A cleft lip and palate is a defect caused by the failure of the soft and bony tissue to fuse in utero. These may occur singly or together and often occur with other congenital anomalies such as spina bifida, hydrocephalus, or cardiac defects.
In infants diagnosed with cleft lip, the fusion fails to occur in varying degrees, causing this disorder to range from a small notch in the upper lip to total separation of the lip and facial structures up into the floor of the nose, with even the upper teeth and gingiva absent. Cleft lip deformities can occur unilaterally, bilaterally, or rarely in the midline.
A cleft palate is an opening of the palate and occurs when the palatal process does not close as usual at approximately weeks 9 to 12 of intrauterine life. The incomplete closure is usually on the midline and may involve the anterior hard palate, the posterior soft palate, or both. It may occur as a separate anomaly or in conjunction with a cleft lip.
Treatment consists of surgical repair, usually of the lip between 6 to 10 weeks of age, followed by the palate between 12 to 18 months of age. The surgical procedures depend on the child’s condition and physician preference. Management involves a multidisciplinary approach that includes the surgeon, pediatrician, nurse, orthodontist, prosthodontist, otolaryngologist, and speech therapist.
Table of Contents
- Nursing Care Plans and Management
- Nursing Problem Priorities
- Nursing Assessment
- Nursing Diagnosis
- Nursing Goals
- Nursing Interventions and Actions
- Recommended Resources
- See Also
- References and Sources
Nursing Care Plans and Management
Nursing goals for clients diagnosed with cleft lip and palate include maintaining adequate nutrition, increasing family coping, reducing the parents’ anxiety and guilt regarding the newborn‘s physical defects, and preparing parents for the future repair of the cleft lip and palate.
Nursing Problem Priorities
The following are the nursing priorities for patients with cleft lip and cleft palate:
- Feeding Difficulties. Infants with cleft lip and cleft palate may have difficulties in breastfeeding or bottle feeding due to structural abnormalities. Ensuring adequate nutrition and addressing feeding challenges are crucial for their growth and development.
- Speech and Language Development. Cleft lip and cleft palate can affect speech production and intelligibility. Early intervention by speech therapists and regular monitoring of speech and language development are essential to address any potential communication difficulties.
- Dental and Orthodontic Issues. Cleft lip and palate can impact the alignment and development of teeth and jaws. Dental problems, such as malocclusion, missing teeth, and dental decay, may require orthodontic and dental interventions to ensure proper oral health and function.
- Ear Infections and Hearing Problems. Children with cleft palate are more prone to middle ear infections (otitis media) and hearing loss due to the dysfunction of the Eustachian tube. Frequent monitoring and timely intervention are necessary to prevent potential hearing impairment.
- Psychological and Social Well-being. Individuals with cleft lip and cleft palate may face challenges related to self-esteem, body image, and social interactions due to visible facial differences. Providing psychological support and addressing any emotional difficulties can contribute to their overall well-being.
- Facial Aesthetics and Plastic Surgery. Reconstructive surgery plays a vital role in correcting the cleft lip and palate, improving facial aesthetics, and restoring normal function. Surgical interventions are typically staged and performed by experienced plastic surgeons.
- Nasal Resonance and Breathing Difficulties. Cleft palate can affect nasal resonance and lead to nasal airway obstruction. Management may involve speech therapy, nasal surgery, and continuous monitoring of nasal function.
Assess for the following subjective and objective data:
- See nursing assessment cues under Nursing Interventions and Actions.
Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with cleft lip and cleft palate based on the nurse’s clinical judgment and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.
Goals and expected outcomes may include:
- The infant will maintain a clear airway as evidenced by clear breath sounds and the absence of cyanosis.
- The infant will display a respiratory rate of 20 to 30 breaths per minute, absence of retractions, and respiratory distress.
- The neonate will exhibit adequate nutritional status to maintain growth and healing.
- The family will report decreased anxiety levels concerning the infant’s condition.
- The family will demonstrate problem-solving skills and the use of resources effectively.
- The family will increase coping ability concerning the infant’s condition and care needs.
- The parents will verbalize that they believe there will be a positive outcome for the infant.
- The parents will demonstrate coping behaviors evidenced by holding and helping with infant care.
- The family will obtain an increased knowledge about the infant’s preoperative and postoperative care.
- The family will verbalize understanding of the disease process and treatment regimen.
- The family will identify possible complications that necessitate medical attention.
- The infant will not experience injury from the incision.
- The infant will be free of trauma, accumulation of substances, and infection.
- The infant will be free of signs and symptoms of ear infection.
- The parents will verbalize understanding of the importance of early treatment.
- The parents will list signs of diminished hearing.
- The parents will verbalize appropriate agencies for support and guidance.
