A presentation on the management of the pediatric condition called cleft lip and cleft palate.

1. PEER GROUP PRESENTATION
MANAGEMENT OF A CHILD WITH CLEFT LIP & PALATE
Protiksha Das
M. Sc. Nursing Student
2nd Year

2. INTRODUCTION
 The dictionary meaning of cleft is a crack, fissure, split or gap. Cleft lip and cleft
palate are congenital malformations of the face.
 It results from the failure of fusion of the first branchial arch during intrauterine
development.
 The cleft can involve the lip, alveolus (gum), hard palate and soft palate and can be
complete or incomplete, unilateral or bilateral.
 The complete formation of lip often occurs by 5 to 12 weeks of gestational age.
 The formation of palate may occur only by 12 to 14 weeks of gestational age.

3. EMBRYOLOGY
 Development of facial structures starts at end of four weeks from five prominence .
 Frontonasal prominence
• Nasal placodes – invagination – nasal pits
 Medial nasal process
 Lateral nasal process
Paired maxillary prominence
 Paired mandibular prominence, around stomodeum

4. EMBRYOLOGY Cont.

5. DEVELOPMENT OF LIPS AND NOSE
2 medial nasal processes fuse in midline – upper lip
Mandibular processes fuse in midline – lower lip
The maxillary and lateral nasal process separated by nasolacrimal groove/ duct
Frontonasal process – bridge of the nose
Medial nasal process – tip pf nose and philtrum of upper lip
Lateral nasal process – ala of the nose.

6. DEVELOPMENT OF LIPS AND NOSE Cont.

7. DEVELOPMENT OF LIPS AND NOSE Cont.
Frontonasal Prominence
Nasal Placode
Nasal Pit
Oral Opening
Maxillary
Process
Mandibular
Arch
Nasomedial Process
Nasolateral
Process
Nasolacrimal
Groove
Mandible
Maxillary
Process
Nasolateral
Process
Nasomedial
Processes
Merging
Philtrum
or Lip
Ear Tubercle
Ear
Hyoid bone
Laryngeal
Cartilages

8. DEVELOPMENT OF PALATE
The palate can be divided into the primary and secondary palates.
1. PRIMARY PALATE :
The primary palate consists of the medial portion of the upper lip and the portion of the
alveolar ridge that contains the central and lateral incisors.
Maxillary and medial nasal process merge.
Containing the premaxilla, alveolus and lip is anterior to the incisive foramen
Formation of intermaxillary segment from merge medial nasal prominences.

9. DEVELOPMENT OF PALATE cont.
2. SECONDARY PALATE:
The secondary palate consists of the remaining
portion of the hard palate and all of the soft
palate .
Formed from 2 outgrowth from maxillary
prominences i.e. palatine shelves.
Containing the uvula, palatal musculature,
maxilla, palatine bones and pterygoid plates.
Fuse in midline at 7th week .

10. DEVELOPMENT OF PALATE cont.

11. INCISIVE FORAMEN
Midline landmark between primary
and secondary palate
• Contains the nasopalatine vessels and nerves.
• The maxillary prominences from both sides grow
towards each other and 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.

12. CLEFT LIP
• A cleft lip occurs when the medial nasal processes fail to fuse with the maxillary process.
• The extent of cleft lip varies from a notch in the vermilion border to a large cleft reaching the
nose floor.
• It is a birth defect which results in a unilateral or bilateral opening in the upper lip between
the mouth and nose.
• It is also known as harelip.

13. CLEFT LIP

14. CLEFT PALATE
• It is a birth defect characterized by an
opening in the roof of the mouth caused
by a lack of tissue development.
• It may be unilateral or bilateral or may
occur in isolation or with a cleft lip.
• It results from the failure of masses of
lateral palatine processes to meet and fuse
together.

15. INCIDENCE
• It is a birth defect characterized by an opening in the roof of the mouth caused by a lack
of tissue development.
• It may be unilateral or bilateral or may occur in isolation or with a cleft lip.
• It results from the failure of masses of lateral palatine processes to meet and fuse
together.
• Cleft lip births, predominantly seen in males.
• Cleft palate births, mostly seen in females.
• If parents have disorders

16. INCIDENCE Cont.
• Monozygotic twins are more prone to get than the non zygotic twins.
• Cleft lip and cleft palate is higher in Asian and lowest in Africans and Americans.
• Babies with isolated cleft palate have lower birth weight than those with isolated cleft
lip.
• Increasing incidence has been reported with increasing parental age (particularly
mothers).
• Incidence is more in the first born child.
• Malnutrition increases the chance of cleft lip and cleft palate..

