This page covers the incidence of Cleft Lip & Palate in New Zealand, a description of the condition, the importance of supporting the parents of babies born with these conditions, management of feeding problems, strapping of the lip, early surgery, on-going care, mid-term treatment and final treatment.
In New Zealand about one baby in every 650 live births is born with a cleft of the lip and/or palate. Clefts of the lip and/or palate occur slightly more often in Maori populations (1:750) than European populations (1:650). Clefting occurs about the 30th day of foetal development as a result of various facial processes failing to fuse together.
This results in a gap in the lip running from one nostril, through the lip to the margin of the mouth. The condition may be one sided or affect both sides. If the cleft involves the palate as well, the gap extends back to the top of the throat thus opening nasal passages to oral cavity. Isolated clefting of the palate can occur and is regarded as a separate congenital defect occurring a little earlier in foetal development at about the 28th day. The expression of clefting ranges from slight notching to very wide deformation.
When babies are born with facial clefts not previously diagnosed by ultra sound, parents may be quite distressed. It is important to quickly dispel possible feelings of blame and rejection, favouring love and support and the early formation of a strong bond between mother and baby. Clefting of the lip can be quite disfiguring especially if bilateral, but the treatment of these conditions by teams of specialists results in adults who lead happy and fulfilled lives. Some even become movie stars!
Baby and parents will be referred early to a regional Cleft Palate Team. This is a team consisting of Plastic and Reconstructive Surgeons, Speech Therapists, Ear Nose & Throat Surgeons, Paediatricians, Orthodontists, Prosthodontists, and Specialist Nurses that specialise in treating these cases.
The second problem is often difficulty with feeding because sometimes the baby is unable to form an air-tight seal and suckle the breast. This is easily overcome. With coaching and practice many mothers are able to breast feed their babies normally. For those continuing to have problems, special teats with wide wings to close of the gaps created by the clefting such as the Haberman Feeder are now available. The mother can express her milk and successfully feed the baby by bottle. Often, mothers use both methods so that normal bonding occurs and at the same time they can be confident of nourishing the baby.
Clefts of the lip often gape at birth. The edges of the lip can easily be approximated by strapping the lip with sticking plaster. The sooner strapping starts the better the result. In more severe cases of combined bilateral cleft lip and cleft palate, specially designed removable plates are sometimes also used to mould the baby’s upper gum pads into better alignment. Strapping and fitting of the removable appliance will usually be carried out by a specialist orthodontist.
The lip and palate are usually repaired by surgery at about 9 months of age. Recent trends are to carry the surgery out a little earlier. The concept is to restore normal function as soon as possible because the helps the developing child to speak more clearly. Once the lip and palate have been repaired there is unlikely to be any further intervention until the patient is about 8 years of age.
In the meantime the Cleft Lip & Palate Team will monitor the child’s hearing and speech development. Grommets may need to be fitted to allow the ears to drain and a course of speech therapy undertaken to improve speech during this time.
From nine months of age until the child starts to get their second teeth, at say age 6 they will be seen at intervals by the local cleft palate team to monitor progress of their speech development and ability to hear. These are most important because they influence the child’s education. Speech therapy sessions and/or grommets to drain the ears are often required during this period. If the surgeons were unable to completely close the palate, the child will be asked to wear a small plastic dental plate to close-off (obturate) the gap.
When the child starts getting their second teeth, the upper front ones often come through crooked. Sometimes a tooth may be missing and occasionally extra teeth are present close to the repaired cleft. A period of orthodontic treatment often helps dramatically and will often be “stabilised” by the insertion of a secondary alveolar bone graft. Small pieces of bone are taken from a donor site (usually the hip) and inserted into the cleft site during an minor operation. The added bone also helps the upper canine teeth to erupt into the dental arch normally and close any gap in the palate that could not be completely repaired during the first operation. Sometimes children also may require an operation to narrow the gap between the soft palate and throat (pharyngoplasty) so they can speak more clearly.
Final orthodontic treatment
Once the upper premolars have emerged the final phase of orthodontic treatment can be started, often in the early teenage years. This usually involves appliances fixed to both arches. Treatment times vary depending on the presenting condition and often exceed 24 months. Here is the completed case. The patient wears a specially designed metal partial denture with prosthesis to replace the absent upper left lateral incisor.
After the final orthodontic phase, revision plastic surgery may be required to improve the appearance of the nose and/or lips.
With the exception of the bottle feeding image, all photos are of the same patient and here she is!
If your new baby is born with a cleft lip and/or cleft palate you can contact the support network at this link http://www.cleftsupport.wellington.net.nz/Integrated_Cleft_Team.html