Nursing Interventions and Actions
Therapeutic interventions and nursing actions for patients with cleft lip and cleft palate may include:
1. Maintaining Airway Clearance and Preventing Aspiration
Infants diagnosed with a cleft palate cannot suck effectively either because pressing their tongue or a nipple against the roof of their mouth forces milk into their pharynx, possibly leading to aspiration. Additionally, because of the local edema that occurs after a cleft lip or palate surgery, it’s important to observe children closely in the immediate postoperative period for respiratory distress. After surgery, the infant has to learn to breathe through the nose, possibly adding to the respiratory difficulty.
Assess the newborn’s respiratory rate, depth, and effort.
Aspiration of secretions or milk may cause tachypnea. Newborns are obligate nose breathers and show signs of distress if their nostrils become obstructed. The newborn’s respiratory rate can be observed most easily by watching the newborn’s abdomen because breathing primarily involves using the diaphragm and abdominal muscles.
Assess skin color and capillary refill.
Bluish discoloration of the skin or prolonged capillary filling happens because of the decreased oxygenation produced by the defect. The nurse should note, however, that the peripheral circulation of a newborn remains sluggish for at least the first 24 hours, which can cause cyanosis in the infant’s feet and hands (acrocyanosis).
Assess for abdominal distention.
The infant may swallow excess air during bottle feeding, causing abdominal distention that may result in upward pressure on the diaphragm and lungs, compromising respiration. To facilitate palpation (if not contraindicated), the knees and legs should be flexed toward the hips, which allows the abdominal muscles to relax.
Place the infant in an infant seat at 30° to 45°.
This position prevents the infant’s tongue from falling back and obstructing the airway. If possible, the infant can be placed in an infant bouncy seat. The semi-upright position facilitates burping, limits regurgitation of fluids, and prevents milk from entering the Eustachian tube and middle ear space, thus minimizing ear infections (Burca et al., 2016).
Position the infant in an upright position greater than 60° during feeding and elevate the head of the crib to 30° after.
General recommendations for body mechanics in infants with cleft lip or palate while feeding include the following: head support for neutral alignment of head and neck; arms forward, trunk midline, hips flexed; and lip, cheek, and jaw stabilization to provide a platform for sucking movements. Infants with cleft palate are fed in an upright position greater than 60° to allow gravity to facilitate fluid transfer and decrease the tendency for nasopharyngeal reflux (Burca et al., 2016).
Allow the infant time to swallow during feedings and provide oral care as appropriate.
Placing a small amount of breast milk or formula into the infant’s mouth and allowing time for swallowing will prevent aspiration. Offering small amounts of sterile water will cleanse the mouth after feeding. Formula or drainage is gently cleaned from the suture line with saline solution.
Provide oral and nasal suctioning as needed.
The purpose of suctioning is to maintain a patent airway and improve oxygenation by removing excess fluids and secretions in the oral and nasal cavities. Following either cleft lip or cleft palate surgery, infants may need their mouth suctioned to remove mucus, blood, and unswallowed saliva. When doing this, be exceedingly gentle, so you don’t touch the suture line with the catheter. Place the infant on their side to allow mouth secretions to drain forward.
Feed the infant slowly and burp frequently.
Burping frequently during feeding will reduce spitting up and prevent excessive swallowing of air. Holding the infant during feedings, burping frequently, and placing the infant in an infant seat after feeding or on the right side propped with a rolled blanket will aid in a positive outcome for this infant.
Position the infant appropriately after surgery.
Following a cleft lip repair, be sure the infant does not turn onto their abdomen because this could put pressure on the suture line, possibly tearing it. Careful positioning ensures the prevention of injury to the operative site.
Provide special nipples or feeding devices such as pigeon feeders with a one-way valve.
Feeding may work better using special bottles or nipples with a wider base. A syringe with a rubber tip, a long nipple with a large hole attached to a squeeze bottle, or a medicine dropper can be used to feed the infant formula or breast milk before and after surgery because sucking motions must be avoided to keep from applying tension on the suture line.
Coordinate with other healthcare teams for the holistic care and management of the infant.
Treatment of the infant diagnosed with cleft lip and palate requires multidisciplinary teamwork with a surgeon, pediatrician, pediatric dentist, orthodontist, nurse, psychologist, speech therapist, and social worker. The public health nurse should be responsible for coordinating parental counseling and referral as needed.
2. Improving Nutritional Status and Teaching Feeding Methods
Before a cleft lip or palate is repaired, feeding the infant becomes a concern because the infant has difficulty maintaining suction with a bottle or breast; there is evidence of slower growth compared to infants without a cleft disorder. Because the deviation of the lip interferes with sucking, infants may be at a better surgical risk as newborns than they are after a month or more of poor nourishment. Feeding is a problem because the cleft prevents negative pressure from being formed within the mouth, which is necessary for successful sucking.
Assess infant sucking and swallowing ability.
The infant with a cleft lip or palate may find it challenging to establish breast and bottle feeding due to impaired sucking ability, compromising nutrition. The cleft may not be readily apparent at birth, so careful examination of the oral cavity and upper palate at birth is essential. To assess sucking ability, the evaluator places an index finger on the infant’s tongue for the infant to suck. Gently feeling the inside of the mouth and identifying the strength of the suck will allow the evaluator to locate the cleft and assess the severity (Burca et al., 2016).
