Cleft lip and Cleft palate

Clefts of the lip and palate are frequent birth defects. In a cleft lip, also called 'hare lip', there is an obvious gap dividing the upper lip on one or both sides. This may be incomplete and presents as only a notch in the lip but, more commonly, the defect extends to the nostril, the upper gum margin and even the palate, that is the roof of the mouth.

• What is cleft lip and palate?
• How is the abnormality caused?
• What are the external manifestations of this defect?
• What are the functional difficulties?
• What is the advice given to the mothers?
• What is the treatment?

What is cleft lip and palate?

Clefts of the lip and palate are frequent birth defects. In a cleft lip, also called 'hare lip', there is an obvious gap dividing the upper lip on one or both sides. This may be incomplete and presents as only a notch in the lip but, more commonly, the defect extends to the nostril, the upper gum margin and even the palate, that is the roof of the mouth. The palate is hard and bony in front and soft and muscular at the back. Sometimes only the palate has a cleft or gap and the lip is normal.

How is the abnormality caused?

There is no known predisposing factor. Something seems to happen in early pregnancy at around 8-10 weeks when the mouth is developing from two halves. Failure of fusion of the two halves in some part or entirely, results in cleft lip or cleft palate or a combination. Alcohol or drug use early in pregnancy may increase the chances of this defect in the baby. There is a higher chance of the defect occurring if a previous child or one parent also has the defect.

What are the external manifestations of this defect?

The extent of structural defect depends on the severity of the cleft. Besides the gap in the lip, there is shortening of the lip width, the floor of the nose is wide open and the nostril of the affected side is wide and flat. In addition, in some cases the gum margin is widely separated and may jut out. In cleft lips that involve both sides of the upper lip, the central portion may project outwards very prominently.

What are the functional difficulties?

•  Sucking - Children with cleft lip and palate are unable to suck at the breast since they cannot close over the nipple and generate a negative suction effect. The milk often regurgitates out through the nose in cases of cleft palate.
•  Repeated chest infections - Due to an abnormal sucking-swallowing mechanism milk often trickles into their air passages causing chest infection.
•  Ear infections - A tube normally connects the ear with the throat. This tube balances the ear pressure with the atmospheric pressure. The opening of this tube in the throat is above the level of the roof of the mouth. If the palate is cleft, milk frequently enters the nose and throat causing infection that may travel up this tube to the ear.
•  Speech defects - Children with cleft palate have defective speech that has a nasal sound because of escape of air through the nose. The degree of speech defect may vary from one child to another.
•  Teeth alignment - children with clefts that involve the gum margin have defective alignment of teeth.

What is the advice given to the mothers?

The foremost problem is feeding. Since the baby is unable to suck effectively at the breast, alternative techniques are tried. Bottles with special long nipples are helpful. Babies may be fed using a spoon if the milk is delivered to the back of the babies' mouth. The baby must be kept in a head up position while feeding to minimize the chances of milk entering the windpipe. This type of feeding takes much longer and requires patience. The best measure that a satisfactory feeding pattern has been established is a progressive gain in the baby's weight.

The mother should also be advised that if the baby develops cough or rapid breathing or cries incessantly she must immediately consult a doctor. This may represent a chest infection or an ear infection respectively.

What is the treatment?

The definitive treatment is surgical repair. The operation depends on the severity of cleft. If only the lip is involved, although it is possible to repair it soon after birth, the best time is at 1-2 months of age when the risks of anaesthesia are lower. If both the lip and palate are cleft the lip is repaired first and the palate is repaired at about 1 year of age, before the child starts to speak.

In some children more than one operation may be necessary. The first operations are meant to correct the functional defects. Any cosmetic improvement may require further operations. The outcome after surgery is usually very good. In cleft palate, however, some degree of speech defect persists that may be helped by the professional guidance of a speech therapist. If the child does not have his palate closed by the time he starts speaking, the degree of speech defect is likely to be greater.