Cleft lip and Cleft Palate

 Cleft lip and Cleft Palate

Cleft Lip (Cheiloschisis); cleft in middle of upper lip.

Cleft Palate (Palatoschisis); Splits in roof of mouth.

Cleft Lip

Cleft lip is congenital facial defect of lip (usually upper lip) due to failure of fusion of maxillary process with nose elevation on frontal prominence.

Extent of defect varies from notch in lip (partial or complete incomplete cleft).

Complete cleft; large cleft reaching floor of nose.

Cleft lip occurance one side called unilateral or both side called bilateral.

Facial or oral malformations occurs in fetus very early in pregnancy; while baby developing inside mother's womb.

Cleft Palate

Cleft palate results from failure of fusion of hard palate with each other and with the soft palate.

Cleft Palate are;

1. Complete

Involving hard and soft palate including gap in the palate.

2. Incomplete

Hole in roof of mouth, usually soft palate.

Types of Cleft lip and Cleft Palate

Left unilateral cleft lip 

Left unilateral cleft lip and palate

Bilateral cleft lip

Bilateral cleft lip and palate

Bilateral cleft lip with full palate

Cleft Palate

Etiology

1. Genetic Predisposition

2. Exposure of viruses/chemical, while fetus developing in womb.

3. Medication during pregnancy 

Anticonvulsants, Methotrexate, immunosuppressants, chemotherapeutic drug.

4. Exposure to X ray

5. Maternal condition

Anemia, Hypoproteinemia

6. Maternal intake of alcohol

7. Maternal smoking during pregnancy

Pathophysiology

Lip development; 3rd-7th week

Palate development; 5th-12th week

Failure of the maxillary process to fuse with premaxillary process fusion.

(Occurs 5th-8th week of gestation)

Complete or partial non-union affect palatal bone, upper lip along with maxilla, premaxilla and tissue of soft palate and uvula.

Cleft lip and cleft palate

Failure or incomplete union of embryonic structures of face result in cleft lip and cleft palate.

Diagnostic Evaluation

1. Prenatal diagnosis of cleft; maternal ultrasonography

2. Physical examination; mouth, palate, nose.

Management

1. Tennison Randall Triangular Flap (Z-plasty) and Millard's Rationale advancement Technique

(Repair of cleft lip; age of 3 months)

2. Create functional Palate (Cleft lip repair)

Reduce chance of fluid entering middle ears and in proper development of teeth and facial bone.

3. Burp baby in between feeds and after feeding.

Complication

1. Feeding problem

Due to separation of lip or opening in palate, cause sucking ineffective.

2. Respiratory infections

Aspiration of feed. Liquid pass from mouth back through nose lead to aspiration pneumonia.

3. Ear infection/ Hearing loss

Children with cleft palate, increase risk of ear infection; middle ear infection.

4. Speech problem

Trouble in speaking

5. Dental problem

Prone to dental cavities, often missing, extra malformed or displaced teeth.

Nursing Management

1. Cleft lip or cleft palate reduce infant's ability to suck. Breast feeding with use of palatal prothesis (palatal obturator).

2. If baby unable to suck the breast, Expressed Brest milk given using syringe, long handle spoon or dropper.

3. Risk of aspiration due to cleft palate, instructed to feed baby in upright position.

4. Burp the baby in between feeds and after feeding.

5. Given all essential care; immunization, warmth, hygiene, prevention of infection.

Care of Baby after Surgery

1. Monitoring the vital signs of the baby.

2. Observe any bleeding from surgical site.

3. Turn baby face one side, for drainage of secretion and preventing aspiration.

4. Arched metallic device "Logan's bow" placed over upper lip and taped to infant cheeks to prevent tension at suture line. 

5. Administered prescribed Analgesics, to reduce the pain. Baby cry causing tension on suture line.

6. Prevent infection at site, using aseptic technique.

7. Secure the baby hand with mummy mittens, to prevent put any object in mouth, may injury surgical repair.