Monitor daily caloric and fluid intake.
Recording daily intake will determine whether the infant is meeting nutritional needs or whether the feeding method needs to be adjusted (gastric gavage will be necessary). Infants diagnosed with cleft lip and palate share the same nutritional growth requirements as other infants without craniofacial defects; however, additional calories may be required when other systemic issues are identified (Burca et al., 2016).
Record the daily weight of the infant.
Documenting daily weight evaluates whether the feeding pattern is successful or needs to be adjusted. Initially, the infant’s anthropometric measurements of weight and height are recorded and plotted for age-appropriate parameters. After initial weight loss in the newborn period, a weight gain of 15 to 30 g per day is the goal (Burca et al., 2016).
Educate the mother on how to massage her breasts and nipples before nursing the infant.
Breast and nipple massage will cause milk to flow freely near the surface for a comfortable suck and will harden breasts, allowing the infant to hold the nipple in his/her mouth. If the surgery will be delayed for one month, the mother will need continuing support from the nursing staff to support her efforts on pumping and to remind her that her breast milk will be very beneficial to her infant and the healing process.
Instruct the mother to apply pressure to the areola using her fingers, guide the nipple to the side of the infant’s mouth, and hold it there during feeding.
Holding the nipple in the infant’s mouth allows the infant to nurse with its gums rather than by sucking if sucking is difficult. It may be possible for an infant with a cleft lip to breastfeed because the bulk of the mother’s breast tends to form a seal against the incomplete upper lip. Although the infant needs the enjoyment of sucking, some surgeons do not want the infant to either breastfeed or suck on a nipple before surgical correction of the disorder to avoid any local bruising of tissue.
Encourage frequent burping after feeding.
When an infant drinks from a bottle, they can swallow some air, which goes down into their stomach along with the milk or formula. Burping will help to prevent aspiration after feeding. Following a feeding, be certain the infant with a cleft lip is burped well because the inability to securely grasp a nipple or syringe edge causes the infant to swallow more air than usual.
Hold the infant upright or a sitting position while feeding.
An upright or a sitting position improves swallowing and prevents milk from coming through the defect and out of the nasal cavity, therefore reducing the risk of aspiration. Therefore, the best feeding method for the infant diagnosed with cleft lip may be to support the infant in an upright position and feed the infant gently using a soft bottle and a commercial cleft lip nipple or a spoon.
An alternative is for the mother to pump her breasts and feed the infant with a bottle.
Pumping breast milk satisfies the mother’s desire to breastfeed and provides an excellent source of nourishment. Review with the mother how to pump or manually express breast milk to maintain a milk supply prior to surgical correction and after, if needed.
Educate the mother regarding the different forms of feeders appropriate for the infant.
Infants diagnosed with a cleft palate cannot suck effectively either because pressing their tongue or a nipple against the roof of their mouth forces the milk into their pharynx. The most successful method for feeding this infant is to use a commercial cleft palate nipple that has an extra flange of rubber to close the roof of the mouth. A Breck feeder may also be used to feed infants with a cleft palate.
Educate parents about the possibility of solid food at the appropriate time.
If the surgery is delayed beyond six months of age or the time when solid food would usually be introduced, teach the parents to be certain any food they offer is soft because particles of coarse food could invade the nasopharynx and be a cause of aspiration.
Instruct the mother who bottle feeds to use some cereal to thicken the milk.
Thicker milk will make swallowing easier due to the increased gravity flow brought about it. Additionally, the infant should be held during feedings or placed in an infant seat after feeding for a positive outcome.
Offer small sips of fluid between feedings.
If a cleft extends to the nares, so the nose and mouth are joined, breathing causes the oral mucous membranes and lips to become dry. Offering small sips of fluids between feedings can help keep the mucous membranes moist and prevent cracks and fissures that could lead to infection.
Refrain from removing the bottle nipple from the infant’s mouth unless necessary.
Removing the nipple may cause the infant to cry, making feeding more challenging. The infant should also be prevented from crying postoperatively because it could cause tension on the suture line. Care should be taken to avoid touching the suture line when inserting the nipple of a bottle or of the medicine dropper.
Keep the infant NPO after the surgery and gradually introduce appropriate diets.
After surgery for cleft lip or palate, an infant is kept nothing by mouth (NPO) for approximately 4 hours and then introduced to liquids such as plain water. Be certain to begin this process with only a small amount each time to prevent vomiting. After palate surgery, only liquids are generally given for the first 3 or 4 days, followed by a soft diet until healing is complete.
Avoid feeding milk post-surgery.
Be certain milk is not included in the first fluids offered because milk curds tend to adhere to the suture line and are difficult to remove. After a feeding, always offer the child a sip of clear water to rinse the suture line and keep it as clean as possible.