17. ETIOLOGY
Genetic factors – it has been estimated that the chances of a child having a cleft lip and cleft palate is 2% when
one of the parent have a cleft lip or cleft palate
Unfavorable maternal factors –
 Illness specially viral infection during the fifth and twelfth weeks of gestation, e.g. rubella.
 Anemia and Maternal malnutrition and Maternal smoking
 Hypoproteinemia
 Effect of certain drugs e.g. corticosteroids, aminopterin.
 Exposure to radiation during pregnancy.
 Physiologic, emotional and traumatic stresses during development.
 Defective vascular supply to the affected area.

18. CLASSIFICATION OF CLEFT LIP AND
CLEFT PALATE:
Indian classification : A simple Indian classification is in current use it is called the Nagpur
classification and was first describe by professor C. Balakrishnan in Indian Plastic surgeon.
Group – 1 (Perialveolar) – it includes only cleft lip in right or left side or bilateral and
rarely in midline. It can have subtypes.
Group – 1A – which indicates cleft lip and alveolus.
Group – 2 (postalveolar)– it includes only cleft palate. Submucous cleft may found or as
fistula or bifid uvula.
Group – 3 (combined) – it includes both cleft lip and palate in midline or may be unilateral
or bilateral.

19. VEAU’S CLASSIFICATION OF CLEFT LIP
AND PALATE
A. CLASSIFICATION OF CLEFT LIP
Class I- A unilateral notching of vermilion not extending into the lip.
Class II- A unilateral notching of vermilion with cleft extending into the lip but
not including the floor of the nose.
Class III- A unilateral cleft of vermilion extending up to the floor of the nose.
Class IV- Any bilateral clefting of the lip either complete or incomplete

20. VEAU’S CLASSIFICATION OF CLEFT LIP
AND PALATE cont.
B . CLASSIFICATION OF CLEFT PALATE
 Class I- Involving only soft palate .
 Class-II- Involving soft palate and hard palate but not the alveolus .
 Class III- Involving soft palate , hard palate and the alveolus on one side .
 Class IV- Involving soft and hard palate and alveolus on both side of
premaxilla

21. VEAU’S CLASSIFICATION OF CLEFT LIP
AND PALATE cont.

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

23. PROBLEM ASSOCIATED WITH CLEFT LIP
AND CLEFT PALATE
 Immediate problem :
• Feeding problem due to ineffective sucking resulting in undernutrition
• Excessive air intake during feeding
• Nasal regurgitation
• Aspiration of feeds
• Breathing difficulty
• Mouth breathing
• Parental anxiety due to defective appearance of the infant

24. PROBLEM ASSOCIATED WITH CLEFT LIP
AND CLEFT PALATE cont.
Long term problem :
• Recurrent ear and throat infection especially otitis media .
•Respiratory tract infection .
•Impairment of speech .
•Malocclusion and misplacement of teeth .
•Hearing problem due to oral malformation especially in cleft palate.
•Impaired body image due to altered shape of face and oral cavity.
•Disturbed parent-child relationship and maladjustment with non acceptance of the infant.
•Nasal distortion
•Exposed nasal cavity

25. DIAGNOSTIC EVALUATION
• History collection
• Prenatal ultrasonography
• Physical examination
• X-ray
• MRI
• Dental imprecisions
• Genetic evaluation

26. MANAGEMENT
 Management of cleft lip and cleft palate requires a team effort involving
•A pediatrician
•A plastic surgeon
•Orthodontics
•Otolaryngology
•ENT specialist
•Speech therapist
•Psychologist
• Nursing and social worker

27. TREATMENT PROTOCOL
 3-6 weeks : infant orthopedics
 10 weeks: primary lip surgery
 18 months : secondary palate surgery
 9 months – 2 years : under supervision of speech therapist and require orthodontic intervention .
 7yrs-8 yrs : correction of incisor malposition.
 7 yrs -10 yrs : secondary alveolar bone grafting
 8yrs -11 yrs : Maxillary advancement tried with framework appliance
 12yrs onward : comprehensive orthodontic treatment with fixed appliance .
 18yrs : orthognathic surgery .

