CLEFT LIP & CLEFT PALATE

Cleft lip and Cleft palate are congenital malformations resulting from the failure of fusion of maxillary process during intrauterine development. This defect may occur alone or together

DEFINITION

CLEFT LIP (Cheiloschisis)It results from failure of fusion of maxillary process with nose elevation on frontal prominence.

Types: Partial or incomplete Complete Unilateral Bilateral

CLEFT PALATE (Palatoschisis)It results from failure of fusion of the hard palate with each other and with the soft palate. Cleft lip also usually occurs with cleft palate.

Type: Complete Incomplete

INCIDENCE & ETIOLOGY

Cleft Lip: 1 in 750 births Cleft Palate: 1 in 2500 births

Cleft lip is predominantly seen in males and cleft palate in females

CAUSES: Medication taken by mother ( Anticonvulsants, chemo drugs, methotrexate or acne

medications with accutane) Exposure to viruses or chemicals Excess exposure to X-ray Maternal : Anemia, Hypoprotinemia Maternal alcohol abuse Maternal smoking.

PATHOPHYSIOLOGYEmbryological Development

Lower lip and nose fuses with 5 major facial prominences

Lip development: 3rd and 7th weekPalate development: 5th and 12th week

Failure of fusion of the maxillary and premaxillary process, Failure of palatal process fusion

CLEFT LIP & CLEFT PALATE

Complete or partial non- union may affect the palatal bone, upper lip along with maxilla,

premaxilla and tissue of sot palate and uvula

COMPLICATIONS

i. Feeding problemsii.Respiratory infectionsiii.Ear infections/ hearing lossiv.Speech problemsv.Dental problems

DIAGNOSTIC EVALUATION

MATERNAL USG

After Birth: Physical examinationA gloved finger is placed in mouth to feel the defect or visual examination with a flash light will confirm the diagnosis

Health Care Team

A plastic surgeon An otolaryngologist An oral surgeon An orthodontist A dentist A prosthodontist A speech therapist An audiologist A nurse co-ordinator A geneticist

Surgical management

CLEFT LIP

Requires one or two surgeries depending on the severity of defect The initial surgery is done at the age of 3 months

1. Tennison- Randal Triangular Flap (Z-Plasty)2. Millard’s Rotational Advancement technique

CLEFT PALATEIt requires multiple surgeries over a course of 18 years

1st Surgery: 6 – 12 monthsCreates a functional palate, reduces the chance of fluid entering the middle ear and help in proper development of teeth and facial bones.

2nd Surgery: 8 yearsBone graft to fill in the upper gum line so it can support permanent teeth and stabilize upper jaw.

3rd Sxg: 20% of cases requires to improve speech

After permanent teeth grows- Braces may be put.

NURSING MANAGEMENT Detected immediately after birth. Avoid complications The defect evokes negative reaction and shock in parents. The nurse must

explain to the parents about the possibility of defect correction. Feeding: Reduces infants ability to suck.-Breast feeding is possible with the use of palatal prosthesis (Palatal Obturator)-If baby is unable to suck, expressed breast milk may be given using syringe with a rubber tube. Long handled spoon or dropper or soft nipple with a large hole.

Mother and family should be demonstrated, the various techniques of feeding the baby.

Explain to parents about the risk of aspiration Small bolus should be given from the corner of the mouth Give baby sufficient time to swallow Burp the baby in between the feeds and after feeding The baby must be given all essential care including

immunization, warmth, hygiene, prevention of infection Explain about follow up to the parents.

Care of baby before Surgery

Basic pre- operative care is required Consent must be taken prior to surgery All investigation reports must be entered in patient’s file. The baby must be kept NPO atleast 6 hours prior to surgery

Care of baby after Surgery

Closely observe Vital Signs. Observe for any bleeding from the site of surgery Turn the baby’s face to one side, for drainage of secretions and

preventing aspirations.

Protect surgical site from injury: Position the baby on back side. Arm and elbow restraint to prevent child from touching suture. Restrains to be removed periodically Logan’s bow

Thank you

Administer the prescribed analgesic, to minimize pain. Prevent infection to the operated area. Do not allow the baby to put any object in mouth Provide love and affection to the baby.