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Multidisciplinary care essential in successful cleft lip/palate repair

In the May 2017 issue of Pediatrics, the American Academy of Pediatrics published a clinical report entitled “The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate.”

The report stressed the importance of children receiving their specialty cleft-related care from a multidisciplinary cleft or craniofacial team with adequate volumes to promote successful outcomes.

Akron Children’s James A. Lehman Jr., MD Craniofacial Center specializes in correcting deformities of the face and skull. Our center is certified by the American Cleft Palate-Craniofacial Association as an approved center, and annually treats more than 500 patients, ranging from newborns to young adults.

Timely referrals and treatment
Children should be referred to the Craniofacial Center as soon as an abnormality is detected. Early intervention reduces stress and anxiety for families, and minimizes future health problems related to the craniofacial disorder.

Interventions are carefully timed to restore appearance and function as effectively as possible. While the appropriate timing and order of treatment ensures the best possible outcomes, treatment is individualized to meet the specific needs of each patient family.

Care of the infant with cleft lip/palate
If a cleft-related condition is identified at birth, the infant should be referred to our craniofacial team as soon as possible, ideally within the first week.

Feeding problems
Feeding is the most common difficulty experienced in infants who have cleft lip and palate or isolated cleft palate. Infants with an isolated cleft lip with no palatal involvement typically do not have feeding difficulties, although obtaining optimal latch can be challenging.

Infants with cleft palate are unable to create enough suction to extract milk from the breast or bottle. There are several cleft nursing systems that allow for feeding without the child having to create suction. This includes a squeeze bottle system, Haberman system, pigeon nipple and Dr. Brown’s specialty nursing system.

We will determine the correct nursing system for the infant and guide the parents in using it. Mothers who wish to breastfeed will also be guided in pumping and feeding expressed milk.

Some children may experience dysphagia and/or silent aspiration and will require assistance from our team’s feeding specialists.

Growth and development
As the primary care physician, you will continue to monitor the infant for adequate growth, weight gain and development. Developmental delays or other signs of an underlying syndrome may not become apparent until the first year or later.

Infants with cleft lip and/or palate will have similar weight gain and growth as other infants. Increased monitoring or interventions for poor growth may be necessary so craniofacial surgery does not have to be postponed for inadequate nutrition.

Pre-surgical molding
Pre-surgical molding is the next major step in caring for infants with either a cleft lip or cleft lip and palate, depending on the severity. Children with isolated cleft palate do not require molding.

There are two major forms of pre-surgical molding, categorized as either active (i.e. Latham appliance) or passive (i.e. nasal alveolar molding). Both forms are offered at Akron Children’s. They’re used to help achieve a better surgical outcome by molding the maxillary, alveolar and nasal tissues to create a more symmetrical appearance.

Lip and nose surgery
Lip and nose correction is typically the first surgical procedure. Although the timing can vary, it usually occurs between 3 and 6 months of age. Exact timing is based on the extent and severity of the cleft as well as any comorbidities. Most children spend one night in the hospital following lip and nose surgery.

Cleft palate repair
Palate surgery is typically the second major procedure performed and usually requires an overnight stay. Timing varies between 6 and 12 months of age, depending on the extent, severity and comorbidities.

The main purpose of palate repair is to separate the oral and nasal cavities to allow for normal speech development. The soft palate is responsible for velopharyngeal closure and several sounds that are made in everyday speech.

Successful separation of the cavities will be determined at the postoperative visit, but the child will require follow-up between 2 ½ to 3 years of age to evaluate speech development.

“Even with successful repair of the soft palate, up to 15 percent of patients may develop velopharyngeal dysfunction, which may require surgical correction,” said Niyant Patel, MD, craniofacial surgeon.

Hearing
Most infants born with cleft lip and/or palate will pass their newborn hearing screening. However those with palatal involvement will likely develop middle ear effusions, which will require the placement of myringotomy tubes to allow for hearing and appropriate auditory and speech development. This procedure is typically coordinated with cleft lip or palate surgery. Our audiologist will provide regular hearing assessments as part of our team care.

Make a referral to the Craniofacial Center through Epic or by calling 330-543-4970.

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