Clefts of the lip and palate are frequent
birth defects. In a cleft lip, also called 'hare lip', there
is an obvious gap dividing the upper lip on one or both
sides. This may be incomplete and presents as only a notch
in the lip but, more commonly, the defect extends to the
nostril, the upper gum margin and even the palate, that is
the roof of the mouth. The palate is hard and bony in front
and soft and muscular at the back. Sometimes only the palate
has a cleft or gap and the lip is normal.
How is the abnormality caused?
There is no known predisposing factor.
Something seems to happen in early pregnancy at around 8-10
weeks when the mouth is developing from two halves. Failure
of fusion of the two halves in some part or entirely,
results in cleft lip or cleft palate or a combination.
Alcohol or drug use early in pregnancy may increase the
chances of this defect in the baby. There is a higher chance
of the defect occurring if a previous child or one parent
also has the defect.
What are the external
manifestations of this defect?
The extent of structural defect
depends on the severity of the cleft. Besides the gap in the
lip, there is shortening of the lip width, the floor of the
nose is wide open and the nostril of the affected side is
wide and flat. In addition, in some cases the gum margin is
widely separated and may jut out. In cleft lips that involve
both sides of the upper lip, the central portion may project
outwards very prominently.
What are the functional
difficulties?
Sucking - Children with cleft lip and
palate are unable to suck at the breast since they cannot
close over the nipple and generate a negative suction
effect. The milk often regurgitates out through the nose in
cases of cleft palate.
Repeated chest infections - Due to an
abnormal sucking-swallowing mechanism milk often trickles
into their air passages causing chest infection.
Ear infections - A tube normally connects
the ear with the throat. This tube balances the ear pressure
with the atmospheric pressure. The opening of this tube in
the throat is above the level of the roof of the mouth. If
the palate is cleft, milk frequently enters the nose and
throat causing infection that may travel up this tube to the
ear.
Speech defects - Children with cleft
palate have defective speech that has a nasal sound because
of escape of air through the nose. The degree of speech
defect may vary from one child to another.
Teeth alignment - children with clefts
that involve the gum margin have defective alignment of
teeth.
What is the advice given to the
mothers?
The foremost problem is feeding. Since the
baby is unable to suck effectively at the breast,
alternative techniques are tried. Bottles with special long
nipples are helpful. Babies may be fed using a spoon if the
milk is delivered to the back of the babies' mouth. The baby
must be kept in a head up position while feeding to minimize
the chances of milk entering the windpipe. This type of
feeding takes much longer and requires patience. The best
measure that a satisfactory feeding pattern has been
established is a progressive gain in the baby's weight.
The mother should also be advised that if the
baby develops cough or rapid breathing or cries incessantly
she must immediately consult a doctor. This may represent a
chest infection or an ear infection respectively.
What is the treatment?
The definitive treatment is surgical repair.
The operation depends on the severity of cleft. If only the
lip is involved, although it is possible to repair it soon
after birth, the best time is at 1-2 months of age when the
risks of anaesthesia are lower. If both the lip and palate
are cleft the lip is repaired first and the palate is
repaired at about 1 year of age, before the child starts to
speak.
In some children more than one operation may be necessary.
The first operations are meant to correct the functional
defects. Any cosmetic improvement may require further
operations. The outcome after surgery is usually very good.
In cleft palate, however, some degree of speech defect
persists that may be helped by the professional guidance of
a speech therapist. If the child does not have his palate
closed by the time he starts speaking, the degree of speech
defect is likely to be greater.
Baby with cleft lip
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