28. STAGE OF MANAGEMENT
1. Fabrication of a passive obturator
2. Pre-surgical orthopedics
3. Surgical management of cleft lip
4. Surgical management of cleft palate

29. STAGE OF MANAGEMENT cont.
1. Passive maxillary obturator :
• Intraoral prosthetic device
• Fills the palatal clefts
• Provides false roofing against which child can suck.
• Reduces the feeding difficulties like insufficient
suction , choking , excessive air intake.
• Obturator is fabricated using cold cure acrylic after
selective blocking of all the undesirable undercuts .

30. STAGE OF MANAGEMENT cont.
2. Presurgical orthopedics :
• Nasoalveolar Molding
• Creation of good functioning palate .
• Normalize tongue position
• Help in speech development
• Improve symmetry of nose and cleft of maxilla
• Psychologically boost patient and parents as the
patient get continue supervision .

31. SURGICAL MANAGEMENT
For cleft lip – 10 weeks of age
10 pound weight and
10 grams of hemoglobin.
For cleft palate – 10 months of age
10 kg weigh and
10 gm of hemoglobin
.

32. 3.SURGICAL REPAIR TECHNIQUE FOR
CLEFT LIP
 Cleft lip repair :
• 3 to 6 months
• Cheiloplasty
• Ralph Millard’s Rotation advancement technique
• The Rotation advancement repair of the
unilateral cleft lip deformity as described by
Millard is the most commonly used method of
repair .
 Cleft palate repair :
• 9 to 12 months .
• palatoplasty
• Von langenback procedure
• Veauwardilkilners
• Three flap technique &millards
• Double revising ‘Z’ plasty

33. NURSING MANAGEMENT OF A CHILD
WITH CLEFT LIP AND CLEFT PALATE
Ineffective airway clearance
related to tracheobronchial
aspiration of feedings as
evidence by abnormal breath
sounds, cyanosis, dyspnea.
• Assess the infant’s respiratory rate, depth, and effort.
• Assess skin color and capillary refill
• Assess for abdominal distention
• Place the infant in an infant seat at a 30° to 45°.
• Position the infant in an upright position during
feeding and elevate the head of the crib 30° after.
• Teach the mother about the feeding technique.
• Provide oral and nasal suctioning as needed.

34. NURSING MANAGEMENT OF A CHILD
WITH CLEFT LIP AND CLEFT PALATE cont.
 Imbalanced nutrition, less
than body requirements
related to inability to suck,
repeated infection as
evidence by poor feeding,
underweight, weakness of
the swallowing muscles.
• Assess infant sucking and swallowing ability.
• Monitor daily caloric and fluid intake.
• Record daily weight of the newborn.
• Encourage frequent burping after feeding
• Hold the infant in an upright or a sitting
position while feeding.
• Teach the mother about correct method of
feeding.
• An alternative is for the mother to pump her
breasts and feed the infant with a bottle.
• Instruct mother who bottle feed to use some
cereal to thicken the milk

35. NURSING MANAGEMENT OF A CHILD
WITH CLEFT LIP AND CLEFT PALATE
cont…
 Parental anxiety related to
congenital defect of the newborn
as evidence by severe reaction
to the appearance of an infant
with a facial defect, expression
of guilt, blame, and
helplessness, feelings of
inadequacy and uncertainty,
worried and anxious about
impending surgery..
• Assess level of anxiety and need for
information.
• Encourage expression of concerns and
questions about the condition
• Provide an accepting environment and
attitude and handle the infant in a gentle,
caring, way.
• Discuss the surgical procedures for correction
of the defects using pictures and models.
• Allow to view pictures of children with
successful defect repair.

36. NURSING MANAGEMENT OF A CHILD
WITH CLEFT LIP AND CLEFT PALATE cont.
 Deficient knowledge related to lack of information about care of newborn,
lack of information on feeding and surgical procedure to correct defect as
evidence by request for information about cause of defects, feeding
techniques, prevention of complications caused by defects.
 Risk for aspiration related to anatomical defect.
.

37. THANK YOU