Instruct the parents regarding oral care.
Educate the parents to be diligent about oral health care. In infants with clefts involving the maxillary alveolar ridge (upper gum), it is common for some teeth to be misshapen or turned. Prudent twice-daily gum and teeth brushing with an age-appropriate toothbrush and toothpaste are crucial, as are bi-yearly dental visits for monitoring.
3. Reducing Anxiety and Enhancing Coping
A mother’s first reaction to a disfigured newborn is one of shock, hurt, disappointment, and guilt. Some parents may regard the deformity as a result of their inadequacies. They may desire to hide the child from relatives and friends. The client and the family need understanding, a concrete basis for hope, and practical advice. Family stress often occurs because of the multiple surgeries that may be required throughout childhood.
Assess the level of anxiety and need for information.
This provides information to allay anxiety manifested by the infant’s appearance at birth with a level increased with the location and extent of the defect. Children can be affected by the fear experienced by their parents, thus magnifying the psychological impact on the child.
Assess family coping methods used and their effectiveness.
This provides information about coping methods and the need to develop new coping skills. Family attitudes directly affect a child’s feeling of self-worth, and a child with special needs may strengthen or strain family relationships.
Observe the parent’s interaction with the infant.
Observe whether the parents look at their infant’s face while feeding or caring for the infant. This helps identify the parents’ acceptance of the infant’s condition and helps them progress toward the improvement of their coping skills.
Determine the parent’s current knowledge and perception of the situation.
The lack of information or unrealistic expectations can interfere with family members and the client’s response to the defect and the situation.
Encourage expressing concerns and questions about the condition to discuss feelings about the infant’s appearance.
This provides an environment conducive to venting feelings to facilitate the adjustment to the infant’s defect. It also provides an opportunity to examine realistic fears and misconceptions about the condition.
Provide an accepting environment and attitude and handle the infant in a gentle, caring way.
This promotes trust and conveys to parents that an infant is a valuable human baby deserving of love and caring. Provide an open environment wherein the parents, and the child feel accepted in their present condition without feeling judged and can promote a sense of dignity and control.
Communicate with parents in a calm and honest way.
This promotes a calm and supportive environment to reduce anxiety and instill hope. Provide accurate and consistent information to reduce the parents’ anxiety and enable them to make decisions and choices based on realities.
Assist the family or parents in recognizing or clarifying fears to begin developing coping strategies for dealing with these fears.
Coping skills are often stressed after diagnosis and during the different phases of treatment. Support and counseling are often necessary to enable the parents to recognize and deal with fear and to realize that control and coping strategies are available.
Allow parents to stay with the infant and encourage them to assist in care as appropriate.
This reduces anxiety and promotes bonding that may be blocked by an infant’s appearance. It is equally important from a psychological standpoint as a parent may need caring support to bond with an infant whose face is deformed in this way.
Emphasize the infant’s positive features when providing information.
This promotes positive feelings for the infant. The developing child senses the parents’ feelings and acquires either a positive or a negative self-image. The client and family need understanding, a concrete basis for hope, and practical advice.
Explain procedures and stay with the family during anxiety-producing procedures and consultations, as appropriate.
Accurate information allows the parents or family to deal more effectively with the reality of the situation, thereby reducing anxiety and fear of the unknown.
Suggest visits with parents who have a child with a similar defect and were successfully repaired, or show them photos.
This provides support and information to reduce anxiety. The surgical repair of cleft lip and palate results is currently excellent. It is also helpful to show parents photographs of infants with good repairs to assure their child’s outcome can be successful.
Inform parents of usual ages for cleft lip repair and/or cleft palate, stages of surgery, and type of procedure performed.
This provides information to reduce fear and anxiety and to know what to expect. If a cleft lip is discovered while the infant is still in utero, fetal surgery can repair the condition, although this procedure is not usually attempted. If the disorder is discovered at birth, a cleft lip can be repaired surgically shortly thereafter, often at the time of the initial hospital stay or between 2 and 12 weeks of age.
Refer the parents to additional resources for necessary counseling and support.
Referrals to community support groups may be useful from time to time to assist the parents in dealing with anxiety. Many communities have support groups for parents of children born with cleft lip or palate. Referral to these groups can offer the parents additional support. The National Cleft Palate Foundation is one such support group.
Encourage family members to express problem areas and explore solutions together.
This reduces anxiety, enhances understanding, and provides an opportunity to identify problems and problem-solving strategies. Help them understand that any negative feelings they feel toward the infant or themselves, such as sadness or anger, are normal. This assurance does not instantly make them feel better about what has happened, but the knowledge the feelings they are experiencing are normal can help them begin to deal with such emotions.
Assist family members in identifying three healthy coping mechanisms they can use.
This empowers the family to find the solution appropriate for them. Recognizing one’s own strengths and areas for improvement provides an opportunity for personal growth, enhancing the potential for success once the infant returns home with the parents.
