Cleft Lip and Cleft Palate

There are certain problems that a child with a cleft lip and palate faces:

• Feeding: A newborn with a cleft lip and palate is unable to suckle on the mother’s breast as well as on a feeding bottle with a nipple. 
• Tooth development: A child with a cleft lip and palate may have an improper arrangement of teeth. Some teeth may also be missing in their case. 
• Speech: A child with a cleft lip and palate may have an improper or nasal-sounding speech.
• Hearing: Some babies with a cleft palate are more prone to middle ear infections (otitis media) which can impair their hearing ability.

Cleft lips are characterised into four classes:

• Class 1: Unilateral cleft on the lip, starting from the inner edge of the lip but not extending to the lip line (vermilion border of the lip).
• Class 2: Unilateral cleft on the lip extending from the inner edge of the lip to the lip line.
• Class 3: Unilateral cleft on the lip extending from the inner edge of the lip to the base of the nose.
• Class 4: Bilateral clefting of the lip to any extent.

Cleft palates are characterised into four classes:

• Class 1: Cleft presents as a straight line in the middle of the soft palate - our palate has two sections, a softer section at the back of the roof of the mouth and a hard (bony) section that you can feel when you press your tongue against the roof of the mouth just behind the teeth.
• Class 2: Cleft presents as a straight line in the middle of the soft and hard palate but does not extend to the ridge from where the teeth develop.
• Class 3: Cleft presents as a straight line extending from the soft and hard palate and then diverting 45 degrees to the right, separating one side of the ridge of the teeth.
• Class 4: Cleft presents as a straight line extending from the soft and hard palate and then diverting 45 degrees to the right and left separating both the sides of the ridge of the teeth. This leaves a hanging piece of bone in the middle.

Cleft lip and palate can usually be seen soon after birth. Depending on the type of cleft lip and palate, they could appear as:

• A split in the upper lip that may be limited to the lip line or extend up to the nose.
• Splits on both sides of the lips.
• A thin gap in the roof of the mouth; the gap may be limited to the back or extend up to the front of the roof of the mouth.
• A clear gap in the roof of the mouth.

Usually, children with a cleft lip will also have a cleft palate. Apart from this, children with a cleft lip and palate may have difficulty swallowing and suckling. They could also be more prone to ear infection and speech problems.

There are different causes of cleft lip and palate:

• Genetic: If a child’s parents had a cleft lip or palate, then the child is also likely to have one.
• Nutrition: Excessive consumption of vitamin A by a pregnant woman is associated with the occurrence of cleft lip and palate in her baby. Folic acid deficiency (vitamin B9 deficiency) in the expecting mother can also lead to cleft lip and palate.
• Smoking: Women who smoke, put their child at risk of developing cleft lip and palate.
• Medications: Certain medications like anti-seizure medicine (phenobarbitone), tetracyclines and steroids can increase the chances of cleft lip and palate in the baby. If you are ill but planning to get pregnant soon, do let your doctor know so he or she can prescribe medicines that don't have longer-term side-effects.
• Syndromes: There are certain syndromes like Gorlin syndrome and Apert syndrome which can cause cleft lip and palate in the baby.

It is almost impossible to diagnose a cleft lip and palate in a scan during pregnancy. A cleft lip and palate can only be diagnosed by the doctor through oral examination immediately after birth.

Read more: Checkup during pregnancy

Cleft lip and palate require a long-term multidisciplinary approach for their treatment. Cleft lip repair is done within the first three after birth to six months after birth whereas a cleft palate repair is done by the age of 12 months. The follow-up surgeries continue until the late teen years. 

• Pre-surgery procedures: Procedures that are done before three months of age, to improve the outcome of future surgeries are:
  • Lip taping: A procedure to narrow the gap between the baby’s cleft lip, it involves using surgical tape on the baby's face in a way that encourages the lip gap to close a little bit before surgery.
  • Nasoalveolar moulding: A device is used to mould the lip and gum tissues - this helps to reduce the gap and bring the lips and nose in a more appropriate position before stitching up the clefts during surgery.
• Treatment for feeding: Newborn babies are given a custom-made plug called an obturator which closes the gap of the cleft, thus helping the newborn feed on breastmilk or formula.
• Surgical treatment of a cleft lip: The surgery required for the treatment of cleft lip is called cheiloplasty for which the baby is put under general anaesthesia. The surgery aims at closing the space between the lips with the help of already existing tissues and muscles. The surgery also corrects any nasal deformity.
• Surgical treatment of a cleft palate: The surgical closure of a cleft palate is called palatoplasty. The procedure involves closure of the space along with the correction of the abnormally placed muscles. The stitches are not tightly placed so that the tissues can join together on their own without putting any pressure.
  There are various stitching techniques like von Langenbeck's bipedicle flap technique, the two-stage palatal repair and many others which can be used to treat a cleft palate.
  A child with a cleft palate may require bone graft surgery, which is usually done at the age of 8-12 years.
• Speech therapy: Around 30-40% of the children with a cleft palate require surgeries to improve their speech. Speech therapy is also given to the child by a professional therapist between the ages of four and five.
• Orthodontic (braces) treatment: Children with a cleft lip or cleft palate often require braces for the proper positioning of their adult teeth. The treatment usually starts at the age of 12-15 years. The braces treatment can go on for a long period of time as the child may not develop all the teeth.