Cleft Lip and Palate
- What is cleft lip and palate?
- How much experience do you have treating cleft lip and palate?
- Who gets cleft lip and palate?
- What does a baby with cleft lip and palate look like?
- How are cleft lip and palate treated?
- Do babies with cleft lip and palate have difficulty feeding?
What is cleft lip and palate?
Cleft lip and palate are incomplete formations of the upper lip and palate (roof of the mouth) leaving a cleft (gap) in the affected area. Clefts occur when parts of the lip or roof of the mouth don't fuse together during pregnancy.
Cleft lip affects how the lip works and distorts nearby structures like the nose. Cleft lip can occur alone or with cleft palate.
Cleft lip can be unilateral (on one side of the lip) or bilateral (on both sides). Unilateral cleft lip is the mildest cleft form. This form does not affect speech or the development of teeth.
In cleft palate, the inside of the nose and mouth are not separated. This leaves an opening in the roof of the mouth. A cleft palate affects speech because the muscles at the back of the palate, which are needed for normal speech, are not formed properly.
A submucous cleft palate is a cleft that is covered by the mucous membrane lining the roof of the mouth. This makes the cleft hard to see when looking in the mouth.
How much experience do you have treating cleft lip and palate?
Our craniofacial team has a great deal of experience treating all types of cleft lip and palate. They are the most common problems we treat.
Right now we are treating 639 children with cleft lip and/or palate. Each year we have almost 200 children come to our Center for treatment for the first time. Each year we perform an average of 300 surgeries on cleft lip and palate.
Who gets cleft lip and palate?
(Left) Complete unilateral cleft lip and palate.
(Right) Cleft lip and nose repair is done; child is now having cleft palate closure surgery.
Cleft lip and palate are congenital defects, or birth defects, that occur very early in pregnancy between the fourth and eighth week.
Cleft lip and palate are the most common malformations of the head and neck region. Cleft lip and palate occur in all infants but are more common in some races.
In Caucasians, cleft lip with or without cleft palate occurs in around one in 1,000 live births. The rate is twice as common in Asians, and about half as common in African Americans. Around one baby in every 2,000 births has a cleft palate, but no cleft lip.
Most bilateral cleft lips (86%) and unilateral cleft lips (68%) are linked with a cleft palate.
Unilateral clefts are nine times as common as bilateral clefts, and occur twice as often on the left side than the right.
Males are more likely to get cleft lip and palate, and females are more likely to get cleft palate alone.
Most cleft lips and palates (60%) are not linked with anything that occurs during or after pregnancy. The exceptions are:
- Exposure to the drug phenytoin (Dilantin) during pregnancy is linked with a tenfold increase in the rate of cleft lip.
- Smoking while pregnant doubles the rate of cleft lip.
- Alcohol, anticonvulsants and retinoic acid (vitamin A) are linked with other birth malformations that include cleft lip and palate.
Genetic abnormalities can result in conditions or syndromes that include cleft lip and palate. A syndrome is a disease or disorder that has more than one identifying feature or symptom.
While cleft lip and palate have a genetic component, a single gene has not been identified.
- More than 40% of cleft palates are part of malformation syndromes.
- The most common syndrome associated with cleft lip and palate together is van der Woude syndrome.
- The most common syndrome linked with cleft palate is velocardiofacial syndrome.
(Left) Complete bilateral cleft lip with twisting of the skin under the nose and no skin between the nostrils.
(Right) Although this baby was also born with a bilateral cleft lip, these are both incomplete.
The risk for passing on clefting in subsequent pregnancies depends on whether the child has cleft lip and palate or cleft palate alone.
With one affected child or parent with cleft lip and palate, the risk of cleft lip and palate in the next pregnancy is 4%.
If two children have cleft lip and palate, the risk increases to 9%. And, if one parent and one child have been affected, the risk is 17%.
For families with a history of cleft palate, the risk of cleft palate in subsequent pregnancies if there is one affected child is 2%.
If two children have been affected the risk is 1%. If one parent has cleft palate the risk is 6%. And if one parent and one child have been affected, the risk is 15%.
What does a baby with cleft lip and palate look like?
A cleft lip can range from microform cleft lip (a small notch in the red part of the upper lip) to complete bilateral cleft lip (two wide gaps in the upper lip and a collapsed and stretched nose).
The muscle, skin and lining of the lip are missing in the gap of a cleft. They are in the wrong place on each side of the cleft and distort the nearby tissues.
(Left) Unilateral complete cleft lip. (Right) Unilateral incomplete cleft lip.
The nose, or nostril, is stretched as a result of the pull of the abnormal attachments of the muscles on each side of the cleft.
A cleft palate can only be seen when the baby's mouth is open. It is a gap along the middle of the roof of the mouth.
When you look at a cleft palate through the mouth, you are looking up into the nose.
This explains why fluid or formula can come out of the baby's nose while eating and why the infant has difficulty feeding.
How are cleft lip and palate treated?
During cleft lip surgery, the skin, muscle and lining are put in the proper place. The nose is also treated at the time of the first surgery, but often needs some minor surgeries as the child grows.
During cleft palate surgery, the muscles at the back of the palate need to be put in their proper place across the cleft so the child can learn to speak normally.
Bilateral cleft lip repair
(Left) The skin needed to do the repair is present, but not in the right place or shape.
(Center) Surgery puts the skin, muscle and cartilage back in the correct position.
(Right) After 1 year, the lip and nose have relaxed in the new position. The scars are visible as white lines.
The care for a child with a cleft requires a complex, lengthy treatment plan lasting until adulthood (see table below).
The goal of our cleft team is to minimize the number of steps in the treatment plan by improving the outcome of each step.
Recent advances in presurgical orthopedics, such as nasoalveolar molding and gingivoperiosteoplasty (a procedure to close a cleft in the gum), are early interventions that reduce the need for surgeries as the child grows up.
All members of the craniofacial team may need to be involved in the care of a child with a cleft at different times. This table lists the key interventions for treatment by age. An intervention is what is checked and what is done based on the findings.
| Age | Intervention |
|---|---|
| * This table does not contain every intervention that may be needed by a particular child at a certain age. | |
| Prenatal |
|
| Birth-1 month |
|
| 1-4 months |
|
| 5-15 months |
|
| 16-24 months |
|
| 2-5 years |
|
| 6-11 years |
|
| 12-21 years |
|
Do babies with cleft lip and palate have difficulty feeding?
At first, infants with cleft lip and palate often have a hard time feeding, but with the right technique and help they can learn to feed very well.
Nurses and infant feeding specialists offer detailed feeding instructions and support for new parents of babies with cleft lip and palate.
Find out more about feeding instructions.