Assist the family in establishing the child’s short- and long-term goals and the importance of integrating the child into family activities.
This promotes involvement and control over situations and maintains parental roles. To promote effective bonding, the parents need to hold and interact with their infant during both the preoperative and postoperative periods.
Encourage them to follow home routines and meet the child’s needs with the participation of family members.
This increases the child’s sense of security and sense of belonging. The mother or parents who have fed their infant preoperatively and have been allowed to assist with feedings during hospitalization will feel more confident after discharge.
Give positive feedback to the family and praise family efforts in the development of coping and problem-solving techniques in caring for the child.
Praise encourages the family to continue involvement in long-term care. Support the parents with attention, compassion, time, respect, honesty, advocacy, and understanding. These are essential to prepare the parents for the challenges they may face and meet their needs for compassion and caring.
Teach the family that overprotective behavior may hinder growth and development and treat the child as normally as possible.
This enhances family understanding of the importance of making a child one of the family and the adverse effects of overprotection of the child. Reinforce the child’s positive attributes, stressing that a scar is only one small aspect of who they are.
Refer the family and the child to community support groups as appropriate.
Many communities have support groups for parents of children born with a cleft lip or palate. Referral to these groups can offer the parents additional support. The National Cleft Palate Foundation provides parent education materials on its website.
Assist in the referral of the parents to genetic counseling.
Because of the genetic influence, the parents of a child diagnosed with a cleft lipo should be referred for genetic counseling to ensure they understand they have a small increased chance of having another child with a cleft lip or palate and that any future children are at a greater risk than usual for this problem.
4. Preventing Injury and Infections
Cleft lip and cleft palate can lead to many complications. Early feeding difficulties limit the infant’s weight gain and growth and may lead to learning disabilities, speech disorders, recurring upper respiratory tract infections, and chronic ear disease. Abnormal anatomy of the orofacial cavity makes cleaning the maxillary incisors difficult, leading to higher dental caries rates (Burca et al., 2016). Early identification of complications and the prevention of several injury risks are keys to ensuring optimal healing and recovery of an infant or child diagnosed with cleft lip and/or palate and who underwent surgical repair. Changing the contour of the palate when it is repaired also changes the slope of the eustachian tube to the middle ear. This can lead to a high incidence of middle ear infection or otitis media because organisms are able to reach this area from the oral cavity more readily than usual.
Assess suture lines for cleanliness, redness, swelling, or drainage frequency.
This provides information indicating possible infection and the need for cleansing away formula or drainage. The incision line should appear clean and intact and free of erythema or drainage during the postoperative period.
Assess for respiratory distress following palate surgery.
This monitors breathing through a smaller airway caused by edema and breathing through the nose. Because of the local edema that occurs after a cleft lip or palate surgery, it’s important to observe the infant closely in the immediate postoperative period for respiratory distress. After surgery, the infant has to learn to breathe through the nose, possibly adding to the respiratory difficulty.
Assess for signs of infection such as fever, pain, pulling on an ear, or discharge from the ear.
Review the signs of infection such as fever, pain, pulling on an ear, or discharge with the parents. Fever can be as high as 40°C (104°F). Infants’ Earaches may manifest by general irritability, frequent rubbing or pulling at the ear and rolling of the head from side to side.
Visualize the inner ear and palpate the mastoid process.
With an infection, the tympanic membrane appears inflamed or reddened. It may bulge forward into the external canal because of fluid and edema behind it. Palpate the mastoid process behind the ear to be certain it doesn’t feel tender to your touch. If it does, the infection probably has spread out of the middle ear into the mastoid cells, a serious complication that may lead to meningitis.
Screen the infant/child for hearing loss.
The child needs to be screened for hearing difficulty because the angle of the eustachian tube may be changed in surgery, and they may develop more ear infections than usual, which can possibly lead to some hearing impairment. Hearing loss may impair cognitive and language development, which can hamper the education and communication abilities of the developing child.
Monitor lip protective device taped on operative site.
This relaxes the site and prevents tension on sutures caused by facial movement or crying. After cleft lip surgery, the suture line may be held in close approximation by a Logan bar (a wire bow taped to both cheeks) or an adhesive bandage such as a Band-aid simulating a bar that brings together the incision line but does not cover the incision. Assess that this is secure and continues to protect the suture line from tension after each feeding or cleaning of the suture line.
Perform strict care of the suture line.
Infection and subsequent scarring may result if crusts from serous drainage are allowed to form on a cleft lip suture line. Most surgeons prescribe cleaning the suture line with sterile water or sterile saline with sterile cotton-tipped applicators after every feeding or whenever the normal serum that forms on suture lines accumulates.
Provide ordered analgesics for pain, hold, cuddle, or rock child, anticipate needs to prevent crying.
Furnish adequate pain relief, so the infant does not cry because this puts increased tension on the sutures. To help avoid crying, try to anticipate the infant’s needs by having formula ready to feed. Help the parents use whatever measures, such as rocking, carrying, or holding, that are necessary to make the infant feel secure and comfortable.
