using specialized
fissured nipples and bottles controlling the flow rate
of pumped breast milk or formula.

34. 
 Soft-bodied bottles are squeezed in synchronization with
infant sucking to reduce the effort of feeding and
maximize the amount of feed entering the mouth.
 The infant should be burped during pauses in feeding.
 Feeding should not be continued for more than 30
minutes, to avoid the infant becoming tired.
 Parents should be warned that the neonate will lose
weight (up to 10% of birth weight) after birth, but
reassured that the birth weight will be regained within 2
postnatal weeks, and increase by at least 1 ounce per day
thereafter. Infants should have their weight monitored at
weekly intervals until it has stabilized.
 Parents should be provided with instruction on
appropriate postoperative care to protect the wound and
promote healing, with maintenance of good wound care
and nutrition as well as careful bathing and feeding.

35.  Prevention
 Although the etiologies of cleft lip and palate are
multifactorial, several recommendations are suggested-
 Avoidance of teratogenic medications during pregnancy
is mandatory.
 seizure medications should be adjusted by a neurologist
before conception, to prevent teratogen exposure.
 Prenatal multivitamins (including folic acid
supplementation),
 Antismoking counseling.
 Advice on the importance of minimizing perinatal alcohol
consumption are strongly encouraged.

Cont..

36. 
 Clefts of the lip and palate are generally divided into two
groups, isolated cleft palate and cleft lip with or without
cleft palate, representing a heterogeneous group of
disorders affecting the lips and oral cavity. These defects
arise in about 1.7 per 1000 liveborn babies, with ethnic
and geographic variation Typically, children with these
disorders need multidisciplinary care from birth to
adulthood and have higher morbidity and mortality
throughout life than do unaffected individuals. .
Prevention is the ultimate objective for clefts of the lip and
palate, and a prerequisite of this aim is to elucidate causes
of the disorders.

CONCLUSION

37. 
 BIBLIOGRAPHY
 http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0002046/
 http://www.nlm.nih.gov/medlineplus/ency/article/001051.h
tm
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 http://www.healthlinkbc.ca/kb/content/special/aa112054.ht
ml
 Peadiatric nursing.caring for children.Jane ball and Ruth
binder.Page no 486 -490.
 Peadiatric nursing care plan.Jaypee.Page no 465.
 Essential peadiatric nursing.Piyush gupta.2nd edition.Page no
466 -477.
Cont..

38. 