Cleft Care

First Few Weeks(Primary concern of the parent feeding)

 

(a) A soft squeeze bottle for feeding, nipple of which can be modified. The hole is made bigger which helps to drip the milk in baby’s mouth.

(b) Feeding position for cleft baby.

How to make feeding easy for a child with a cleft palate?

  • Use a squeeze soft bottle
  • Conventional nipple can be modified by making the hole big enough so that milk drips down drop by drop without much effort.

(a) Feeding position for cleft baby.

(b) Use of Paladi for feeding.

(c) A baby with extensive cleft.

(d) Feeding plate.

(e) Feeding with plate in mouth which covers the gap.

How to feed such a child?

Feeding Position

  • Mother should hold the baby in the lap at about 45° keeping his/her head high so that milk/feed does not get into lungs.
  • Use small feeds at each time
  • Frequent burping should be initiated following feed
  • Use of deep spoon called Paladi can be useful

How does this help the child?

  • Child is unable to create negative pressure because of the defect in the palate and hence cannot suck the milk from nipple.
  • Big hole in the nipple helps drip the milk effortlessly
  • Drip the milk in the area of intact palate, watch for milk getting down for the child to swallow. It should not get into breathing tube or come out of nose.

Whom to consult at this stage?

  1. A specialist nurse helps you to understand how to feed the cleft baby
  2. To watch out for weight gain; chest infection and such things get in touch with pediatrician
  3. For recurrent ear infections ENT surgeon may be consulted. It is a good idea to get hearing tested.

3 Months

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(a, b) Plastic surgery for repair of lip,(c) pre surgery, (d) repaired lip.

Primary cleft lip surgery!!!

What is the purpose of surgery?

  • To close gap in lip and also front part of the palate

Who does the surgery?

  • Cleft palate surgeon

6 months –1 year

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(a) Normal palate is mobile and separates nose cavity from throat during speech, (b) Short palate allows air to escape in nose therefore causes high pitched nose sound during speaking.

Can the child hear properly??

Can the child start speech??

Whom to consult?

  • ENT Surgeon
  • Speech Therapist

What to watch out for?

  • Throat infection
  • Chest infection
  • Ear infection with hearing loss

9 months –1 year

Palate Repair!!!

What is the purpose of second surgery?

  • To close back part of palate down up to the soft palate
  • Revision of lip and deepening of sulcus when upper lip is not very mobile
  • To develop good speech both upper and lower lip should meet

1 year – 6 years

Can the child talk properly??

Whom to consult?

  • Speech Therapist

What to watch out for?

  • Nasality of voice
  • Speech and language problem

Who else to consult?

  • Dentist
  • Orthodontist

What else to watch out for?

  • Erupting milk teeth
  • Oral hygiene, dental caries
  • Tooth erupting in the palate or at site of operation
  • Articulation problems
  • Irregular permanent teeth
  • Escape of fluids from nose

6 years– 9 years

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(a) Front teeth may grow inwards then normal position, (b) Orthodontic plate with spring is used to push the tooth towards lip, (c) Corrected tooth.

To check for irregularities of teeth!!!

To check quality of speech development!!!

Review by the cleft surgeon!!!

Whom to consult?

To be under constant review with the following people:

  • Speech therapist
  • Cleft surgeon
  • Orthodontist

What to watch out for at this stage?

  • Development of teeth in the cleft region
  • Evaluation of effects of surgery on growth of upper jaw.
  • Rotation of teeth/Absence of permanent teeth
  • Abnormal Jaw movement/Facial asymmetry
  • Anterior/posterior placement of teeth
  • Escape of fluid from mouth to nose

9 years –12 years

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(a) Scarring in palate due to surgery causes narrow upper jaw which is expanded with orthodontic appliance, (b) After expansion, (c, d) The malaligned teeth are corrected with fixed orthodontic appliances. The big hole seen in the palate is filled with bone through secondary alveolar bone graft (SABG). Afterwards the missing teeth are replaced with artificial teeth.

Speech improvement has taken place or not!!!

Does fluid escape from mouth to nose!!!

IF YES

Whom to consult?

  • Plastic surgeon/Oral surgeon

What is the purpose?

  • Prepare child for bone grafting
  • Secondary bone graft is done to fill the bony defect underneath the skin of lip and mucosa
  • Purpose is to make two halves of the upper jaw one and provide bone support for upper adult canine to erupt normally
  • Also helps to close communication between mouth and nose.

7 years –14 years

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(a) X-ray shows big bony defect in upper jaw, (b) After orthodontic treatment, ready for bone graft, (c) The defect has been filled with bone, (d) After removal of braces and completion of orthodontic treatment.

  1. Wrong position of teeth erupting in the mouth
  2. Extra teeth or missing teeth in the mouth
  3. Narrow upper jaw
  4. Interlocking of upper and lower teeth–cross bite

Whom to consult?

  • Orthodontist
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(a1,a2,a3) Pretreatment: Young girl developed small upper jaw has missing teeth, (b1,b2) During orthodontic treatment, (c1,c2,c3) At completion of orthodontic treatment, (d1,d2,d3,d4) After removal of braces and replacement of missing teeth with a removable partial denture. A happy patient.

What is the purpose?

  • To correct irregularities of teeth
  • To harmonize jaw bones
  • To create good smile and balanced face
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Fig. 7.9*

(a1,a2,a3,a4) A young boy of bilateral cleft lip and palate has bad teeth. (b1,b2,b3,b4) During orthodontic treatment. (c1,c2,c3,c4) At completion of orthodontic treatment and removal of braces. (d1,d2,d3) After replacement of missing tooth with plate which also serves as a obturator that covers hole in the palate and therefore helps in improvement in speech and prevents food from escaping through nose

18 years and above

Scar revision or rhinoplaty

Rehabilitation of missing teeth

Whom to consult?

  • Orthodontist
  • Prosthodontist
  • Plastic Surgeon

To check if facial balance can be managed with braces alone or child needs a surgery. If surgery is needed, it may require joint consultation with an Orthodontist, an Oral Surgeon and a Plastic surgeon.

What is the purpose?

  • Harmonize upper and lower jaw
  • Orthognathic surgery by Orthodontist
  • Rehabilitation of missing teeth
  • implant denture by Prothodontist
  • Rhinoplasty
  • to improve shape of the nose by Plastic Surgeon
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(b)

An adult patient of cleft lip has been treated for lip revision and nose surgery (a) Pre treatment, (b) Post treatment.

Adulthood and Marriage

  • Clinical geneticist

Milestones to Good Outcome

Cleft children are not different from other kids.

  • They can grow and live normally

Cleft Surgeon is your friend

  • Do not forget to see him at regular intervals
  • Do not see him only when you need surgery

Consult Speech Therapist

  • He may guide you for speech and hearing problems
  • Follow timings of treatment 6 months to 2 years are critical for speech

Consult orthodontist

  • 6 years and above orthodontic consultation is important
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