Apply soft elbow restraints and remove periodically to perform ROM on arms and allow for movement and holding; a child may need a jacket restraint to prevent rolling over.
This prevents the child from touching or injuring the operative site. Keep elbow restraints in place as necessary, so they do not put their fingers in their mouth and poke or pull at the sutures.
Remove sharp objects or toys, and avoid the use of forks, straws, or other pointed objects.
Nothing hard or sharp must come in contact with a recent cleft suture line. Observe the infant after palate repair carefully, therefore, to be certain they do not put toys with sharp edges into their mouths. It’s also good practice to not allow them to use a straw to drink or hold a toothbrush to clean their teeth, so they don’t brush the suture line accidentally.
Feed with a cup or spoon if palate repair was done; avoid placing a spoon in the mouth.
When the child begins to eat soft food, observe that they don’t use a spoon because spoons can invariably be pushed against the roof of their mouth and possibly disrupt sutures. If being fed rather than allowing the infant to use a spoon invokes an intense reaction, it is probably better to leave a child on a liquid diet until the sutures are removed.
Accompany the child when playing or ambulating.
This prevents trauma caused by accidental falls and prevents crying as much as possible. Play should be quiet, particularly in the immediate postoperative period. The nurse may instruct the parents to provide reading, drawing, or coloring materials.
Teach parents about cleansing suture sites and applying antibiotic ointment. Let the parents perform a return demonstration after.
This prevents infection and enhances comfort and healing. Instruct them not to rub the suture line and use a smooth, gentle, rolling motion to avoid loosening the sutures. Teach them to gently dry the suture line with a dry sterile cotton-tipped applicator afterward. Remember that the infant has sutures on the lip that need the same meticulous care as those visible on the outside.
Teach parents feeding methods for the infant and allow them to practice appropriate techniques using a syringe soft tube in the mouth away from any suture line or a cup for an older child.
This promotes nutrition following surgery without sucking on a nipple. Specialized feeding bottles can make feeding easier for the infant by reducing the need to generate high negative pressures. In at least one study, infants diagnosed with cleft lip and palate with compressible bottles gained more weight and required less intervention compared with infants using rigid bottles (Burca et al., 2016).
Provide diversional activities suitable for the child’s developmental age and situation.
Sutures on the lip or palate feel extremely odd, so most children not only run their tongue over their sutures but also don’t respond to advice not to do this. Because this often occurs when children have nothing to think about, help the parents provide diversional activities such as reading or singing to keep the child’s attention off the suture line.
Advise parents not to allow the child to play with small toys or those that are sharp or require sucking or blowing; suggest soft, stuffed toys for an infant.
This removes the possibility of placing a toy in the mouth or damaging an incision. Observe the infant after palate repair carefully to be certain they do not put toys with sharp edges into their mouths. The nurse should also teach the parents to keep objects such as the child’s thumb, tongue blades, toast, cookies, forks, and pacifiers out of the mouth.
Position the infant in an upright position during feeding.
Infants who underwent cleft palate repair are fed in an upright position greater than 60° to allow gravity to facilitate fluid transfer and prevent milk from entering the eustachian tube and middle ear space, thus minimizing ear infections (Burca et al., 2016).
Educate the parents regarding signs and symptoms of complications that are needed to be reported immediately.
Remind the parents of the importance of recognizing and reporting signs of pharyngeal infection to their primary care provider promptly so it can be treated before the infection spreads to the middle ear.
Apply a warm or cold compress to decrease pain and promote comfort.
A warm compress may be applied locally to increase the child’s comfort. Cold may also be beneficial. An ice pack may be prescribed to reduce edema and pressure.
Instruct the parents never to insert anything into the child’s ear. Parents are instructed not to insert cotton swabs or any object into the child’s ears, especially when cleaning. These objects may rupture the tympanic membrane, further complicating the child’s ear infection.
Encourage the intake of liquids and soft foods, as indicated.
Movement of the eustachian tube, such as chewing, may increase the pain. Liquids and a soft diet may reduce pain as they do not involve vigorous chewing. The child may name some foods and fluids they are willing to eat; they may eat less than usual but ensure that they take an adequate amount.
Clean the skin around the ears thoroughly.
The child may experience ear drainage, which they may not notice at times. The skin around the client’s ears must be clean and protected from drainage to prevent tissue breakdown.
Educate the parents regarding treatment using myringotomy tubes.
Because the eustachian tube may remain partially closed in its changed position, serous otitis media (accumulation of fluid in the middle ear) also tends to occur more frequently in these children than in others. If this happens, myringotomy tubes may be inserted to drain the middle ear fluid and to help protect hearing.
Inform the parents about the importance of routine screening for hearing loss.
Be certain the parents understand the need for routine screening for hearing loss during childhood because this is a common early sign of serous otitis media. All children should be followed up to make sure that the condition is resolved and to evaluate any hearing loss that may have occurred.
