Nursing management of Cleftlip and Cleftpalate

1. CLEFT LIP AND CLEFT PALATE
Rajalakshmi.S
Lecturer
Josco College of Nursing, Edappon

2. Introduction
• Cleft lip and cleft palate are congenital
malformations resulting from the failure of
fusion maxillary processes during intrauterine
development. The defect may occur either
along or together.

4. TYPES

5. • Cleft lip ( cheiloschisis): a cleft lip result from
failure of maxillary process with nose elevation on
frontal prominence. The extent of defect varies from
a notch in the lip ( partial or incomplete cleft) to
large cleft reaching the floor of nose ( complete
cleft). Cleft lip can occur on one side ( unilateral) or
may be on both sides ( bilateral)

7. • cleft palate (Palatoschisis ) : cleft palate results
from failure of fusion of the hard palate with
each other and with the soft palate. Cleft lip
also usually occurs with clef palate. Cleft palate
may be complete ( involving hard and soft
palate, possibly including a gap in the palate) or
incomplete ( a ‘hole’ in the roof of the mouth,
usually in soft palate).

8. Incidence and etiology
• Cleft lip- 1 in 750 births
• Cleft palate 1 in 2500 births
• Cleft lip predominantly seen in males
• Cleft palate more in females
• 15 % of affected infants have associated defects
• It occur during intrauterine development
• Most cases cause is unknown
• Also occur due to combination of genetic and
environmental factors
• Chance is more if parent or sibling has had the
problem

9. Potential causes
• Medication taken by mother during pregnancy
• Exposure to viruses or chemicals while fetus is
developing in the womb
• Exposure to X-ray
• Maternal medical conditions
• Maternal intake of alcohol
• Maternal smoking during pregnancy

10. Pathophysiology
• Failure of incomplete union of the embryonic
structures of the face.
• Fusion of the maxillary and premaxillary processes
normally occurs between the 5th and 8th intrauterine
weeks
• The palatal process fuse about 1 month later
• Failure of fusion result in the cleft lip and palate.
• This partial or incomplete nonunion may involve
more than the palatal bone and the upper lip.

11. • It may affect the maxilla, premaxilla, and tissues of
the soft palate and uvula.
• All of these defects or any combinations of them may
occur.

12. Diagnostic evaluation
• Prenatal diagnosis – maternal ultra sonography
• After birth
Physical examination of moth , palate and nose
confirms the presence of cleft lip and palate.
A gloved finger placed in the mouth to feel the
defect or visual examination with a flash light
will confirm the diagnosis.

13. Management
• Treatment of child with CL and CP involves
cooperative efforts of a multidisciplinary health
care team including

14. Multidisciplinary health care team
Plastic surgeon
Otolaryngologist
Oral surgeon
Orthodontist
Dentist
Prosthodontist
Speech pathologist
Speech therapist
Audiologist
Nurse coordinator
Geneticist

15. Cleft lip management
• Requires 2 surgeries depending upon the severity of
defect
• Initial surgery – performed at 3 months of age
• Procedure –
Tennison Randall Triangular Flap ( Z- platy )
Millard rotational advancement technique
Combination of these two techniques

16. Cleft palate management
• Requires multiple surgeries over the course of
18 years.
• First surgical repair between the age of 6 – 12
months
• For cleft palate, Palatoplasty named as Wardle’s
procedure is done

17. • Initial surgery – crate a functional palate ( reduces the
chance of fluid entering the middle ears and help in
proper development of teeth and facial bones)
• Bone graft – 8 years old ( fill the upper gum line so
that it can support permanent teeth and stabilizes the
upper jaw)

18. • Further surgeries to improve speech – 20 % of
child with cleft palate requires further surgeries
to improve speech
• Once permanent teeth grow , braces may be put
to straighten the teeth

19. Nursing diagnosis
• Ineffective airway clearance related to
tracheobronchial aspiration of feeding or trauma of
oral surgery
• Acute pain related surgical incision and elbow
restraints
• Imbalanced nutrition less than body requirement
related to inability to suck and to the surgical repair
• Deficient knowledge about feeding techniques and
surgery related to unfamiliar with the information

20. • Interrupted family process related to family reaction
to an infant
• Impaired skin integrity related to surgical repair
• Risk for infection related to surgical repair and
aspiration

21. Nursing care
Care of baby at birth
• Cleft lip and palate is detected during initial
neonatal assessment
• Identify and give prompt management to
associated, congenital anomalies and life
threatening complications
• Nurse must explain to the parents about possibility
of defect correction
• Breast feeding is possible with palatal prosthesis.
If the baby is unable to suck the breast , expressed
milk may be given using syringe with a rubber
tube.

22. • Expressed milk or artificial feeding also be given with
long handled spoon or soft nipple with large hole.
• Mother and family members should be demonstrated,
the various techniques that can be used for feeding the
baby at home.
• Explain to the parent about the risk of aspiration due to
cleft palate.
Instructed to give feed the baby in upright position.
Small bolus should be given from the corner of the
mouth.
Give sufficient time to baby to swallow .
Give small frequent feed.

23. • Burp the baby
• Explain to the parents about importance of adequate
nutrition
• Give all essential care to the baby ( Immunization,
warmth, hygiene, prevention of infection)
• Explain about the timely follow-up to the
parents

24. • Preoperative care
Basic preoperative care is required
Prepare the baby according to the surgeon’s
orders
Consent
All investigations must entered in patient file
NPO at least 6 hrs
• Post operative care
Closely observe and monitor vital signs
observe for any bleeding from surgical site
Turn the baby’s face to one side to drain the
secretion and prevent aspiration

25. Protect the surgical site from injury
 Position the baby on back or side and arm
or elbow restraints are applied to prevent
him/ her from touching the suture line
 Logan’s bow must be placed over the upper
lip and taped to the infant’s cheek to prevent
tension at the suture line.
Administer prescribed analgesics
Advise to apply petroleum jelly for several
days after surgery

26.  Prevent infection at site
Avoid the use of suction or other objects in the
mouth, such as tongue depressor, thermometers,
pacifers, spoons, and straws.
Provide love and affection to the baby

27. Reference
• Sharma Rimple; Essentials of peadiatric nursing, 2nd
ed;2017, Jaypee brothers medical publishers(p) Ltd, New
delhi.
• Hockenberry Marilyn J Hockenberry, Wilson David,
Rodgers Cheryl C. Wong’s essentials of peadiatric nursing;
10th ed, Elsevier publications, New delhi; 2017
• James Rowen Susan; Nursing care of children: Principles
and practice; 2nd ed;elsevier publishers, London; 2002

28. • Varghese Susamma, Susmitha Anupama .Text Book
of Peadiatric Nursing; 1st ed;, Jaypee brothers
publishers (p)Ltd; New delhi, 2015
• https:/nurseslab.com