According to the American Cleft Palate-Craniofacial Association, the most common birth defect in America is the cleft lip and cleft palate, affecting almost 1 in every 600 births. The cleft is formed very early in development--about 7 to 12 weeks--when development of the upper jaw is impaired. Causes of a cleft lip are generally unknown. Although there are significant risks of related birth defects in children born with a cleft lip, the cleft lip itself is repairable through surgical and orthodontic means.
Cleft Types
Different types of cleft lip and palate combinations exist, but the two basic versions are the unilateral--on one side of the child's nose--and the bilateral--on both sides of the child's nose. The three structures that are referred to when discussing a cleft are the lip, the hard (or front) palate and the soft (or rear) palate. It is possible, though uncommon, to have a cleft lip develop alone. Clefts are generally measured by those that include the gum, upper jaw and hard palate and those that extend deeper into the soft palate. Clefts can vary in severity, although bilateral clefts tend to be worse and take more effort to repair successfully. Clefts that extend into the soft palate are likewise more difficult to repair and can leave children unable to swallow, or have difficulty swallowing, breathing and breast-feeding.
Chromosomal Abnormality
A cleft lip and/or palate may be the first visible birth defect in a child who may have other chromosomal abnormalities, including Down syndrome. Some factors doctors look for in ultrasounds to begin to rule out other problems after a cleft lip is detected are developmental weight--fetuses with some chromosomal abnormalities develop much more slowly than otherwise healthy fetuses--a nose bud, a second phalangeal joint in the middle finger and a nuchal fold (neck measurement) that isn't unduly thick. Some parents may opt to have an amniocentesis test done to rule out further abnormalities.
Traditional Surgery
Traditional treatment for a cleft palate begins with a first surgery within the first few months, sometimes even the first few days, of life. This first surgery is to repair the lip, which will apply horizontal pressure to the child's upper jaw and hopefully start to bring the separated bones of the hard palate slightly closer together. Children undergoing traditional treatment require a larger number of surgeries between birth and adolescence. Upwards of a dozen or more surgeries are required to repair the lip, gum, dental work, soft palate and upper jaw, including a particularly difficult bone graft normally scheduled for when the child is about 8 years old. Final surgeries in the late teens will likely include cosmetic surgery to repair the nose.
Nasoalveolar Molding
A newer technique, called nasoalveolar molding developed by Dr. Court Cutting and Dr. Barry Grayson at New York University, combines the molding techniques used in orthodontic work and the latest cosmetic surgical techniques. This combined approach was developed in an attempt to limit the number of surgeries in cleft palate patients in early development. A mold similar to a orthodontic retainer is made for the child within a few days of birth. This mold is used to help reduce any gaps in the bone of the upper jaw and minimize the spaces before the initial surgery is done. This approach takes a bit longer at the outset, but considering the goal of minimizing the amount of corrective work the surgeon has to do, this can be an attractive option for many parents.
Overtreatment
Some of the most emotionally charged issues develop during the hospital stay after a child with a cleft palate is born. Due to the separation in his lip and palate, it is highly unlikely that a child with a cleft will be able to breast-feed successfully. It is possible that some nurses and lactation specialists unfamiliar with cleft palates may insist on mothers trying to breast-feed these children, causing undue stress on both child and mother. Also, some hospitals may insist on children with clefts being treated in NICU centers even though there is no particular intensive care issue that needs to be addressed. According to NYU and Children's Hospital of Philadelphia cleft palate teams, unless the baby has an infection or a heart or respiratory problem, there is no reason a child with a cleft palate should not be treated as any other healthy child postpartum.
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