Administer analgesics and antipyretics as prescribed.
The child may need analgesics and antipyretics such as acetaminophen and decongestant nose drops to open the eustachian tubes and allow air to enter the middle ear. These are given for only 2 to 3 days because if they are given longer, a rebound effect can occur, causing edema and a subsequent increase in mucous membrane inflammation. Instruct the parents to administer acetaminophen every 4 hours or ibuprofen every 8 hours as prescribed.
Explain to parents that usual feeding patterns may be resumed in 2 weeks for lip repair or in 4 to 6 weeks for palate repair.
This provides an estimated time based on suture removal and healing to resume regular bottle feeding or return to baseline dietary status. The infant receives feedings by dropper until the wound is completely healed (1 to 2 weeks). Care should be taken to avoid touching the suture line when inserting the medicine dropper.
Refer parents and the child to appropriate professional resources after discharge.
Children diagnosed with cleft problems tend to receive better, more frequent, and well-coordinated care when seen in an interprofessional team setting, including pediatric dentists, audiologists, speech pathologists, geneticists, and craniofacial surgeons, so referring parents to an appropriate interprofessional center before discharge is critical for these infants and their families.
Provide instructions when complications are identified at home.
Ear infections and dental decay may accompany cleft palate. Parents are instructed to take the child to the health care provider at the first sign of earache.
5. Initiating Patient Education and Health Teachings
Mothers of infants diagnosed with cleft lip and palate may have limited knowledge about feeding their infants and may lack information regarding regurgitation, colic, and swallowing during feedings. Mothers may feel stressed or confused when various healthcare professionals provide conflicting feeding suggestions. Feeding instructions help parents develop confidence in properly caring for their infant diagnosed with cleft lip and palate (Burca et al., 2016).
Assess the presence of acceptance of methods used by parents and their knowledge of the cause and type of defects.
This provides information about a defect that may be inherited or congenital, partial or complete, unilateral or bilateral cleft of the lip and/or palate, adequate nutritional status, and freedom from infection before surgery is done.
Assess the parent’s ability to feed the infant with a defect and their knowledge about preoperative and postoperative needs and care.
Education and support begin prenatally if the deformity is diagnosed in advance of delivery. A child born with a facial deformity encounters many problems. Feedings are difficult and may require special nipples. As the child grows, irregular tooth eruptions, drooling, delayed speech, and the need for intermittent hospitalization and frequent clinic appointments can be frustrating.
Inform the parents of the general timing of surgical repair and what to expect from the neonate. Show them photographs of infants before and after surgical repair.
If the infant’s weight is optimal and he has no other neonatal anomalies, he may undergo surgery to repair a cleft lip shortly after birth. Surgery may also occur in 2 to 3 months or as late as 8 months to allow for bonding and rule out other congenital anomalies. The cleft palate may be repaired in two steps by 12 to 16 months, or repair of the soft palate may proceed in 6 to 18 months and repair of the hard palate, as late as age 5. The timing of the procedures is related to normal growth changes, and repair usually takes place before speech development.
Teach and observe parents hold the infant while feeding in the appropriate position and using the appropriate feeding devices.
Holding the head upright reduces the possibility of aspiration. The positioning includes the head’s support, the midline trunk, and the hips slightly flexed. Special nipples or devices are used because the cleft interferes with the ability to suck and liquid often flows into the nose when taken into the mouth. The act of breastfeeding encourages the normal physiological muscular movement and coordination of the mouth and face (Burca et al., 2016).
Teach and observe to feed slowly and in small amounts, burping frequently, and extend the nipple or feeding device well back into the mouth.
This prevents choking, abdominal distention, a possible liquid flow into the nose, or aspiration into the lungs, causing pneumonia, otitis media, or upper respiratory infections. Following a feeding, be certain the infant with a cleft lip is burped well because the inability to securely grasp a nipple or syringe edge causes the infant to swallow more air than usual.
Inform parents that feeding should not last any longer than 20 to 30 minutes.
Prolonged feedings may deplete an infant’s energy and cause fatigue. Infants may benefit from a learned rhythm during feedings. Pacing the feeding in rhythm with the infant’s reactions during feeding may increase the infant’s control of oral intake by helping maintain organization in sucking, swallowing, and breathing (Burca et al., 2016).
Instruct in the use and care of pre-operative orthodontic devices (plastic palate mold) for an infant with cleft palate.
This promotes the alignment of the maxilla and more normal speech sounds and prevents food from entering the nasal cavity. One issue that may remain is that because palate repair narrows the upper dental arch, a child may be left with less space in the upper jaw for the eruption of the teeth and would therefore require follow-up treatment by a pediatric dentist.
Instruct parents to cleanse the lip, oral cavity, and nose with water before and after feeding.
This prevents infection or skin breakdown with cleft lip or palate. Offering small sips of fluid between feedings can help keep the mucous membranes moist and prevent cracks and fissures that could lead to infection.
