CLEFT LIP/ CLEFT PALATE
CLEFT LIP
The maxillary and nasal median process normallyfuses between weeks 5 and 8 of intrauterine
life.
Infants with cleft lip === the fusion fails to occur , causing this disorder to range from a small
notch in the upper lip to total separation of the lip and facial structure up into the floor of the nose
with the upper teeth and gingival absent.
Deviation may be unilateral or bilateral
Nose is usually flattened === because the incomplete fusion of the upper lip has allowed it to
expand in a horizontal dimension.
Prevalent among boys than girls
Have associated birth defects
Causes
1. Occurs as a familial tendency or occurs from the transmission of multiple genes
o teratogenic factors present during weeks 5 to 8 of intrauterine life
2. Viral infection
3. Deficiency of folic acid
Assessment:
Cleft lip- detected by a sonogram while the infant is in utero.
1. Difficulty feeding – because the infant cannot form a vacuum with the mouth to suck but may be
able to breastfeed
2. Mouth breathing – results in increased swallowed air, causing distended abdomen, pressure
against the diaphragm
3. Mucous membranes of the oropharynx become dried and cracked with increase infection
Management
Referred for genetic counseling == to ensure that they understand that they have 4% chance of
having another child with cleft lip/palate or future children are at a greater risk.
PREOPERATIVE Nursing Care:
1. Feed in upright position
2. Feed with soft large holed nipple or rubber tipped syringe or cleft lip or palate nurser
3. Burp frequently because of swallowed air
4. Teach parents to give water after each feeding to cleanse the mouth
5. Prevent infection from irritation of the lip
6. Restrain infant’s arm if needed
7. Provide a pacifier to increase sucking pleasure
POSTOPERATIVE Nursing Care:
1. Maintain patent airway
2. Cleanse the suture line to prevent crust formation and eventual scarring
3. Prevent crying – because of the pressure on the suture line ( encourage the parent to stay with
the infant)
4. Place the infant in SUPINE position with arm or elbow restraints (change the position to the side
or sitting up to prevent hypostatic pneumonia; remove restraints at least 3X a day only when
supervised)
5. Support the parents by accepting and treating the infant as normal
6. Suture line is held by a LOGAN BAR (A wire bow taped to both cheeks)
Therapeutic Management
Cleft lip- fetal surgery while still in the utero or repaired surgically shortly after == during hospital stay or
between 2-10 weeks of age
Nasal mold apparatus applied before surgery to shape a better nostril
Early repair helps infants enjoy the pleasure of sucking
Gives a problem on facial contours ==== another surgery will be done when the child
reaches 4-6 years === Nasal rhinoplasty ---- to straighten a deviated nasal septum
CLEFT PALATE
The palatal process closes at approximately weeks 9 to 12 of intrauterine life.
Failure of union of embryonic structure of face; fusion of palatal structures, may involve
the soft oor hard palate and may extend into the nose, forming an oronasal passageway
an opening of the palate is usually at the midline and may involve the anterior hard palate, the
posterior soft palate or both.
May be a separate anomaly
As a rule: it occurs in conjunction with a cleft lip
Occurs more frequently in girls.
HARELIP --- the old term for cleft palate
Causes
Polygenic inheritance or environmental influences
Assessment
Cleft palate – determined by depressing the newborn’s tongue with a tongue blade.
1. Infection- especially aspiration pneumonia
2. cannot suck effectively == because pressing their tongue or a nipple against the roof of their mouth
would force milk up into their pharynx leading to aspiration.
Commercial cleft palate nipple that has an extra flange or rubber to close the roof of the mouth.
Can be used with a plastic bottle that can be squeeze gently to increase the flow of the
feeding to compensate for poor sucking.
Breck feeder — similar to a bulb syringe
Haberman feeder
If surgery is delayed beyond 6 months === which is the age of the child for his 1 st intro of food
-------- soft food should be given.
Can be fitted with a plastic palate guard to form a synthetic palate and help prevent this.
3. Speech – palate is needed to trap air in the mouth
4. Dental development- excessive dental caries, malocclusion from displacement of the maxillary arch
5. Hearing problems- caused by recurrent otitis media ( Eustachian tube connects the nasopharynx and
middle ear and easily transports foreign material to ear.)
PREOPERATIVE Nursing care:
1. Same as for Infants with cleft lip EXCEPT
Feed by gavage if necessary
Encourage early use of spoon and cup
2. Teach parents the need for proper dental hygiene and the importance of regular dental supervision
POSTOPERATIVE Nursing Care:
1. Same as for infants with cleft lip EXCEPT
When maintaining a patent airway, try to avoid use of suction that traumatizes the
operative site
3. Place the child in PRONE Trendelenburg position to prevent aspiration and promote postural
drainage
4. Avoid trauma to suture line by
telling the child not to rub tongue on roof of mouth
avoid the use of straw, spoon, toothbrush
5. provide liquid diet
NO MILK – because of curd formation on suture line
6. Recognize the need for emotional support of the parents since recovery is longer and the progress
is uncertain
Cleft palate needs a 2 stage palate repair:
a. Soft palate repair at 3-6 months of age
b. Hard palate repair at 15 -18 months of age
COMPLICATION:
1. OTITIS MEDIA
o If changing the contour of the palate there is also a change in the contour of the Eustachian
tube to the middle ear.
o Eustachian tube may remain partially closed ---- accumulation of fluid to the middle ear -----
infection
MYRINGOTOMY tubes may be inserted to drain middle ear fluid and help protect
hearing.