Teach parents to avoid the prone position and place the child on the back or side.
This prepares the child for treatments that will be done postoperatively. Following a cleft lip repair, be sure that the infant does not turn onto their abdomen because this could put pressure on the suture line, possibly tearing it. Placing the child in an infant bouncy chair is another possibility.
Inform parents of procedures for correcting defects, medications, procedures to prepare the infant for surgery, and what to expect postoperatively.
This prepares the parents for surgical correction of defects and what to expect during convalescence. Because facial contours change as a child grows, a revision of the original septum may be necessary when the child reaches 4 to 6 years of age. Some infants may have a nasal mold apparatus applied before surgery to shape a better nostril.
Educate parents regarding the importance of future dental follow-up consultations.
One issue that may remain is that because palate repair narrows the upper dental arch, a child may be left with less space in the upper jaw for the eruption of teeth, creating poor teeth alignment. All children born with a cleft palate need follow-up treatment by a pediatric dentist skilled in children’s dental problems so that as the child grows, extractions or realignment of teeth can be done as indicated.
Inform the parents about the importance of consulting with a speech therapist.
Children also need follow-up to detect if speech difficulty occurs. After surgical repair, about 80% of children affected by cleft palate progress to develop normal speech, yet referral to speech therapy early in infancy should always occur to ensure successful speech development.
Provide educational resources regarding breastfeeding and the manual expression of breast milk.
There are a variety of resources available to teach mothers how to pump. One such resource is the Maximizing Milk Production with Hands-on Pumping video developed by Dr. Jane Morton and Breast Milk Solutions. One hospital’s quality improvement project downloaded an initiating pumping video on their intranet site to support their standard education for mothers who required this assistance (Burca et al., 2016).
Provide discharge and follow-up instructions clearly.
Support the infant’s transition to home after discharge with follow-up appointments and home visits. Assessment data for follow-up include quantitative measurements (length, weight, head circumference, growth, adequate numbers of wet/dirty diapers, maternal milk volume and comfort, and time spent feeding) and qualitative reports from the family (Burca et al., 2016).
Offer the parents information regarding home care and community resources.
In large cities, special cleft palate clinics are available where several specialists can collaborate in convenient consultation. The parents are instructed about the resources available in the state in which they live. The American Cleft Palate-Craniofacial Association, the Cleft Palate Foundation, the March of Dimes Birth Defect Foundation, and state programs for children with special needs are examples of community referrals that should be offered to parents.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues, and on electrolytes and acid-base balance.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other care plans related to the care of the pregnant mother and her baby:
- Abortion (Termination of Pregnancy) | 8 Care Plans
- Cervical Insufficiency (Premature Dilation of the Cervix) | 4 Care Plans
- Cesarean Birth | 11 Care Plans
- Cleft Palate and Cleft Lip | 7 Care Plans
- Gestational Diabetes Mellitus | 8 Care Plans
- Hyperbilirubinemia (Jaundice) | 4 Care Plans
- Labor Stages, Induced, Augmented, Dysfunctional, Precipitous Labor | 45 Care Plans
- Neonatal Sepsis | 8 Care Plans
- Perinatal Loss (Miscarriage, Stillbirth) | 6 Care Plans
- Placental Abruption | 4 Care Plans
- Placenta Previa | 4 Care Plans
- Postpartum Hemorrhage | 8 Care Plans
- Postpartum Thrombophlebitis | 5 Care Plans
- Prenatal Hemorrhage (Bleeding in Pregnancy) | 9 Care Plans
- Preeclampsia and Gestational Hypertension | 6 Care Plans
- Prenatal Infection | 5 Care Plans
- Preterm Labor | 7 Care Plans
- Puerperal & Postpartum Infections | 5 Care Plans
- Substance Abuse in Pregnancy | 9 Care Plans
References and Sources
- Burca, N. D. L., Gephart, S. M., Miller, C., & Zukowsky, K. (2016, October). Promoting Breast Milk Nutrition in Infants With Cleft Lip and/or Palate. Advances in Neonatal Care, 16(5), 337-344.
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2010). Nursing Care Plans Guidelines for Individualizing Client Care Across the Life Span (8th ed.). F.A. Davis Company.
- Kenner, C., Altimier, L., & Boykova, M. V. (Eds.). (2019). Comprehensive Neonatal Nursing Care. Springer Publishing Company.
- Leifer, G. (2018). Introduction to Maternity and Pediatric Nursing. Elsevier.
- Silbert-Flagg, J., & Pillitteri, A. (2018). Maternal & Child Health Nursing: Care of the Childbearing & Childrearing Family. Wolters Kluwer. Tolarova, M. M., & Elluru, R. G. (2022, March 10). Pediatric Cleft Lip and Palate Clinical Presentation: Physical Examination. Medscape Reference. Retrieved July 18, 2022.
Reviewed and updated by M. Belleza, R.N.